Health Care Ethics (NCM 108)

CREDIT UNIT/COURSE CREDIT: Theory: 3 units

TIME DURATION : 54 hours (Independent Study 10 - 16 hours)

COURSE DESCRIPTION:
This course deals with the application of ethico-moral concepts and principles affecting care
of the individuals, families, population group and community. It involves discussion of issues
and concerns in varied health care situations. The learners are expected to apply sound
ethical decision-making in varied health scenarios.
Republic of the Philippines
INSTRUCTIONS ON HOW TO DO THIS MODULE
1. NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Begin reading and studying the Module. This Module is designed for individualized
instruction and is Cabanatuan
outcomes-based. Read the
City, Nueva information
Ecija, Philippinesat your own pace or
according to the timelines established
ISO 9001:2015 by your subject teacher. In most cases, the
CERTIFIED
student will be studying the modules independently.
2. COLLEGE OF NURSING
Read the learning objectives of each chapter. These learning objectives specify what
you are expected to learn and what you will be expected to do as a result of studying
this Module.
3. Start to read and study. After each topic, you have to complete all the SELF-STUDY
GUIDE QUESTIONS immediately. Check your answers against the discussion part of
the Module. If you have incorrect answers, re-read the appropriate section of the text
in the Module, and then write the correct answer(s). All answers must be written in a
short bond paper. Then submit to your subject teacher.
4. You can now move onto the next Unit in the Module. Continue to read and study the
MODULE
Module—repeating steps 2 & 3 of these instructions—until you reach the end of the
Module.
5.
HEALTHCARE ETHICS
From time to time follow-up conference between you and your subject teacher will
take place for feedback on what you have learned. Follow-up conference can be in the
form of text, personal message, call, and video call.
6. NCM 108
If you have any questions about the Health Care Ethics module, please contact the
subject teacher.

KRISTHINE ABEGAIL M. GAMIAO, MAN, RN

A.Y. 2024 - 2025

Health Care Ethics 1

(NCM 108)
 HEALTH CARE ETHICS (NCM 108)
CREDIT UNIT/COURSE CREDIT: Theory : 3 units
TIME DURATION: Theory : 54 hours
(Independent Study 10 – 16 hours)

COURSE DESCRIPTION:
This course deals with the application of ethico-moral concepts and principles
affecting care of the individuals, families, population group and community. It
involves discussion of issues and concerns in varied health care situations. The
learners are expected to apply sound ethical decision-making in varied health
scenarios.

INSTRUCTIONS ON HOW TO DO THIS MODULE

1. Begin reading and studying the Module. This Module is designed for individualized
instruction and is outcomes-based. Read the information at your own pace or
according to the timelines established by your subject teacher. In most cases, the
student will be studying the modules independently.
2. Read the objectives of each unit. These objectives specify what you are expected to
learn and what you will be expected to do as a result of studying this Module.
3. Start to read and study. After each topic, you have to complete all the SELF-STUDY
GUIDE QUESTIONS immediately. Check your answers against the discussion part of
the Module. If you have incorrect answers, re-read the appropriate section of the text
in the Module, and then write the correct answer(s). All answers must be written in a
short bond paper. Then submit to your subject teacher.
4. You can now move onto the next Unit in the Module. Continue to read and study the
Module—repeating steps 2 & 3 of these instructions—until you reach the end of the
Module.
5. From time to time follow-up conference between you and your subject teacher will
take place for feedback on what you have learned. Follow-up conference can be in the
form of text, personal message, call, and video call.
6. If you have any questions about the module, please contact the subject teacher.

No part of this module maybe reproduced or transmitted in any form or by any means, electronic
or mechanical including photocopying, recording, or any information storage and retrieval
system, without permission from the author/s of the module and the College of Nursing, Nueva
Ecija University of Science and Technology, Gen. Tinio St. Cabanatuan City, Nueva Ecija.

Health Care Ethics 2

(NCM 108)
 TABLE OF CONTENTS
Unit 1. Theories and Principles of Health Ethics 5
A. Ethical Theories 5
Deontology 5
Teleology 5
Utilitarianism 6
B. Virtue Ethics 7
Virtues Ethics in Nursing 7
Core Values of a Professional Nurse 8
C. Ethical Principles 8
Autonomy 8
Patient’s Rights 8
Filipino Patient’s Bill of Rights 9
Informed Consent 10
Proxy Consent/ Legally Acceptable
Representative Confidentiality 11
Accountability 11
Veracity 11
Fidelity 12
Justice 12
Beneficence 12
Non-maleficence 12
D. Other Relevant Ethical Principles 12
Principle of Double Effect 12
Principle of Legitimate Cooperation 13
Principle of Common Good and Subsidiarity 14
E. Principle of Bioethics 14
Principle of Stewardship and Role of Nurses as Stewards 14
Principle of Totality and its integrity 16
Ethico-moral Responsibility of Nurses in Surgery 16
Sterilization/ Mutilation 17
Presentation of Bodily Issues on Organ Donation 19
Principles of Ordinary and Extraordinary Means 23
Principles of Personalized Sexuality 23

Unit 2. Bioethics and its Application in Various Health Care Situations 25

A. Sexuality and Human Reproduction 25
Human Sexuality and its Moral Evaluation 25
Marriage 25
Fundamental of Marriage 25
Issues on Sex Outside Marriage 26
Issues on Contraception, its Morality, and Ethico-moral
Responsibility of Nurses 26
Issues on Artificial Reproduction, its Morality and Ethico-moral
Responsibility of Nurses 28
Artificial Insemination 28
In-vitro Fertilization 29
Surrogate Motherhood 31
Morality of Abortion, Rape and other Problems Related to
Destruction of Life 32
B. Dignity in Death and Dying 33
Euthanasia 33
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 Inviolability of Human Life 34
Suicide 34
Dysthanasia 35
Orthothanasia 35
Administration of Drugs to the Dying 35
Advance Directives 35
DNR or End of life Care Plan 37
C. Nursing Roles and Responsibility 40
D. Ethical Decision Making Process 41

Unit 3. Bioethics and Research 42

A. Principles of Ethics in Research 42
Nuremberg Code 42
Declaration of Helsinki 42
Belmont Report 43
B. Ethical Issues in Evidenced-Based Practice 44
C. Ethico-moral Obligations of the Nurse in Evidence Based Practices 45
Introduction to Good Clinical Practice Guidelines 45

Unit 4. Ethical Consideration in Leadership and Management 48

A. Moral Decision Making 48
Principle of Moral Discernment 48
Principle of Well-Formed Conscience 48
Strategies of Moral Decision Making Process 48
Ethical Dilemma 49
B. Meaning and Service Value of Medical Care 49
Allocation of Health Resources 49
Issues Involving Access to Care 49

Unit 5. Guidelines and Protocol in Documentation and Health Care Records 51

Unit 6. Ethical Issues Related to Technology in the Delivery of Health Care 53

A. Data Protection and Security 53
Data Privacy Act 2012 (RA 10173 Series of 2012) 53
B. Benefits and Challenges of Technology 55
C. Current Technology Issues And Dilemma 56

Unit 7. Continuing Education Programs on Ethico-Moral Practice in Nursing 58

A. Code of Ethics for Professional Nurses 58
International Council of Nurses Code of Ethics 58
Code of Ethics for Filipino Nurses 59

References 61
Appendices 63
Course Plan Agreement 63
Rubrics 66

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 UNIT 1
THEORIES AND PRINCIPLES OF HEALTH ETHICS

Ethics are moral principles that are concerned with the good of individuals and
the good of society. In this unit, you will learn different ethical theories and principles and
it’s application.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. know the ethical theories;
2. discuss the virtue ethics;
3. explain the different ethical principle; and
4. state the principles of bioethics.

ETHICS AND CODE OF ETHICS

Ethics govern our rights and responsibilities and guide moral decision-making. The
term is derived from the Greek word ethos which can mean custom, habit, character or
disposition.
Throughout the centuries, philosophies, religions and cultures have shaped ethics so
that, throughout the world, different peoples may hold different beliefs. Professional
organizations, such as those governing health care providers, have established ethical
guidelines for all practitioners, regardless of their personal beliefs. Ethics covers the
following dilemmas:
• how to live a good life
• our rights and responsibilities
• the language of right and wrong
• moral decisions - what is good and bad?

A code of ethics takes the emotion out of decision-making. Health care providers
often see patients and their families in difficult situations. Witnessing the pain of others is
difficult. There can be the temptation to "go with one's gut" and make a care decision based
on a feeling rather than on experience, training and a professional code of conduct. When it
comes to patient care, decisions are not always black and white. There can be a lot of gray
areas. A code of ethics helps nurses navigate those gray areas to provide safe and competent
care to their patients.

ETHICAL THEORIES
Ethical theories provide part of the decision-making foundation for decision
making when ethics are in play because these theories represent the viewpoints from which
individuals seek guidance as they make decisions. Broad categories of ethical theory include
deontology, teleology and utilitarianism.

DEONTOLOGY
The deontological class of ethical theories states that people should adhere to their
obligations and duties when engaged in decision making when ethics are in play. This means
that a person will follow his or her obligations to another individual or society because
upholding one’s duty is what is considered ethically correct.
Deontology contains many positive attributes, but it also contains flaws. One flaw is
that there is no rationale or logical basis for deciding an individual’s duties.
A person who adheres to deontological theory will produce very consistent decisions
since they will be based on the individual’s set duties.
For instance, a deontologist will always keep his promises to a friend and will follow
the law.

TELEOLOGY
The teleology is concerned with the consequences of actions which means the basic
standards for our actions being morally right or wrong depends on the good or evil generated.
Teleology or finality is a reason or explanation for something as a function of its end,
purpose, or goal. It is derived from two Greek words: telos (end, goal, purpose)
and logos (reason, explanation).
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 Teleology is a common practice in ethics. Like the definition implies, using teleology
in ethics means you consider and explain actions based on the end result.
For instance, stealing is bad, but a teleological thinker may say, “but in the end, I’m
stealing to feed my family, which is good, so the action is good.” In other words, an action’s
“goodness” is based on the outcome.

Types of Teleological Ethical Theories

1. Ethical Egoism: The ethical egoism is a teleological theory that posits, an action is good
if it produces or is likely to produce results that maximize the person’s self-interest as
defined by him, even at the expense of others. It is based on the notion that it is always
moral to promote one’s own good, but at times avoiding the personal interest could be
a moral action too. This makes the ethical egoism different from the psychological
egoism which holds that people are self-centered and self-motivated and perform
actions only with the intention to maximize their personal interest without helping
others, thereby denying the reality of true altruism (sacrificing one’s personal interest
in the welfare of others).
2. Utilitarianism: The Utilitarianism theory holds that an action is good if it results
in maximum satisfaction for a large number of people who are likely to get affected by
the action. Suppose a manager creates an annual employee vacation schedule after
soliciting the vacation time preferences from all the employees and honor their
preferences, then he would be acting in a way that shall maximize the pleasure of all the
employees.
3. Eudaimonism: Eudaimonism is a teleological theory which posits, that an action is
good if it results in the fulfillment of goals along with the welfare of the human
beings. In other words, the actions are said to be fruitful if it promotes or tends to
promote the fulfillment of goals constitutive of human nature and its happiness.
Suppose manager enforce employee training and knowledge standards at work, which
are natural components of human happiness.

UTILITARIANISM
Utilitarian ethical theories are based on one’s ability to predict the consequences of
an action. To a utilitarian, the choice that yields the greatest benefit to the most people is the
one that is ethically correct.

Two types of utilitarianism

1. Act utilitarianism subscribes precisely to the definition of utilitarianism—a person
performs the acts that benefit the most people, regardless of personal feelings or the
societal constraints such as laws.
2. Rule utilitarianism takes into account the law and is concerned with fairness. A rule
utilitarian seeks to benefit the most people but through the fairest and most just
means available. Therefore, added benefits of rule utilitarianism are that it values
justice and includes beneficence at the same time.

Both act and rule utilitarianism have disadvantages. Although people can use their
life experiences to attempt to predict outcomes, no one can be certain that his/her predictions
will be accurate. Uncertainty can lead to unexpected results making the utilitarian decision
maker appear unethical as time passes, as the choice made did not benefit the most people as
predicted.
Another assumption that a utilitarian decision maker must make concerns his/her
ability to compare the various types of consequences against each other on a similar scale.

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 But, comparing material gains, such as money, against intangible gains, such as happiness, is
very difficult since their qualities differ to such a large extent.
An act utilitarian decision maker is concerned with achieving the maximum good.
Thus, one individual’s rights may be infringed upon in order to benefit a greater number of
people. In other words, act utilitarianism is not always concerned with justice, beneficence or
autonomy for an individual if oppressing the individual leads to the solution that benefits a
majority of people.

VIRTUE ETHICS
Virtue ethics looks at virtue or moral character, rather than at ethical duties and rules,
or the consequences of actions.
Virtue ethics is particularly concerned with the way individuals live their lives, and
less concerned in assessing particular actions.
It develops the idea of good actions by looking at the way virtuous people express
their inner goodness in the things that they do.
To put it very simply, virtue ethics teaches that an action is right if and only if it is an
action that a virtuous person would do in the same circumstances, and that a virtuous person
is someone who has a particularly good character.

VIRTUE ETHICS IN NURSING

A virtue ethics in nursing is concerned with the character of individual nurses and
seeks ways to enable nurses to develop character traits appropriate for actions that enhance
wellbeing.
Virtue ethics can be defined as an approach that emphasizes the character and
disposition of a person, in contrast to an approach that emphasizes duties, rules or principles
(deontology), or one that emphasizes the consequences of actions (consequentialism).
Furthermore, virtue ethics emphasizes being rather than doing. Our being, in other
words, who we truly are, influences our behavior. Thus, virtue ethics in nursing can be viewed
as an approach of ethical deliberation about the moral character and dispositions of nurses
as moral agents that enables them, as virtuous human beings, to fulfil their purpose and
function as professional people. A description of a person’s character and character traits
portrays a way of being instead of acting. Character refers to the structure of one’s personality
with special attention to its ethical components.
A person’s character is a source as well as the product of his/ her value commitments
and actions. Thus, if we consider ethics as a dynamic view between what can be regarded as
right or wrong and revolving around three central concepts, namely “self’, “other” and “the
good”, than virtues, from a virtue ethics perspective, can be seen as the golden thread that
binds them together, and virtue ethics as a framework that can help us understand the virtues
necessary for moral excellence.
Virtue ethics as an approach to moral decision making implies that moral conduct
assumes good characteristics in a nurse as a moral agent. For a nurse to act as a moral agent
that advocates on behalf of a patient during moral decision making in order to demonstrate
excellence and behave well in a sustained manner, requires the development of good
characteristics or virtues.
Virtues enable the nurse to discover the relevant moral aspects of a moral dilemma
and to interpret, judge and evaluate them, and to apply rules, principles and moral theories
wisely to a situation in order to resolve the dilemma.
The intellectual virtues (practical wisdom) and the moral virtues (virtues of
character) are necessary for the realization of various types of moral obligations in nursing,
including dealing with moral dilemmas. Besides the cardinal virtues expounded by ancient
Greek philosophers, such as the virtues of courage, temperance, prudence and justice. The
reflection, empathy, fairness, honesty, dedication, responsibility and respect for people as
virtues for the nurse as a moral agent. In addition, the following five virtues as applicable to
health professionals: trustworthiness, integrity, discernment, compassion and
conscientiousness.
Decision-making about moral issues in health care demands that the health
practitioner or the nurse exercise rational control over emotions. The virtues are necessary
for rational control, because it takes a so-called mean position between the vices or excess
and deficiency.

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 Self-control in situations of moral difficulty is possible if the nurse possesses virtues.
In this manner, a nurse who demonstrates these virtues in a balanced form can be seen as a
virtuous nurse. Where virtues reflect the characteristic in itself, virtuousness refers to the
quality of that virtue, especially when demonstrated in character. Virtuous nurses are ethical
nurses, because they have a deep desire to behave well, irrespective of the circumstances.

CORE VALUES OF A PROFESSIONAL NURSE

Nursing is a caring profession. Caring encompasses empathy for and connection with
people. Caring is best demonstrated by a nurse's ability to embody the core values of
professional nursing.
The nurse assumes the caring role in the promotion of health, prevention of diseases,
restoration of health, and alleviation of suffering and, when recovery is not possible, in
assisting patients towards peaceful death. The nurse collaborates with other members of the
health team like physician, medical technologist, physical and occupational therapist,
dietician and nutritionist, etc. and other sectors to achieve quality healthcare. Moreover, the
nurse works with the individuals, families, population groups, community and society in
ensuring active participation in the delivery of holistic healthcare.
Within the context of the Philippine society, nursing education with caring as its
foundation, subscribes to the following core values which are vital components in the
development of a professional nurse:
1.1 Love of God
1.2 Caring as the core of nursing
a. Compassion
b. Competence
c. Confidence
d. Conscience
e. Commitment (commitment to a culture of excellence, discipline, integrity and
professionalism)
1.3 Love of People
a. Respect for the dignity of each person regardless of creed, color, gender and
political affiliation.
1.4 Love of Country
a. Patriotism (Civic duty, social responsibility and good governance)
b. Preservation and enrichment of the environment and culture heritage

The caring professional nurse integrates these values in clinical practice and carefully
integrating these values ensures that the legacy of caring behavior embodied by nurses is
strengthened for the future nursing workforce.

ETHICAL PRINCIPLES
Nurses are held to seven ethical principles: autonomy, accountability, veracity,
fidelity, justice, beneficence and non-maleficence.
1. AUTONOMY
Self-determination that is free from both controlling interferences by others and
personal limitations preventing meaningful choice (such as inadequate
understanding or faulty reasoning). Having the capacity to act with autonomy does
not guarantee that a person will actually do so with full understanding and without
external controlling influences. Autonomy requires the patient to have autonomy of
thought, intention and action when making decisions regarding health care
procedures.
Therefore, the decision making process must be free of coercion or coaxing. In order
for a patient to make a fully informed decision, she/he must understand all risks and
benefits of the procedure and the likelihood of success.

Patient’s Rights
1. Right to medical treatment
• The patient has the right to receive medical and/ or surgical advice and
treatment which fully meet the currently accepted standards of quality care.
• The currently accepted standards are those adopted by the Department of
Health, Philippine Pediatric Society and other Specialty Societies as applicable

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 in our hospital setting, and in the light of accepted contemporary medical
practice.
• The patient shall be treated with utmost care, consideration, respect and
dignity without discrimination of any kind.
2. Right to information
• The right to know the identity and professional status of the individuals
involved in the care, diagnosis and/or treatment of the patient.
• The right to information about what kind/ type of medical/ surgical services
are available, and what are the charges/costs are involved.
• The right to be given a clear description of the patient’s medical condition,
with probable/definitive diagnosis, prognosis (i.e., an opinion as to the likely
future course of any illness), and of the treatment options considered, the
risks and complications that may be encountered.
• The description given to the patient is within scope and level of
understanding.
• The right to know the names of any medication or procedures to be
prescribed, its actions, and potential side-effects given the patient’s condition.
• The right to access medical information which relates to the patient’s
condition and treatment.
3. Right to choices
• The right to accept or refuse any procedure/medication, investigation or
treatment, and to be informed of the likely consequences of doing so.
• The right to second medical and/ or surgical opinion.
• The right to refuse to take part in medical research programs.
• The right to choose doctor and or health care personnel in accordance to
medical/surgical needs (applicable to private patients).
4. Right to privacy
• The right to have privacy, dignity, religious and cultural beliefs respected.
• The right to have information relating to medical condition be kept
confidential.
• The right of a pediatric patient to the company of a parent or guardian.
5. Right to complaint
• The right to make a complaint through proper channels provided for by the
hospital authority, and to have complaint dealt with promptly and fairly.
6. Right to health education
• Patient’s shall have the right to seek and obtain health education or advice
with regards to promotive, preventive and curative medical, surgical and
rehabilitative to maintain or regain good health and healthy life.
7. Right to a healthy and safe environment
• The patient has the right to healthy and safe environment that is conductive
to good health supportive of the rest and recuperation. Reasonable safety
measures should be assured within the hospital facility.

Filipino Patients’ Bill of Rights

1. The patient has the right to considerate & respectful care, irrespective of socio-
economic status.
2. The patient has the right to obtain from his physician complete current
information concerning his diagnosis, treatment and prognosis in terms the
patient can reasonably be expected to understand. When it is not medically
advisable to give such information to the patient. The information should be
made available to an appropriate person in his behalf. He has the right to know
by name or in person, the medical team responsible in coordinating his care.
3. The patient has the right to receive from his physician information necessary to
give informed consent prior to start of any procedure and or treatment. Except
in emergencies, such information for informed consent should include but not
necessarily limited to the specific procedure and or treatment, the medically
significant risks involved, and the probable duration of incapacitation. Where
medically significant alternatives for care or treatment exist, or when the patient
requests information concerning medical alternatives, the patient has the right

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 for such information. The patient has also the right to know the name of the
person responsible for the procedure and/or treatment.
4. The patient has the right to refuse treatment / life-giving measures, to the extent
permitted by law and to be informed of the medical consequence of his action.
5. The patient has the right to every consideration of his privacy concerning his own
medical care program. Case discussion, consultation, examination and treatment
are confidential and should be conducted discreetly. Those not directly involved
in his care must have the permission of the patient to be present.
6. The patient has the right to expect that all communication and records pertaining
to his care should be treated as confidential.
7. The patient has the right that within its capacity, a hospital must make
reasonable response to the request of patient for services. The hospital must
provide evaluation, service and or referral as indicated by the urgency of care.
When medically permissible a patient may be transferred to another facility only
after he has received complete information concerning the needs and
alternatives to such transfer. The institution to which the patient is to be
transferred must first have accepted the patient for transfer.
8. The patient has the right to obtain information as to any relationship of the
hospital to other health care and to other health care and educational institutions
in so far as his care is concerned. The patient has the right to obtain as to the
existence of any professional relationship among individuals, by name who are
treating him.
9. The patient has the right to be advised if the hospital proposes to engage on or
perform human experimentation affecting his care or treatment. The patient has
the right to refuse or participate in such research projects.
10. The patient has the right to expect reasonable continuity of care; he has the right
to know in advance what appointment times the physicians are available and
where. The patient has the right to expect that the hospital will provide a
mechanism whereby he is informed by his physician or a delegate of the
physician of the patient's continuing health care requirements following
discharge.
11. The patient has the right to examine and receive an explanation of his bill
regardless of source of payment.
12. The patient has the right to know what hospital rules and regulations apply to his
conduct as a patient.

Informed Consent
Doctors will give you information about a particular treatment or test in
order for you to decide whether or not you wish to undergo a treatment or test. This
process of understanding the risks and benefits of treatment is known as informed
consent.
Informed consent is based on the moral and legal premise of patient
autonomy: You as the patient have the right to make decisions about your own
health and medical conditions.
You must give your voluntary, informed consent for treatment and for most
medical tests and procedures. The legal term for failing to obtain informed consent
before performing a test or procedure on a patient is called battery (a form of
assault). For many types of interactions (for example, a physical exam with your
doctor), implied consent is assumed. For more invasive tests or for those tests or
treatments with significant risks or alternatives, you will be asked to give explicit
(written) consent.
Under certain circumstances, there are exceptions to the informed consent
rule. The most common exceptions are these:
• An emergency in which medical care is needed immediately to prevent serious
or irreversible harm
• Incompetence in which someone is unable to give permission (or to refuse
permission) for testing or treatment

Components of Informed Consent

1. You must have the capacity (or ability) to make the decision.

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 2. The medical provider must disclose information on the treatment, test, or
procedure in question, including the expected benefits and risks, and the
likelihood (or probability) that the benefits and risks will occur.
3. You must comprehend the relevant information.
4. You must voluntarily grant consent, without coercion or duress.
Essential Elements of Informed Consent
1. Confidentiality
2. New information
3. Voluntary participation
4. Person/s to contact for study information
5. Rights of subject, if study related injury
6. Reasons for termination
7. Duration of study
8. Number of subjects

Proxy Consent/ Legally Acceptable Representative

Proxy consent is the process by which people with the legal right to consent
to medical treatment for themselves or for a minor or a ward delegate that right to
another person. There are three fundamental constraints on this delegation:
a. The person making the delegation must have the right to consent.
b. The person must be legally and medically competent to delegate the right to
consent.
c. The right to consent must be delegated to a legally and medically competent
adult.
(an aged person in a coma, a two-month old child).

For the ethical and legal use of proxy consent, two conditions must be present:
a. The patient or research subject cannot offer informed consent
b. The person offering the consent ought to determine what the incompetent
person would have decided where he or she able to make the ethical decision.
This second condition is difficult to ascertain and may be subject to dispute.

Two Types of Proxy Consent for Adults

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

Decisions of proxy consent should be made in view of the good of the

individual patient, not for the higher good of society, nor for a class good, because
this would amount to manipulation of the person.

2. ACCOUNTABILITY
Accountability means taking responsibility for one's actions. Nurses must accept the
professional and personal consequences associated with the decisions they make
regarding patient care.

3. VERACITY
Veracity is the principle of truth telling, and it is grounded in respect for persons and
the concept of autonomy. In order for a person to make fully rational choices, he or
she must have the information relevant to his or her decision. Moreover, this
information must be as clear and understandable as possible.

Truth telling is violated in at least two ways.

a. By the act of lying, or the deliberate exchange of erroneous information.
However, the principle of veracity is also violated by omission, the deliberate
withholding of all or portions of the truth.

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 b. By the deliberate cloaking of information in jargon or language that fails to
convey information in a way that can be understood by the recipient or that
intentionally misleads the recipient.
In the health care context, there are two broad applications of veracity.
a. The first relates to patient care and such issues as informed consent. Patients
and families rely upon physicians and other caregivers for the information they
need to make informed choices about their care. They also expect to be told the
truth about their care, including any errors or untoward events. Alternatively,
some patients or patients’ families do not want to be told the truth, placing the
physician, nurse or other health care professional in a situation in which his or
her duty to obtain informed consent is compromised by the wishes of the
patient or family.
b. The second application relates more generally to professional ethics and the
basic expectation that we are honest in our professional interactions. This
particular application of veracity is apparent in a broad range of issues
including professional relationships, documentation standards, billing
practices, risk management, peer review, community relations, and regulatory
reporting, and compliance.

4. FIDELITY
Fidelity in nursing means that nurses must be faithful to the promises they made as
professionals to provide competent, quality care to their patients.

5. JUSTICE
The idea that the burdens and benefits of new or experimental treatments must be
distributed equally among all groups in society. Requires that procedures uphold the
spirit of existing laws and are fair to all players involved. Reproductive technologies
create ethical dilemmas because treatment is not equally available to all people.
The health care provider must consider four main areas when evaluating justice:
a. fair distribution of scarce resources
b. competing needs
c. rights and obligations
d. potential conflicts with established legislation

6. BENEFICENCE
Beneficence requires that the procedure be provided with the intent of doing good
for the patient involved. Demands that health care providers develop and maintain
skills and knowledge, continually update training, consider individual circumstances
of all patients, and strive for net benefit.

7. NON-MALEFICENCE
Non-maleficence requires that a procedure does not harm the patient involved or
others in society. Infertility specialists operate under the assumption that they are
doing no harm or at least minimizing harm by pursuing the greater good. However,
because assistive reproductive technologies have limited success rates uncertain
overall outcomes, the emotional state of the patient may be impacted negatively. In
some cases, it is difficult for doctors to successfully apply the do no harm principle.

OTHER RELEVANT ETHICAL PRINCIPLES

PRINCIPLE OF DOUBLE EFFECT
The principle of double effect is often invoked to explain the permissibility of an
action that causes a serious harm, such as the death of a human being, as a side effect of
promoting some good end. According to the principle of double effect, sometimes it is
permissible to cause a harm as a side effect (or “double effect”) of bringing about a good result
even though it would not be permissible to cause such a harm as a means to bringing about
the same good end.
Thomas Aquinas is credited with introducing the principle of double effect in his
discussion of the permissibility of self-defense in the Summa Theologica. Killing one’s
assailant is justified, he argues, provided one does not intend to kill him.

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 Aquinas observes that “Nothing hinders one act from having two effects, only one of
which is intended, while the other is beside the intention. Accordingly, the act of self-defense
may have two effects: one, the saving of one’s life; the other, the slaying of the aggressor.”
As Aquinas’s discussion continues, a justification is provided that rests on
characterizing the defensive action as a means to a goal that is justified: “Therefore, this act,
since one’s intention is to save one’s own life, is not unlawful, seeing that it is natural to
everything to keep itself in being as far as possible.”

Four Conditions for the Application of the Principle of Double Effect

1. The act itself must be morally good or at least indifferent.
2. The agent may not positively will the bad effect but may permit it. If he could attain
the good effect without the bad effect he should do so. The bad effect is sometimes
said to be indirectly voluntary.
3. The good effect must flow from the action at least as immediately (in the order of
causality, though not necessarily in the order of time) as the bad effect. In other
words, the good effect must be produced directly by the action, not by the bad effect.
Otherwise the agent would be using a bad means to a good end, which is never
allowed.
4. The good effect must be sufficiently desirable to compensate for the allowing of the
bad effect.

The Principle of Double Effect Will Be Invoked of the Following Reasons

1. When the act by its nature is evil.
2. When the good effect directly proceeds from the evil effect and not from the act itself.
3. When there is no sufficient reason for the performance of an act with two effects, one-
good, the other-evil.
4. When the motive of the agent is not honest.

Example of a situation, to kill a person whom you know to be plotting to kill you would
be impermissible because it would be a case of intentional killing; however, to strike in self-
defense against an aggressor is permissible, even if one foresees that the blow by which one
defends oneself will be fatal.

PRINCIPLE OF LEGITIMATE COOPERATION

The principle of legitimate cooperation portrays the principle of the double effect in
a scenario in which more than one person participates in the actions being evaluated.
Cooperation comes from the Latin word cum which means “with” and operari which
means “to work”. Cooperation is working with another in the performance of an action.

Criteria to Judge Principle of Legitimate Cooperation

• The moral object of your action is good and you are operating out of good intentions.
• The evil is only tolerated as a side effect of your action
• Your cooperation is only material cooperation, not formal
• Your cooperation is remote rather than proximate so it causes minimal evil effects
• Your action does not cause scandal

Various Degrees of Cooperation

The degrees of cooperation may vary according to the gravity or essentiality of the
shared act in the performance of an evil action.
1. Formal and Material Cooperation
Formal Cooperation- consists of an explicit intention and willingness for the evil act.
The one formally cooperating categorically wills and intends the evil action.
Example: A medical director who wills and intends the evil act of contraception by
means of hysterectomy at the request of an interested party, by arranging with the
members of the O.R. team as to the operation and its schedule.
Material Cooperation- consists of an act other than the evil act itself but facilitates
and contributes to its achievement. The one materially cooperating may provide
means apart from the evil act itself which is used to carry out the performance of an
evil act.

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 2. Direct and Indirect Cooperation
Direct Cooperation- consists of direct participation in the performance of an evil act.
The one directly cooperating gets involved by openly and straightforwardly taking
part in the practice of an evil action.
Indirect Cooperation- consists of an act that is not intimately connected with the
performance of an evil act as in formal and direct cooperation but whose effect may
have an indirect bearing upon it.
3. Proximate and Remote
Proximate Cooperation- consists of an act that is intimately linked with the
performance of an evil action due to its close bearing.
Remote Cooperation- consists of an act with a distant bearing upon or connection
with the execution of an evil act.

Moral Rules Governing Cooperation

a. No one should formally and directly cooperate in the performance of an evil action.
b. If a reason sufficiently grave exists, material cooperation in the performance of an evil
action may be morally excused.
c. If the material cooperation is proximate, a reason sufficiently graver should exist so
as to be morally excused without which evil is incurred.

PRINCIPLE OF COMMON GOOD

The principle of common good as “the sum total of social conditions which allows
people, either as groups or as individuals, to reach their fulfilment more fully and more
easily.” It is about the progress of persons.
A society that wishes and intends to remain at the service of the human being at every
level is a society that has the common good – the good of all people and of the whole person as
its primary goal.
We must be interested in the good of all, even of people nobody thinks about because
they have no voice and no power. The goods of the earth are there for everyone. The common
good consists not only of the material or external good of all human beings; it also includes
the comprehensive good of the human being, including even the spiritual good.
The common good of society is not an end in itself. It is only part of a bigger picture,
the ultimate end of which is God. The common good, as a mere materialistic socio-economic
ideal, would count for little without any transcendental goal.

PRINCIPLE OF SUBSIDIARITY
The subsidiarity principle is intended to ensure that decisions are taken as closely as
possible to the citizen and that constant checks are made as to whether action at Community
level is justified in the light of the possibilities available at national, regional or local level.
Principle of subsidiarity often considered a result of the principle of the common
good, subsidiarity requires those in positions of authority to recognize that individuals have
a right to participate in decisions that directly affect them, in accord with their dignity and
with their responsibility to the common good.
Decisions should be made at the most appropriate level in a society or organization,
that is, one should not withdraw those decisions or choices that rightly belong to the
individuals or smaller groups and assign them to a higher authority.

PRINCIPLE OF BIOETHICS
PRINCIPLE OF STEWARDSHIP AND ROLE OF NURSES AS STEWARDS
Stewardship is defined as governance, which refers to the wide range of functions
carried out by the steward as they seek to achieve national health policy objectives. In
addition, stewards help to improve overall levels of population health. The objectives are
likely to be framed in terms of equity, coverage, access, quality, and patients' rights.
The traditional definition of stewardship in the Book of Genesis, God appoints
humanity as the steward of all creation.
State-orientated definitions of stewardship is that the function of government is
responsible for the welfare and interests of the population, especially the trust and legitimacy
by the general public.
In 2001, the Institute of Medicine proposed six aims to improve the health care
system for the 21st century. The recommendations were that health care should be:

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 1. safe
2. effective
3. patient-centered
4. timely
5. efficient
6. equitable

These recommendations have been assumed by the health care community. This lead
to leadership opportunities for nursing that initiate dialogue with colleagues to use
knowledge base ideas. This allows nursing leaders for transformational structures, programs
and systems to meet the six recommendations of the Institute of Medicine (2001).
It can therefore be assumed that nursing managers/leaders in all disciplines of
nursing will be the safety officers and stewards for their organizations and institutions. To
achieve the six aims, nurse leaders will have to engage in developing, assessing and refining
innovative and fresh modes of health care delivery.

Personal Stewardship
To meet the domains of stewardship in health care and the nursing profession, it is
crucial that nurse leaders engage with the development of self. Succession planning to
develop and nurture a new generation of transformational nurse leaders may be the only way
to achieve this. To meet the concept of lifelong learning, nurse leaders or stewards will need
to use of mentors and personal coaches to assist them in refining skills and improving
competencies. Healthy nurse leader stewards will thus become visible and sound role models
within their institutions to maintain the balance between self and professional fulfilment.

Social Stewardship
Another prospect of stewardship is to revive a sense of social purpose among public
sectors of management, together with assisting to restore a sense of trust and legitimacy to
the role of the state.
This ‘attractiveness’ of a stewardship approach may be a realistic (and achievable)
possibility to channel fresh and emerging systems of integrated care in more socially
responsible ways.
We are social beings, committed to build a just, free and fraternal world; we have
rights and duties; the world has been created by God for all and, therefore, all humans have
the right to a share in the goods of the earth.

Ecological Stewardship
Through our work, we have to improve the world, but not destroy it, nor exploit it.
Protect against pollution, deforestation, chemical dumping and the exploitation of the
environment, we have to respect biodiversity.
As humans, we are part of the universe and, therefore, we have to be ecologically
aware and responsible. “Moral garbage is the cause of ecological garbage”
Transitioning a healthcare facility from a presumably chemical-laden, waste-
generating environment to a finely tuned green operation
Green operation equates to “being good stewards to the environment, our people and
our resources,” says Robert Biggio, senior vice president of facilities and support services of
BMC. “It is a holistic approach to our work and how we operate, and is incorporated into the
fabric of our culture.”
Green operation has an implication in energy conservation, food sourcing and
integrated waste program.

Biomedical Stewardship
Health care providers are obliged to respect and improve human life and nature; they
must not play God; they must accept death not as a medical failure but as part of human life.
Above all, they must respect the right to life, which is the basic human right.

Stewardship of Nursing
The leadership potential of stewardship in nursing requires new models of delivery
of care, and we need to address the ever-changing nature of the work of a nurse. With
evolving new roles in the nursing profession, collaboration with nursing research colleagues

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 will be required to develop mechanisms of evaluation and assessment which further refine
evidence that supports the essential and exclusive contributions of the professional nurse in
outcomes of care and prevention.
Development and enhancement of the evidence in research call for nursing stewards
who will embark on such issues to design new financial models in order to constantly build
the business side of nursing care delivery models. Such leadership will become synergistic
with the work in the area of stewardship of the health care system.
Future nurse leaders or stewards will be directly centered on working with nurse
practitioners and nurse educators to transform the practice environments in which they
work. The intended outcome is to make practice environments more positive, healthy and
engaging. Areas for dialogue may be within:
1. patient-population centeredness
2. safety for patients and health care personnel
3. the needs of an ageing workforce
4. increased autonomy for advanced nurse practitioners
5. increased respect for the contributions made by professional nurses
6. clarification of the caring work of the nurse, and
7. enhancement of the collaborative practice of the multidisciplinary health care team.

Lastly, but perhaps most importantly, an opportunity for nursing stewardship lies in
the regulatory and accreditation aspects of the profession. Nurse leaders or stewards are
finding themselves collaborating with regulatory boards to improve on standards of practice,
certification and accreditation, thus ensuring that standards and regulations support the
nurse of the future and new models of care delivery, and remain true to a patient/population-
centered health care system.
Another aspect is for nurse leaders or stewards to influence decision-making at the
point of service. An ‘invigorating’ nurse leader or steward is urgently needed. Nurses should
create health care environments that uphold value-based nursing practice by acknowledging
that who one is – one’s moral character – is essential for leadership. Nurse leaders or
stewards need to engage with how this is to be done, utilizing character, dialogue and shared
meanings and values.
The future of nursing is rapidly changing. Things are somewhat chaotic at times, but
the opportunities for stewardship are many and varied. We are ideally suited to serve as
nurse leaders or stewards in all aspects of health care.

PRINCIPLE OF TOTALITY AND ITS INTEGRITY

This principle states that all decisions in medical ethics must prioritize the good of
the entire person, including physical, psychological and spiritual factors. According to the
philosopher Thomas Aquinas, all of the organs and other parts of the body exist for the sake
of the whole person. Because the purpose of the part is to serve the whole, any action that
damages a part of the body or prevents it from fulfilling its purpose violates the natural order
and is morally wrong.
The human body is an integral part of the human person and is therefore worthy of
human dignity. Human body must be kept whole. No body part should be removed, mangled
or debilitated unless doing so is necessary for the health of a more essential body part or the
body of a whole. However, a single part may be sacrificed if the loss is necessary for the good
of the whole person. Also, an unessential or redundant body part may be removed for the
good of another person.

Applications
• The amputation of a gangrenous limb, because the person could die if the gangrene
spread.
• Surgeries that needlessly remove body parts or organs are immoral
• Torture is a moral evil because it seeks to disintegrate the body and the spirit

Ethico-Moral Responsibility of Nurses in Surgery

A surgical nurse, more correctly called a perioperative nurse, is a vital part of the
surgical team. The registered nurse in the operating room may perform tasks in the
preoperative, intraoperative or postoperative phase of surgery.

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 Perioperative nurses work with other members of the surgical team, the patient and
family members to ensure the surgery is safe and effective.
Registered Nurse has ethical and moral responsibility to represent the patient's
interests, show humility, respect and protect patient autonomy and preserve patient dignity.
They have responsibility to themselves, their profession, and their patients to maintain the
highest ethical principles. It is important to advocate for patient care, patient rights, and
ethical consideration of practice.

Ethico-Moral Aspects in Nursing

• Autonomy - the right/freedom to decide, the patient has the right to refuse despite
the explanation of the nurse. Example: surgery, or any procedure.
• Non-maleficence - the duty not to harm/cause harm or inflict harm to others (harm
maybe physical, financial or social).

Responsibility of Nurses in Surgery

Duties in the Operating Room
1. Perioperative nurses assess patients prior to surgery and complete documentation
that is used by other members of the team.
2. They perform patient education and provide emotional support to the patient and
family.
3. During and after the operation, the perioperative nurse may perform tasks such as
taking the patient’s pulse and blood pressure, emptying suction equipment or
removing dirty linens.
4. Perioperative nurses must know how to operate all equipment in the operating
rooms and where all supplies and equipment are stored.
5. Helping to transport a patient to surgery or to the post-anesthesia recovery area.
6. The perioperative nurse may administer medications to help sedate the patient prior
to a procedure, order supplies or instruments and assure that equipment is properly
cleaned and stored.
7. The perioperative nurse may also be responsible for sterilization of instruments in
some organizations.

The Scrub Nurse

• Perioperative nurses may work as either scrub or circulating nurses.
• While the physicians perform the surgery and manage the anesthesia, the scrub nurse
selects and passes instruments, tools and supplies used during the operation.
• Since infection is one of the biggest risks of any surgery, she watches carefully for
possible contamination to assure sterile technique is maintained at all times.
• The scrub nurse will assure that all items on the surgical trays are counted before and
after the operation so the patient doesn't wind up with something extra inside him.

The Circulating Nurse

• The circulating nurse is the extra pair of hands for each of the other health-care
professionals in the room.
• She will assist the surgeon, assistant and scrub nurse in donning their sterile clothing
or protective equipment.
• She may bring more dressings or pick up an instrument that has been dropped.
• If the anesthesiologist needs his cart restocked or an additional vial of medication, the
circulating nurse will perform those tasks.
• The circulating nurse is also the room monitor.
• She keeps an eye on all activity to keep the patient and the surgical team safe.

Sterilization
In Bioethics, sterilization is a surgical technique leaving a male or female unable to
reproduce. It is a method of birth control.

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 Common Sterilization Methods
In Males
• Vasectomy is when the vas deferens (the tubes which connect the testicles to the
prostate) are cut and closed. This prevents sperm produced in the testicles to enter
the ejaculated semen (which is mostly produced in the seminal vesicles and prostate).
• Castration (also known as orchiectomy) is any action, surgical, chemical, or
otherwise, by which an individual loses use of the testicles: the male gonad.
In Females
• Tubal ligation which is known popularly as "having one's tubes tied". The Fallopian
tubes, which allow the sperm to fertilize the ovum and would carry the fertilized
ovum to the uterus, are closed. This generally involves a general anesthetic and a
laparotomy or laparoscopic approach to cut, clip or cauterize the fallopian tubes.
• Hysterectomy is when the uterus is surgically removed, permanently preventing
pregnancy and some diseases, such as uterine cancer.

Type of Sterilization
1. Direct or Indirect
a. Direct Sterilization refers to a type of sterilization that is directly willed either as
an end or a means. (Ex. Vasectomy or ligation).
b. Indirect Sterilization refers to a type of sterilization that is not wilfully employed
either as an end or a means. (Ex. Surgical removal of the ovaries or testicles sick
with cancer).
2. Temporary or Permanent
a. Temporary Sterilization refers to a type of sterilization that brings about
provisionary and reversible sterility (Ex. Oral and hormonal contraceptives)
b. Permanent Sterilization refers to a type of sterilization that creates irreversible
and lasting sterility. (Ex. Hysterectomy, oophorectomy, salpingectomy)
3. Medical or Surgical
a. Medical sterilization refers to a type of sterilization that produces medically-
sterilizing effect. (as temporarily like: Pills for women who doesn’t want to get
pregnant).
b. Surgical sterilization refers to a surgical procedure that sterilizes or renders one
unable to reproduce.
4. Punitive or Eugenic
a. Punitive Sterilization refers to a type of sterilization which is a form of penalty or
punishment usually ascribed to sex-related crimes. It may be permanent, surgical
form of sterilization
b. Eugenic Sterilization- refers to a type of sterilization that is intended for one whose
genetic or eugenic make up is seen to produce defective offspring.

Moral Issues on Sterilization

The Catholic church has strongly condemned all artificial methods of Contraception
(a position also held by most Protestant churches up to 1930, when the Anglican church voted
for change). This includes the contraceptive pill, condoms and also medical procedures such
as vasectomy and ligation. In fact, the church regards contraception as mortally sinful. The
official position is stated in the papal encyclical Humanae Vitae, issued by Pope Paul VI in
1968.

Mutilation
Mutilation is an act or physical injury that degrades the appearance or function of the
(human) body, usually without causing death.

Types of Mutilation
1. Major Mutilation
Refers to the procedure that destroys the functional integrity of the human body so
that it becomes incapacitated of its natural function. It may usually be done by means
of surgical procedures. Ex. Radical Mastectomy, Appendectomy, Herniorrhaphy,
Caesarean Section, Craniotomy.

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 2. Minor Mutilation
Refers to the procedure that diminishes but does not destroy the functional integrity
of the human body. Ex. Biopsies (mole, warts), excision of ingrown.

Moral Issues on Mutilation

The principle of totality assumes that parts exist for the whole. The good of the part
is subordinated to the good of the whole; the whole is the determining factor for the part and
can dispose of its own interest.
Aristotle puts it briefly as totum quam parte, prius esse necesse est. The main notions
on which the principle grounds itself are “the whole, the part, and their mutual relationships.”
Regarding the part, Aristotle explains it in the following manner: A part denotes any
portion of a major into which it can “be divided, for that which is taken from a quantum qua
quantum” remains always a part of it.
Even though the scholastics unanimously accepted the justification of mutilation by
Thomas Aquinas, there are differences in the application of these principles to particular
issues.
• A diseased part is harmful to the whole body.
• Another question pertains to “the predicament of a person who was ordered by a
tyrant to cut off his own hand.”
• Another case is “the necessity to amputate an extremity.”
• Concerning the morality of mutilation, traditional moral theologians base their
arguments that man/woman has only a limited right over his/her body.
• More precisely, mutilation on the ground of the principle of totality is justified only
by the physical good of the person.

When the health of the body or life of the person is in danger and there is no other
means by which health can be restores or life can be saved except through mutilation, the
right reason dictates that mutilation can be done. Restoration of health or preservation of
life can be a sufficient reason for the performance of mutilation.

Presentation of Bodily Issues on Organ Donation

Organ donation is the process when a person allows an organ of their own to be
removed and transplanted to another person, legally, either by consent while the donor is
alive or dead with the assent of the next of kin.
Donation may be for research or, more commonly, healthy transplantable organs and
tissues may be donated to be transplanted into another person.

Common transplantations include:

• kidneys
• Heart
• Liver
• Pancreas
• Intestines
• Lungs
• Bones
• bone marrow
• Skin
• Corneas
REPUBLIC ACT NO. 7170
An act authorizing the legacy or donation of all or part of a human body after death for
specified purposes

Be it enacted by the Senate and House of Representatives of the Philippines in Congress

assembled:
SEC. 1. Title. – This Act shall be known as the “Organ Donation Act of 1991.”
SEC. 2. Definition of Terms. – As used in this Act the following terms shall mean:
a) “Organ Bank Storage Facility” – a facility licensed, accredited or approved under the law
for storage of human bodies or parts thereof.
b) “Decedent” – a deceased individual, and includes a still-born infant or fetus.

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 c) “Testator” – an individual who makes a legacy of all or part of his body.
d) “Donor” – an individual authorized under this Act to donate all or part of the body of a
decedent.
e) “Hospital” – a hospital licensed, accredited or approved under the law, and includes a
hospital operated by the Government.
f) “Part” – includes transplantable organs, tissues, eyes, bones, arteries, blood, other fluids
and other portions of the human body.
g) “Person” – an individual, corporation, estate, trust, partnership, association, the
Government or any of its subdivisions, agencies or instrumentalities, including
government-owned or -controlled corporations; or any other legal entity.
h) “Physician” or “Surgeon” – a physician or surgeon licensed or authorized to practice
medicine under the laws of the Republic of the Philippines.
i) “Immediate Family” of the decedent – the persons enumerated in Section 4(a) of this Act.
j) “Death” – the irreversible cessation of circulatory and respiratory functions or the
irreversible cessation of all functions of the entire brain, including the brain stem. A
person shall be medically and legally dead if either:
1) In the opinion of the attending physician, based on the acceptable standards of medical
practice, there is an absence of natural respiratory and cardiac functions and,
attempts at resuscitation would not be successful in restoring those functions. In this
case, death shall be deemed to have occurred at the time these functions ceased; or
2) In the opinion of the consulting physician, concurred in by the attending physician, that
on the basis of acceptable standards of medical practice, there is an irreversible
cessation of all brain functions; and considering the absence of such functions, further
attempts at resuscitation or continued supportive maintenance would not be
successful in restoring such natural functions. In this case, death shall be deemed to
have occurred at the time when these conditions first appeared.
The death of the person shall be determined in accordance with the acceptable
standards of medical practice and shall be diagnosed separately by the attending
physician and another consulting physician, both of whom must be appropriately
qualified and suitably experienced in the care of such patients. The death shall be
recorded in the patient’s medical record.
SEC. 3. Person Who May Execute A Legacy. – Any individual, at least eighteen (18) years of age
and of sound mind, may give by way of legacy, to take effect after his death, all or part of his
body for any purpose specified in Section 6 hereof.
SEC. 4. Person Who May Execute a Donation. –
a) Any of the following persons, in the order of priority stated hereunder, in the absence of
actual notice of contrary intentions by the decedent or actual notice of opposition by a
member of the immediate family of the decedent, may donate all or any part of the
decedent’s body for any purpose specified in Section 6 hereof:
1) Spouse;
2) Son or daughter of legal age;
3) Either parent;
4) Brother or sister of legal age; or
5) Guardian over the person of the decedent at the time of his death.
b) The persons authorized by sub-section (a) of this section may make the donation after
or immediately before death.
SEC. 5. Examination of Human Body or Part Thereof. – A legacy or donation of all or part of a
human body authorizes any examination necessary to assure medical acceptability of the
legacy or donation for the purpose(s) intended.
For purposes of this Act, an autopsy shall be conducted on the cadaver of accident, trauma,
or other medico-legal cases immediately after the pronouncement of death, to determine
qualified and healthy human organs for transplantation and/or in furtherance of medical
science.
SEC. 6. Persons Who May Become Legatees or Donees. – The following persons may become
legatees or donees of human bodies or parts thereof for any of the purposes stated
hereunder:
a) Any hospital, physician or surgeon – For medical or dental education, research,
advancement of medical or dental science, therapy or transplantation;
b) Any accredited medical or dental school, college or university – For education, research,
advancement of medical or dental science, or therapy;

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 c) Any organ bank storage facility – For medical or dental education, research, therapy, or
transplantation; and
d) Any specified individual – For therapy or transplantation needed by him.
SEC. 7. Duty of Hospitals. – A hospital authorized to receive organ donations or to conduct
transplantation shall train qualified personnel and their staff to handle the task of
introducing the organ donation program in a humane and delicate manner to the relatives
of the donor-decedent enumerated in Section 4 hereof. The hospital shall accomplish the
necessary form or document as proof of compliance with the above requirement.
SEC. 8. Manner of Executing a Legacy. –
a) Legacy of all or part of the human body under Section 3 hereof may be made by will. The
legacy becomes effective upon the death of the testator without waiting for probate of
the will. If the will is not probated, or if it is declared invalid for testamentary purposes,
the legacy, to the extent that it was executed in good faith, is nevertheless valid and
effective.
b) A legacy of all or part of the human body under Section 3 hereof may also be made in any
document other than a will. The legacy becomes effective upon death of the testator and
shall be respected by and binding upon his executor or administrator, heirs, assigns,
successors-in-interest and all members of the family. The document, which may be a
card or any paper designed to be carried on a person, must be signed by the testator in
the presence of two witnesses who must sign the document in his presence. If the
testator cannot sign, the document may be signed for him at his discretion and in his
presence, in the presence of two witnesses who must, likewise, sign the document in the
presence of the testator. Delivery of the document of legacy during the testator’s lifetime
is not necessary to make the legacy valid.
c) The legacy may be made to a specified legatee or without specifying a legatee. If the
legacy is made to a specified legatee who is not available at the time and place of the
testator’s death, the attending physician or surgeon, in the absence of any expressed
indication that the testator desired otherwise, may accept the legacy as legatee. If the
legacy does not specify a legatee, the legacy may be accepted by the attending physician
or surgeon as legatee upon or following the testator’s death. The physician who becomes
a legatee under this subsection shall not participate in the procedures for removing or
transplanting a part or parts of the body of the decedent.
d) The testator may designate in his will, card or other document, the surgeon or physician
who will carry out the appropriate procedures. In the absence of a designation, or if the
designee is not available, the legatee or other persons authorized to accept the legacy
may authorize any surgeon or physician for the purpose.
SEC. 9. Manner of Executing a Donation. – Any donation by a person authorized under
subsection (a) of Section 4 hereof shall be sufficient if it complies with the formalities of a
donation of a movable property.
In the absence of any of the persons specified under Section 4 hereof and in the absence of
any document of organ donation, the physician in charge of the patient, the head of the
hospital or a designated officer of the hospital who has custody of the body of the deceased
classified as accident, trauma, or other medico-legal cases, may authorize in a public
document the removal from such body for the purpose of transplantation of the organ to
the body of a living person: Provided, That the physician, head of hospital or officer
designated by the hospital for this purpose has exerted reasonable efforts, within forty-
eight (48) hours, to locate the nearest relative listed in Section 4 hereof or guardian of the
decedent at the time of death.
In all donations, the death of a person from whose body an organ will be removed after his
death for the purpose of transplantation to a living person, shall be diagnosed separately
and certified by two (2) qualified physicians neither of whom should be:
a) A member of the team of medical practitioners who will effect the removal of the organ
from the body; nor
b) The physician attending to the recipient of the organ to be removed; nor
c) The head of hospital or the designated officer authorizing the removal of the organ.
SEC. 10. Person(s) Authorized to Remove Transplantable Organs. – Only authorized medical
practitioners in a hospital shall remove and/or transplant any organ which is authorized to
be removed and/or transplanted pursuant to Section 5 hereof.
SEC. 11. Delivery of Document of Legacy or Donation. – If the legacy or donation is made to a
specified legatee or donee, the will, card or other document, or an executed copy thereof,

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 may be delivered by the testator or donor, or his authorized representative, to the legatee
or donee to expedite the appropriate procedures immediately after death. The will, card or
other document, or an executed copy thereof, may be deposited in any hospital or organ
bank storage facility that accepts it for safekeeping or for facilitation or procedures after
death. On the request of any interested party upon or after the testator’s death, the person
in possession shall produce the document of legacy or donation for verification.
SEC. 12. Amendment or Revocation of Legacy or Donation. –
a) If the will, card or other document, or an executed copy thereof, has been delivered to a
specific legatee or donee, the testator or donor may amend or revoke the legacy or
donation either by:
1) The execution and delivery to the legatee or donee of a signed statement to that
effect; or
2) An oral statement to that effect made in the presence of two other persons and
communicated to the legatee or donee; or
3) A statement to that effect during a terminal illness or injury addressed to an
attending physician and communicated to the legatee or donee; or
4) A signed card or document to that effect found on the person or effects of the testator
or donor.
b) Any will, card or other document, or an executed copy thereof, which has not been
delivered to the legatee or donee may be revoked by the testator or donor in the manner
provided in subsection (a) of this section or by destruction, cancellation or mutilation of
the document and all executed copies thereof.
Any legacy made by a will may also be amended or revoked in the manner provided for
amendment or revocation of wills, or as provided in subsection (a) of this section.
SEC. 13. Rights and Duties After Death.
a) The legatee or donee may accept or reject the legacy or donation as the case may be. If
the legacy or donation is of a part of the body, the legatee or donee, upon the death of
the testator and prior to embalming, shall effect the removal of the part, avoiding
unnecessary mutilation. After removal of the part, custody of the remainder of the body
vests in the surviving spouse, next of kin or other persons under obligation to dispose of
the body of the decedent.
b) Any person who acts in good faith in accordance with the terms of this Act shall not be
liable for damages in any civil action or subject to prosecution in any criminal proceeding
of this Act.
SEC. 14. International Sharing of Human Organs or Tissues. – Sharing of human organs or
tissues shall be made only through exchange programs duly approved by the Department
of Health: Provided, That foreign organ or tissue bank storage facilities and similar
establishments grant reciprocal rights to their Philippine counterparts to draw human
organs or tissues at any time.
SEC. 15. Information Drive. – In order that the public will obtain the maximum benefits from
this Act, the Department of Health, in cooperation with institutions, such as the National
Kidney Institute, civic and non-government health organizations and other health related
agencies, involved in the donation and transplantation of human organs, shall undertake a
public information program.
The Secretary of Health shall endeavor to persuade all health professionals, both
government and private, to make an appeal for human organ donation.
SEC. 16. Rules and Regulations. – The Secretary of Health, after consultation with all health
professionals, both government and private, and non-government health organizations
shall promulgate such rules and regulations as may be necessary or proper to implement
this Act.
SEC. 17. Repealing Clause. – All laws, decrees, ordinances, rules and regulations, executive or
administrative orders, and other presidential issuances inconsistent with this Act, are
hereby repealed, amended or modified accordingly.
SEC. 18. Separability Clause. – The provisions of this Act are hereby deemed separable. If any
provision hereof should be declared invalid or unconstitutional, the remaining provisions
shall remain in full force and effect.
SEC. 19. Effectivity. – This Act shall take effect after fifteen (15) days following its publication
in the Official Gazette or in at least two (2) newspapers of general circulation.

Approved, January 7, 1992

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 PRINCIPLES OF ORDINARY AND EXTRAORDINARY MEANS
Ordinary Means of Conserving Life
A person has a moral obligation to use ordinary or proportionate means of preserving
his or her life. Proportionate means are those that in the judgment of the patient offer a
reasonable hope of benefit and do not entail an excessive burden or impose excessive expense
on the family or the community.
Cronin’s definition (1956), ordinary means of conserving life are those means
commonly used in given circumstances, which this individual in his present physical,
psychological and economic condition can reasonably employ with definite hope of
proportionate benefit.

Extraordinary Means of Conserving Life

A person may forgo extraordinary or disproportionate means of preserving life.
Disproportionate means are those that in the patient's judgment do not offer a reasonable
hope of benefit or entail an excessive burden, or impose excessive expense on the family or
the community.
Cronin’s definition (1956), extraordinary means of conserving life are those means
not commonly used in given circumstances, or those means in common use which this
individual in his present physical, psychological and economic condition cannot reasonably
employ, or if he can, will not give him definite hope of proportionate benefit.

PRINCIPLES OF PERSONALIZED SEXUALITY

Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic
tensions. Sex is a search for the completion of the human person through an intimate personal
union of love expressed by bodily union. Sex is a symbolic (sacramental) mystery.
Sexuality is a complex aspect for our personality and self. Our sexuality is defined by
sexual thoughts, desires and longings, erotic fantasies, turns-on and experiences.
Personalized Sexuality is based on the understanding of sexuality as one of the basic
traits of the human person and must be developed in ways consistent with enhancing human
dignity.
This element of human character often leads to a loss of human dignity and an
inability to pursue the truly fulfilling goals of human life.

As the image of God, man is created for love.

GENESIS 1-3
Teaches that God created person as male and female and
blessed their sexuality as a great and goal gift.

The Gift of Sexuality

• must be used in keeping with its intrinsic, invisible, specifically human teleology.
• must be a loving, bodily, pleasurable expression of the complementary, permanent
self-giving of a man and a woman to each other.

Values of Sexual Morality

1. Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic
tensions.
2. Sex is a search for the completion of the human person through an intimate personal
union of love expresses by bodily union.
3. Sex is a social necessity for the procreation of children and their education in the
family so as to expand the human community and guarantee is future beyond the
death of individual members.
4. Sex is a symbolic (sacramental) mystery.
5. Sex is based on the understanding of sexuality as one of the basic traits of the human
person and must be developed in ways consistent with enhancing human dignity.

For Secular Humanist, Reasonable Uses of Sex

(secular humanism is a set of beliefs that emphasize the importance of reason and of people
rather than religion)

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 1. use sex purely for sake of pleasure apart from any relation to love or family.
2. use it to reproduce (making test tube babies) without any reference to pleasure or
love.
3. expression of unselfish love, but without any relation to marriage or family.

Norms of Sexual Morality

1. Laws or social attitudes that hinder human freedom to achieve these values in ways
the individuals’ desires are unjust and oppressive.
2. Sexual behavior, at least among consenting adults, is entirely a private matter to be
determined by personal choice, free from any moral guilt.

Reasonable Uses of Sex

Sexual behavior, at least among consenting adults, is entirely a private matter to be
determined by personal choice, free from any moral guilt.

SELF-STUDY GUIDE QUESTIONS

1. Discuss the different ethical theories.
2. Discuss the virtue ethics.
3. Explain the different principles.
4. Discuss what informed consent is.
5. Discuss ethical principles and principle of bioethics.

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 UNIT 2
BIOETHICS AND ITS APPLICATION IN VARIOUS HEALTH CARE SITUATIONS

Bioethics is the application of ethics to the field of healthcare. In this unit you will
learn the application of ethics in different health care settings.

Learning Objectives
Upon completion of this unit, I am able to do the following:
5. explain sexuality and human reproduction;
6. discuss the dignity in death and dying;
7. recognize the nursing roles and responsibility; and
8. state ethical decision making process.

SEXUALITY AND HUMAN REPRODUCTION

Human Sexuality and Its Moral Evaluation
Human sexuality is the way people experience and express themselves sexually. This
involves biological, erotic, physical, emotional, social, or spiritual feelings and behaviors.
Because it is a broad term, which has varied over time, it lacks a precise definition.
The biological and physical aspects of sexuality largely concern the human
reproductive functions, including the human sexual response cycle. Someone's sexual
orientation is their pattern of sexual interest in the opposite or same sex.
Physical and emotional aspects of sexuality include bonds between individuals that
are expressed through profound feelings or physical manifestations of love, trust, and care.
Social aspects deal with the effects of human society on one's sexuality, while
spirituality concerns an individual's spiritual connection with others.
Sexuality also affects and is affected by cultural, political, legal,
philosophical, moral, ethical, and religious aspects of life.

Legal Issues on Human Sexuality

Globally, laws regulate human sexuality in several ways, including criminalizing
particular sexual behaviors, granting individuals the privacy or autonomy to make their own
sexual decisions, protecting individuals with regard to equality and non-discrimination,
recognizing and protecting other individual rights, as well as legislating matters regarding
marriage and the family, and creating laws protecting individuals from violence, harassment,
and persecution.
Issues regarding human sexuality and human sexual orientation have come to the
forefront in Western law in the latter half of the twentieth century, as part of the gay
liberation movement's encouragement of LGBT individuals to "come out of the closet" and
engaging with the legal system, primarily through courts. Therefore, many issues regarding
human sexuality and the law are found in the opinions of the courts.

Marriage
Fundamental of Marriage
Under the Family Code of the Philippines (FC), marriage is defined as a special contact
of permanent union between a man and a woman entered into in accordance with law for the
establishment of conjugal and family life. It is the foundation of the family and inviolable
social institution whose nature, consequences, and incidents are governed by law and not
subject to stipulation, except that marriage settlements may fix the property relations during
the marriage within the limits provided by the FC.

Essential Requisites and Formal Requisites in Marriage

• Essential requisites:
✓ Legal capacity of the contracting parties who must be a male and a female
✓ Consent freely given in the presence of the solemnizing officer.
• Formal requisites:
✓ Authority of the solemnizing officer
✓ A valid marriage license except in marriage of exceptional circumstances
✓ A marriage ceremony which takes place with the appearance of the
contracting parties before the solemnizing officer and their personal

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 declaration that they take each other as husband and wife in the presence of
not less than 2 witnesses of legal age.

Parental consent is necessary when the contracting parties are between the ages of
18-21 years of age, in addition to the other requirements.
Generally, divorce is not allowed in the Philippines except in cases wherein divorce is
validly obtained abroad by a foreign spouse capacitating him or her to remarry, the Filipino
spouse shall have capacity to remarry under the Philippine law.

Rights and Obligations Between Husband and Wife

Personal obligations of the spouses to each other:
• Live together
• To observe mutual love, respect and fidelity
• To render mutual help and support

Issues on Sex Outside Marriage

In all cultures, consensual sexual intercourse is acceptable within marriage. In some
cultures, sexual intercourse outside marriage is controversial, if not totally unacceptable, or
even illegal. In some countries, such as Saudi Arabia, Pakistan, Afghanistan, Iran, Kuwait,
Maldives, Morocco, Oman, Mauritania, United Arab Emirates, Sudan, Yemen, any form of
sexual activity outside marriage is illegal.
There are a number of complex issues that fall under the category of marriage. When
one member of a marital union has sexual intercourse with another person without the
consent of their spouse, it may be considered to be infidelity. In some cultures, this act may
be considered ethical if the spouse consents, or acceptable as long as the partner is not
married while other cultures might view any sexual intercourse outside marriage as
unethical, with or without consent.
Furthermore, the institution of marriage brings up the issue of premarital sex
wherein people who may choose to at some point in their lives marry, engage in sexual
activity with partners who they may or may not marry. Various cultures have different
attitudes about the ethics of such behavior, some condemning it while others view it to be
normal and acceptable.
Premarital sex is sexual activity between two people who are not married to each
other. Usually, both parties are unmarried. This might be objected to on religious or moral
grounds, while individual views within a given society can vary greatly. In recent decades,
premarital sex has increasingly become more socially and morally acceptable practice among
Western cultures.
Extramarital sex is sex occurring outside marriage, usually referring to when a
married person engages in sexual activity with someone other than their marriage partner.
Commonly there are moral as well as religious objections to sexual relationships by a married
person outside the marriage, and such activity is often referred to in law or religion as
adultery. Others call it infidelity or "cheating".

Issues on Contraception, its Morality, and Ethico-moral Responsibility of Nurses

Contraception is the deliberate use of artificial methods or other techniques to
prevent pregnancy as a consequence of sexual intercourse. The major forms of artificial
contraception are barrier methods, of which the most common is the condom; the
contraceptive pill, which contains synthetic sex hormones that prevent ovulation in the
female; intrauterine devices, such as the coil, which prevent the fertilized ovum from
implanting in the uterus; and male or female sterilization.

Moral Issues Against Contraception

Those who say contraception is morally wrong do so for a variety of reasons.
1. Contraception is inherently wrong
✓ Contraception is unnatural
✓ Contraception is anti-life
✓ Contraception is a form of abortion
✓ Contraception separates sex from reproduction
2. Contraception brings bad consequences
These are consequentialist arguments against contraception.

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 (consequentialism is the doctrine that the morality of an action is to be judged solely
by its consequences)
✓ Contraception carries health risks
✓ The "contraceptive culture" is dangerous
✓ Contraception prevents potential human beings being conceived
✓ Contraception prevents people who might benefit humanity from being born
✓ Contraception can be used as a eugenic (selection of desired heritable
characteristics in order to improve future generations) tool
✓ Contraception is often misused in mass population control programs in a racist
way
✓ Mass population control programs can be a form of cultural imperialism or a
misuse of power
✓ Contraception may lead to depopulation
3. Contraception leads to "immoral behavior"
✓ Contraception makes it easier for people to have sex outside marriage
✓ Contraception leads to widespread sexual immorality
✓ Contraception allows people (even married people) to have sex purely for
enjoyment
4. Contraception is Anti-life
This argument is based on the premise that life is a good thing. Holders of this view
argue that contraception is morally wrong because:
✓ Life is a fundamental good - it is a good thing
✓ Those who use contraception are engaged in an intentionally "anti-life" act
because they intend to prevent a new life coming into being
✓ They therefore have a bad intention
✓ It is always morally wrong to do something with a bad intention
5. Contraception is a Form of Abortion
Some birth control techniques can operate by preventing the implantation
and development of a fertilized egg.
Those opposed to such methods say that this amounts to an abortion, and that
if abortion is wrong then those forms of contraception must also be wrong.
The forms of contraception included in this objection are:
a) Some birth control pills
✓ Most modern birth control pills can prevent implantation of a fertilized egg,
even though this is not the main way they work
✓ There is no way for the user to know after any act of intercourse whether the
pill prevented implantation (or worked in some other way)
✓ Therefore, using such pills always runs the risk of causing an abortion
✓ It is wrong to run the risk of causing an abortion
b) The "morning-after" pill
✓ This is also capable of operating by preventing implantation of a fertilized egg
c) The IUD
✓ This can operate by preventing implantation of a fertilized egg
6. Contraception Carries Health Risks
Contraception may damage the health of the individual using it in two ways;
either through side effects of the contraceptive or because using contraception allows
people to have more sexual partners and thus increases the possibility of catching a
sexually transmitted disease.
7. Side Effects of Contraception
Some forms of contraception do have side effects that damage health while
others have not been shown to have health risks.
Users considering a particular form of birth control should:
✓ make sure they are aware of its risks
✓ compare those risks to the risks of other forms of contraception
✓ compare those risks to the risks that go with having a baby
✓ take an informed decision based on that information

This is probably not an ethical objection to contraception itself, although it

does involve the ethical issue of informed consent to medical treatment.

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 8. Contraception makes it easier for people to have sex outside marriage
This is certainly true, since sexual intercourse without contraception carries a
significant risk of conceiving a child, which most of those having sex outside marriage
would regard as a deterrent.
People think separating sex from marriage is wrong because:
✓ It makes immoral behavior less risky
✓ It undermines public morality by making it more likely that people will have sex
outside marriage
✓ It weakens the family

Issues on Artificial Reproduction, Its Morality and Ethico-Moral Responsibility of

Nurses
Artificial Insemination (AI)
Artificial insemination is the deliberate introduction of sperm into a
female's cervix or uterine cavity for the purpose of achieving a pregnancy through in vivo
fertilization by means other than sexual intercourse.
If the procedure is successful, the woman will conceive and carry a baby to term in
the normal manner. A pregnancy resulting from artificial insemination is no different from a
pregnancy achieved by sexual intercourse.

The Beneficiaries of Artificial Insemination

• Are women who desire to give birth to their own child who may be single, women
who are in a lesbian relationship
• Women who are in a heterosexual relationship but with a male partner who
is infertile or who has a physical impairment which prevents full intercourse from
taking place.

Preparations
Timing is critical, as the window and opportunity for fertilization is little more than
twelve hours from the release of the ovum. To increase the chance of success, the woman's
menstrual cycle is closely observed, often using ovulation kits, ultrasounds or blood tests,
such as basal body temperature tests over, noting the color and texture of the vaginal mucus,
and the softness of the nose of her cervix. To improve the success rate of AI, drugs to create
a stimulated cycle may be used, but the use of such drugs also results in an increased chance
of a multiple birth.
Pre- and post-concentration of motile sperm is counted. Sperm from a sperm bank
will be frozen and quarantined for a period, and the donor will be tested before and after
production of the sample to ensure that he does not carry a transmissible disease. For fresh
shipping, a semen extender is used.
If sperm is provided by a private donor, either directly or through a sperm agency, it
is usually supplied fresh, not frozen, and it will not be quarantined. Donor sperm provided in
this way may be given directly to the recipient woman or her partner, or it may be
transported in specially insulated containers. Some donors have their own freezing
apparatus to freeze and store their sperm.

Techniques
The human female reproductive system. The cervix is part of the uterus. The cervical
canal connects the interiors of the uterus and vagina.
Semen used is used either fresh, raw, or frozen. Where donor sperm is supplied by a
sperm bank, it will always be quarantined and frozen, and will need to be thawed before use.
The sperm is ideally donated after 2-3 days of abstinence, without lubrication as the lubricant
can inhibit the sperm motility. When an ovum is released, semen is introduced into the
woman's vagina, uterus or cervix, depending on the method being used. Sperm is occasionally
inserted twice within a 'treatment cycle.

Risks
There are a few risks when undergoing artificial insemination. The risk of conceiving
twins or triplets increases if a woman receives IUI at the same time as other fertility

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 medication, such as gonadotrophin. A pregnancy with more than one fetus increases the
chances of complications, such as premature birth or miscarriage.
Nowadays, doctors only prescribe fertility medication when there are difficulties with
ovulation, or producing the egg cells from which an embryo develops. Ovarian
hyperstimulation syndrome (OHSS) can cause the ovaries to swell after combining fertility
medication and IUI. It is rare, and symptoms are usually mild-to-moderate, but it can
sometimes have serious complications.
In mild cases of OHSS, symptoms include bloating, slight abdominal pain, and possibly
nausea and vomiting. More severe cases may feature dehydration, chest pain and shortness
of breath. Staying hydrated and taking paracetamol normally alleviates the pain, but more
severe cases may require hospital treatment.

In-Vitro Fertilization
In vitro fertilization (IVF) is a complex series of procedures used to help with fertility
or prevent genetic problems and assist with the conception of a child.
During IVF, mature eggs are collected (retrieved) from ovaries and fertilized by
sperm in a lab. Then the fertilized egg (embryo) or eggs (embryos) are transferred to a uterus.
One full cycle of IVF takes about three weeks. Sometimes these steps are split into different
parts and the process can take longer.

IVF can also be done if you have certain health conditions. IVF may be an option if you or your
partner has:
• Fallopian tube damage or blockage. Fallopian tube damage or blockage makes it
difficult for an egg to be fertilized or for an embryo to travel to the uterus.
• Ovulation disorders. If ovulation is infrequent or absent, fewer eggs are available for
fertilization.
• Endometriosis. Endometriosis occurs when the uterine tissue implants and grows
outside of the uterus — often affecting the function of the ovaries, uterus and fallopian
tubes.
• Uterine fibroids. Fibroids are benign tumors in the wall of the uterus and are common
in women in their 30s and 40s. Fibroids can interfere with implantation of the
fertilized egg.
• Previous tubal sterilization or removal. If you've had tubal ligation — a type of
sterilization in which your fallopian tubes are cut or blocked to permanently prevent
pregnancy — and want to conceive, IVF may be an alternative to tubal ligation
reversal.
• Impaired sperm production or function. Below-average sperm concentration, weak
movement of sperm (poor mobility), or abnormalities in sperm size and shape can
make it difficult for sperm to fertilize an egg. If semen abnormalities are found, your
partner might need to see a specialist to determine if there are correctable problems
or underlying health concerns.
• Unexplained infertility. Unexplained infertility means no cause of infertility has been
found despite evaluation for common causes.
• A genetic disorder. If you or your partner is at risk of passing on a genetic disorder to
your child, you may be candidates for preimplantation genetic testing — a procedure
that involves IVF. After the eggs are harvested and fertilized, they're screened for
certain genetic problems, although not all genetic problems can be found. Embryos
that don't contain identified problems can be transferred to the uterus.
• Fertility preservation for cancer or other health conditions. If you're about to start
cancer treatment — such as radiation or chemotherapy — that could harm your
fertility, IVF for fertility preservation may be an option. Women can have eggs
harvested from their ovaries and frozen in an unfertilized state for later use. Or the
eggs can be fertilized and frozen as embryos for future use.

Risks of IVF include:

• Multiple births. IVF increases the risk of multiple births if more than one embryo is
transferred to your uterus. A pregnancy with multiple fetuses carries a higher risk of
early labor and low birth weight than pregnancy with a single fetus does.
• Premature delivery and low birth weight. Research suggests that IVF slightly
increases the risk that the baby will be born early or with a low birth weight.
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 • Ovarian hyperstimulation syndrome. Use of injectable fertility drugs, such as human
chorionic gonadotropin (HCG), to induce ovulation can cause ovarian
hyperstimulation syndrome, in which your ovaries become swollen and painful.
• Symptoms typically last a week and include mild abdominal pain, bloating, nausea,
vomiting and diarrhea. If you become pregnant, however, your symptoms might last
several weeks. Rarely, it's possible to develop a more severe form of ovarian
hyperstimulation syndrome that can also cause rapid weight gain and shortness of
breath.
• Miscarriage. The rate of miscarriage for women who conceive using IVF with fresh
embryos is similar to that of women who conceive naturally — about 15% to 25% —
but the rate increases with maternal age.
• Egg-retrieval procedure complications. Use of an aspirating needle to collect eggs
could possibly cause bleeding, infection or damage to the bowel, bladder or a blood
vessel. Risks are also associated with sedation and general anesthesia, if used.
• Ectopic pregnancy. About 2% to 5% of women who use IVF will have an ectopic
pregnancy — when the fertilized egg implants outside the uterus, usually in a
fallopian tube. The fertilized egg can't survive outside the uterus, and there's no way
to continue the pregnancy.
• Birth defects. The age of the mother is the primary risk factor in the development of
birth defects, no matter how the child is conceived. More research is needed to
determine whether babies conceived using IVF might be at increased risk of certain
birth defects.
• Cancer. Although some early studies suggested there may be a link between certain
medications used to stimulate egg growth and the development of a specific type of
ovarian tumor, more-recent studies do not support these findings. There does not
appear to be a significantly increased risk of breast, endometrial, cervical or ovarian
cancer after IVF.
• Stress. Use of IVF can be financially, physically and emotionally draining. Support
from counselors, family and friends can help you and your partner through the ups
and downs of infertility treatment.

The chances of giving birth to a healthy baby after using IVF depend on various factors,
including:
• Maternal age. The younger you are, the more likely you are to get pregnant and give
birth to a healthy baby using your own eggs during IVF. Women age 41 and older are
often counseled to consider using donor eggs during IVF to increase the chances of
success.
• Embryo status. Transfer of embryos that are more developed is associated with
higher pregnancy rates compared with less-developed embryos (day two or three).
However, not all embryos survive the development process. Talk with your doctor or
other care provider about your specific situation.
• Reproductive history. Women who've previously given birth are more likely to be
able to get pregnant using IVF than are women who've never given birth. Success
rates are lower for women who've previously used IVF multiple times but didn't get
pregnant.
• Cause of infertility. Having a normal supply of eggs increases your chances of being
able to get pregnant using IVF. Women who have severe endometriosis are less likely
to be able to get pregnant using IVF than are women who have unexplained infertility.
• Lifestyle factors. Women who smoke typically have fewer eggs retrieved during IVF
and may miscarry more often. Smoking can lower a woman's chance of success using
IVF by 50%. Obesity can decrease your chances of getting pregnant and having a baby.
Use of alcohol, recreational drugs, excessive caffeine and certain medications also can
be harmful.

There are several moral issues with in vitro.

First of all, the child is created outside the womb by human devices as a sperm and a
harvested egg are combined.
Second, many children (embryos) are created and some are frozen for later use while
several are placed in the mother's womb. The survival for these embryos is low, sometimes
quoted around 25%. So in essence, multiple children are created, knowing that most of them
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 will not live. Some physicians only place 2-3 embryos in the mother, hoping that one or all of
them will survive. Other physicians place more embryos in the mother, and if too many live,
they then abort the "extras" and leave a more "manageable" number of embryos in the womb.
The frozen embryos have an uncertain fate. Some of them remain frozen for an
inestimable period of time, children that have been created and then frozen! Does it seem
right to create life and then leave it? Some of the frozen embryos may be thawed later for a
repeat cycle of IVF, and most do not survive. In some cases, embryos are donated to other
couples or some may be donated for research (i.e.: killing them in the name of scientific
study).
The overall problem with IVF is that it destroys life as it creates life. Meaning, the
chance of one child surviving carries with it the necessity of many other children (embryos)
having been created and then dying. So for the one surviving child, many other children have
been given life (combining sperm and egg) with the knowledge that most of them won't make
it.

Surrogate Motherhood
Surrogate mother is a woman who helps a couple to have a child by carrying to term
an embryo conceived by the couple and transferred to her uterus, or by being inseminated
with the man's sperm and either donating the embryo for transfer to the woman's uterus or
carrying it to term.

There are two kinds:

1. Traditional surrogate. It's a woman who gets artificially inseminated with the
father's sperm. She then carries the baby and delivers it for you and your partner to
raise. A traditional surrogate is the baby's biological mother. That's because it was
her egg that was fertilized by the father's sperm. Donor sperm can also be used.
2. Gestational surrogates. A technique called "in vitro fertilization" (IVF) now makes it
possible to gather eggs from the mother, fertilize them with sperm from the father,
and place the embryo into the uterus of a gestational surrogate. The surrogate then
carries the baby until birth. She doesn't have any genetic ties to the child because it
wasn't her egg that was used. A gestational surrogate is called the "birth mother."
The biological mother, though, is still the woman whose egg was fertilized.

The Ethical Issues that are Pertinent in the Surrogacy Process

While there are many religious organizations that frown upon the process of
surrogacy, this concept is oftentimes the only option for some individuals to start a family. It
is for this reason that some highly controversial and key ethical issues be addressed.
✓ Attachment with the Gestational Mother – In a surrogate situation, the gestational
mother is the woman who carries the baby to term. This can be a very taxing process
both physically and emotionally – and unique in that after the surrogate mother
physically carries the baby throughout the pregnancy, she needs to physically and
emotionally detach herself from the child once it is born.
✓ Involvement with the Gestational Mother – Because the gestational mother will not
likely be the child's primary caretaker, there could be legal questions that arise in
terms of what – if any – involvement she will have with the child once born.
✓ Identity of the Child – There are also ethical considerations that are brought to mind
in terms of informing the child of his or her surrogate mother, as doing so may have
an effect on the child's self-identity. In addition to the above issues, there is also the
✓ factor of surrogate mother compensation. It is typically expected that the intended
parents of the child will reimburse the surrogate mother for her medical and other
related expenses. This can include an amount for her hospitalization as well as
incidentals such as her maternity clothing, meals, and other similar costs that she may
be out during her time of pregnancy.
✓ There are also surrogate situations where the individual or couple who are the
intended parents will pay a fee to the surrogate mother for carrying their baby. With
this in mind, it is thought by some that surrogacy could be thought of as being a luxury
that is only available to the wealthy – and in some cases it could even be thought of as
pregnancy-for-hire.
✓ In any case, however, the process that allows for a loving individual or parents to have
a child of their own can allow intended parents to follow through on their intentions

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 of starting a family, regardless of any medical or other factors that would otherwise
prevent them from being able to do so.

Morality of Abortion, Rape and Other Problems Related To Destruction of Life

Abortion
For centuries, Western culture in general and Christians in particular have held to a
view of the sanctity of human life. In our society today this view is beginning to erode into a
quality-of-life standard. Where once we saw the disabled, the retarded, and the unborn as
having a special place in God’s world, now we have moved into a position of judging on the
quality of human life. No longer is life as such seen as sacred and worthy to be saved. Now, it
is seen as something to be judged and evaluated. If we arbitrarily feel that life is not worth
living, then it is advisable to terminate it.
Abortion is the premature termination of pregnancy prior to birth. Induced abortion
is caused by the woman herself or by another, usually a medical doctor

Questions to Ponder
• “When does human life begin?”
• “At what point is it to be valued and protected to the same extent as the lives of human
beings who already have been born?”
• Conflict between the positions for and against centers on so-called absolute rights
• “Is abortion the taking of human life?”

Point of Argument on Abortion

• Fetus is not an actual human life in the womb after the 12th week, when the brain
structure is essentially complete and a fetal electrocardiogram through the pregnant
woman can pick up heart activity.
• When the child breathes on its own, are the only points at which human life begins.
• Human being able to survive without life support of some kind.
• If they cannot breathe for themselves or eat and drink on their own they are not
actually human beings.
• Once born-they are considered as human.
• “At what point in development of the conceptus to be valued to the extent that
terminating its life would be equivalent to terminating the life of people who are
already born?”
• Genetic View – human life is to be valued from conception onward.
• The Strong Prochoice Position – human life does not have the value until birth.

Arguments Against Abortion

The genetic view of the beginning of human life
Human life starts at conception (the chromosomes from the sperm and ovum are
united) then a human being exists that must be valued in the same way as if “he or she” were
already born.
Safest position to hold: by valuing a conceptus as a human from conception onward
we are ensuring that we do not act immorally or irreverently toward human life, especially
innocent, unborn life

The Sanctity of Life Argument

Every unborn, innocent child must be regarded as human person with all the rights
of a human person from the moment of conception onward. The conceptus not only has the
right to life, but also that his/her right is absolute. Absolute overrides all other rights that
might come into conflict with it.
For instance, a woman’s right to determine the course of her own procreative life or
even her right to decide between her own life and the life of her conceptus if her pregnancy
is complicated in some way.

Potential Dangers of Abortion

Abortion increases a woman’s chances of having miscarriages in later pregnancies
(especially for young girls who have had an abortion). Self-induced abortion is the most
dangerous of all abortions because they are not done under medical supervision. Can cause
complications like infections and hemorrhage which can kill both the fetus and the mother.
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 It is psychologically destructive to a woman to authorize the “killing of her baby”. A
woman who has committed such terrible act has to live with a great deal of guilt. Emotional
scars will never be eradicated from the psyche.

Rape and Incest

If women do become pregnant after rape or incest, the destruction of human life is
still not justified. Women go through with the pregnancies and, if they do not want the
children because of the circumstances of their conception, they should put them up for
adoption or place them in government-run institutions.
In any case, innocent, unborn conceptuses should not have to pay with their lives for
the sins or crimes of others.

DIGNITY IN DEATH AND DYING

Euthanasia
Euthanasia (from Greek word thanatos means "death") is the practice of intentionally
ending a life to relieve pain and suffering.
Different countries have different euthanasia laws. The British House of Lords select
committee on medical ethics defines euthanasia as "a deliberate intervention undertaken
with the express intention of ending a life, to relieve intractable suffering".
In the Netherlands and Belgium, euthanasia is understood as "termination of life by a
doctor at the request of a patient".
The Dutch law, however, does not use the term 'euthanasia' but includes the concept
under the broader definition of "assisted suicide and termination of life on request".
Physicians sometimes perform euthanasia when it’s requested by people who have a
terminal illness and are in a lot of pain. It’s a complex process and involves weighing many
factors. Local laws, someone’s physical and mental health, and their personal beliefs and
wishes all play a role.

Euthanasia is Categorized in Different Ways

1. Voluntary euthanasia is conducted with the consent of the patient. When the patient
brings about their own death with the assistance of a physician, the term assisted
suicide is often used instead.
2. Non-voluntary euthanasia is conducted when the consent of the patient is
unavailable. Non-voluntary euthanasia involves someone else making the decision to
end someone’s life. A close family member usually makes the decision. This is
generally done when someone is completely unconscious or permanently
incapacitated.
3. Involuntary euthanasia (without asking consent or against the patient's will) is also
illegal in all countries and is usually considered murder.
4. Passive euthanasia entails the withdrawing life support from someone who’s
showing no signs of brain activity.
5. Active euthanasia entails the use of lethal substances or forces (such as
administering a lethal injection), and is the more controversial.

Is euthanasia legal?
People have debated over the ethics and legality of euthanasia and Physician Assisted
Suicide (PAS) for centuries. Today, laws about euthanasia and PAS are different across states
and countries.
1. In the United States, PAS is legal in:
✓ Washington
✓ Oregon
✓ California
✓ Colorado
✓ Montana
✓ Vermont
✓ Washington, D.C.
✓ Hawaii (beginning in 2019)

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 Each of these states and Washington, D.C. have different legal requirements. Not
every case of PAS is legal. In addition, many states currently have Physician Assisted Suicide
measures on legislative ballots, so this list may grow.
2. Outside the United States, PAS is legal in:
✓ Switzerland
✓ Germany
✓ Japan
✓ Netherlands
✓ Belgium
✓ Luxembourg
✓ Colombia
✓ Canada

Controversy Around Euthanasia

There are many arguments both for and against euthanasia and Physician Assisted
Suicide. Most of these arguments fall into four main categories:
1. Morality and religion
Some people believe euthanasia is murder and find it unacceptable for moral reasons.
Many also argue that the ability to decide your own death weakens the sanctity of life.
In addition, many churches, religious groups, and faith organizations argue against
euthanasia for similar reasons.
2. Physician judgement
Physician Assisted Suicide is only legal if someone is mentally capable of making the
choice. However, determining someone’s mental capabilities isn’t very
straightforward. One study of Trusted Source found that doctors aren’t always
capable of recognizing when someone is fit to make the decision.
3. Ethics
Some doctors and opponents of PAS are concerned about the ethical complications
doctors could face. For more than 2,500 years, doctors have taken the Hippocratic
oath. This oath encourages doctors to care for and never harm those under their care.
Some argue that the Hippocratic oath supports PAS since it ends suffering and brings
no more harm. On the other hand, some debate it results in harm to the person and
their loved ones, who must watch their loved one suffer.
4. Personal choice
“Death with dignity” is a movement that encourages legislatures to allow people to
decide how they want to die. Some people simply don’t want to go through a long
dying process, often out of concern of the burden it puts on their loved ones.

Inviolability of Human Life

The inviolability or sanctity of life is a principle of implied protection regarding
aspects of life that are said to be holy, sacred, or otherwise of such value that they are not to
be violated.
The “sanctity of life” is a phrase that in recent decades became commonplace in the
moral and political debates concerning a wide range of bioethical issues: abortion, embryo
research, cloning, genetic engineering, euthanasia, and others. Generally, it is used by those
of us who oppose technologies or practices that we believe violate the intrinsic value of
human life. Some of us who use the term employ it more broadly to denote an ethical
approach concerned not just with a handful of bioethical issues but the entire range of moral
problems that human beings face, from abortion to poverty, from war to the death penalty,
from child abuse to the environment.

Suicide
Suicide is the act of killing yourself, most often as a result of depression or other
mental illness. Mental disorders, including depression, bipolar disorder, autism,
schizophrenia, personality disorders, anxiety disorders, and substance abuse—including
alcoholism and the use of benzodiazepines—are risk factors. Some suicides are impulsive
acts due to stress, such as from financial difficulties, relationship problems such as breakups,
or bullying. Those who have previously attempted suicide are at a higher risk for future
attempts.

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 Suicide rates are highest for men over 69, but are increasing alarmingly in young
people aged 15 to 24.

Suicide Warning Signs

Be concerned if someone you know:
• Talks about committing suicide
• Has trouble eating or sleeping
• Exhibits drastic changes in behavior
• Withdraws from friends or social activities
• Loses interest in school, work or hobbies
• Prepares for death by writing a will and making final arrangements
• Gives away prized possessions
• Has attempted suicide before
• Takes unnecessary risks
• Has recently experienced serious losses
• Seems preoccupied with death and dying
• Loses interest in his or her personal appearance
• Increases alcohol or drug use.

Effective Suicide Prevention

1. Limiting access to methods of suicide—such as firearms, drugs, and poisons.
2. Treating mental disorders and substance misuse.
3. Careful media reporting about suicide.
4. Improving economic conditions.

Dysthanasia
Dysthanasia means "bad death” and is considered a common fault of modern
medicine. Dysthanasia occurs when a person who is dying has their biological life extended
through technological means without regard to the person's quality of life. Technologies such
as an implantable cardioverter defibrillator, artificial ventilation, ventricular assist devices,
and extracorporeal membrane oxygenation can extend the dying process. Dysthanasia is a
term generally used when a person is seen to be kept alive artificially in a condition where,
otherwise, they cannot survive.

Orthothanasia
Orthotanasia refers to the art of promoting a humane and correct death, not
subjecting patients to dysthanasia and not abbreviating death either, that is, subjecting them
to euthanasia. Its great challenge is to enable terminal patients to keep their dignity, where
there is a commitment to the well-being of patients in the final phase of a disease.

Administration of Drugs to the Dying

In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the
guidelines for which are mainly based on expert opinions. The goal of palliative care is
symptom control by a combination of non-pharmacological measures and drugs.
Many of the medications used to manage these symptoms may cause a degree of
sedation, or other side effects. Careful assessment is required, and possibly a review of
medication with changes to drugs, including doses and routes of administration, even when
symptoms have been previously well controlled.
According to Masman et.al (2015) the most frequently prescribed drugs in the
palliative setting are morphine, midazolam and haloperidol. These drugs are given to relieve
symptoms such as pain, restlessness and agitation, which are frequently seen in advanced
cancer.

Advance Directives
Advance directives are legal documents that allow you to spell out your decisions
about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends,
and health care professionals and to avoid confusion later on.

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 Types of Advance Directives
1. Living will
Living will is a legal document used to state certain future health care decisions only
when a person becomes unable to make the decisions and choices on their own. The
living will is only used at the end of life if a person is terminally ill (can't be cured) or
permanently unconscious. The living will describe the type of medical treatment the
person would want or not want to receive in these situations. It can describe under
what conditions an attempt to prolong life should be started or stopped. This applies
to treatments including, but not limited to dialysis, tube feedings, or actual life
support (such as the use of breathing machines).
Before your health care team uses your living will to guide medical decisions,
physicians must confirm that you are unable to make your own medical decisions and
you are in a medical condition that is specified by your state law as terminal illness or
permanent unconsciousness.

Things to think about when writing a living will

✓ If you want the use of equipment such as dialysis machines (kidney machines)
or ventilators (breathing machines) to help keep you alive.
✓ Do not resuscitate orders (instructions not to use CPR if breathing or heartbeat
stops).
✓ If you want fluid or liquid (usually by IV) and/or food (tube feeding into your
stomach) if you couldn't eat or drink.
✓ If you want treatment for pain, nausea, or other symptoms, even if you can't
make other decisions (this may be called comfort care or palliative care).
✓ If you want to donate your organs or other body tissues after death.

It is important to know that choosing not to have aggressive medical treatment is

different from refusing all medical care. A person can still get treatments such as
antibiotics, food, pain medicines, or other treatments. It is just that the goal of
treatment becomes comfort rather than cure. You may end or take back a living will
at any time.

2. Durable power of attorney for health care/Medical power of attorney

A durable power of attorney for health care, also known as a medical power of
attorney, is a legal document in which you name a person to be a proxy (agent) to
make all your health care decisions if you become unable to do so. Before a medical
power of attorney can be used to guide medical decisions, a person's physician must
certify that the person is unable to make their own medical decisions.
If you become unable to make your own health care decisions, your proxy or agent
can speak with your health care team and other caregivers on your behalf and make
decisions according to the wishes or directions you gave earlier. If your wishes in a
certain situation are not known, your proxy or agent will make a decision based on
what he or she thinks you would want. If you regain the ability to make your own
medical decisions, your proxy (agent) can't continue to make medical decisions on
your behalf.
The person you name as a proxy or agent should be someone who knows you well
and someone you trust to carry out your wishes. Your proxy or agent should
understand how you would make decisions if you were able, and should be
comfortable asking questions and advocating to your health care team on your behalf.
Be sure to discuss your wishes in detail with that person. You may also choose to
name a back-up person in case your first choice becomes unable or unwilling to act
on your behalf.

3. POLST (Physician Orders for Life-Sustaining Treatment)

A POLST form also helps describe your wishes for health care, but it is not an advance
directive. A POLST form has a set of specific medical orders that a seriously ill person
can fill in and ask their health care provider to sign. A POLST form addresses your
wishes in an emergency, such as whether to use CPR (cardiopulmonary resuscitation)

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 in an emergency, or whether to go to a hospital in an emergency and be put on a
breathing machine if necessary, or stay where you are and be made comfortable.
A POLST form has to be signed by a qualified member of your health care team, such
as your doctor. Emergency personnel, like paramedics and EMTs (Emergency Medical
Technicians) can't use an advance directive, but they can use a POLST form. Without
a POLST form, emergency personnel are required to provide every possible treatment
to help keep you alive.

4. Do not resuscitate (DNR) orders

Resuscitation means medical staff will try to re-start your heart and breathing using
methods such as CPR (cardiopulmonary resuscitation) and AED (automated external
defibrillator). In some cases, they may also use life-sustaining devices such as
breathing machines.
In the hospital
A Do Not Resuscitate or DNR order means that if you stop breathing or your heart
stops, nothing will be done to try to keep you alive. If you are in the hospital, you can
ask your doctor to add a DNR order to your medical record. You would only ask for
this if you don’t want the hospital staff to try to revive you if your heart or breathing
stopped. Some hospitals require a new DNR order each time you are admitted, so you
might need to ask every time you go into the hospital. But remember that this DNR
order is only good while you are in the hospital. Outside the hospital, it’s a little
different.

5. Organ and tissue donation

Organ and tissue donation can be included in your advance directive. Many states also
provide organ donor cards or add notations to your driver's license.

End of Life Care Plan

The final stages of a terminal illness can be a highly challenging, emotional time. It can
become evident that in spite of the best care, attention, and treatment, your loved one is
approaching the end of their life. At this point, the focus usually changes to making them as
comfortable as possible in order to make the most of the time they have left. Depending on
the nature of the illness and your loved one’s circumstances, this final stage period may last
from a matter of weeks or months to several years. During this time, palliative care measures
can help to control pain and other symptoms, such as constipation, nausea, or shortness of
breath.
Even with years of experience, caregivers often find this final stage of the caregiving
journey uniquely challenging. Simple acts of daily care are often combined with complex end-
of-life decisions and painful feelings of grief and loss. You may experience a range of
distressing and conflicting emotions, such as sorrow and anxiety, anger and denial, or even
relief that your loved one’s struggle is at an end, or guilt that you’ve somehow failed as their
caregiver. Whatever you’re experiencing, it’s important to recognize that late stage caregiving
requires plenty of support. That can range from practical support for end-of-life care and
financial and legal arrangements, to emotional support to help you come to terms with all the
difficult feelings you’re experiencing as you face up to the loss of your loved one.
Late-stage care is also a time for saying goodbye to your loved one, to resolve any
differences, forgive any grudges, and to express your love. While late stage caregiving can be
an extremely painful time, having this opportunity to say goodbye can also be a gift to help
you come to terms with your loss and make the transition from nursing and grief towards
acceptance and healing.
There isn’t a single specific point in an illness when end-of-life care begins; it very
much depends on the individual and the progression of their illness. In the case of Alzheimer’s
disease or another dementia, your loved one’s doctor likely provided you with information
on stages in the diagnosis. These stages can provide general guidelines for understanding the
progression of Alzheimer’s symptoms and planning appropriate care. For other life-limiting
illnesses, the following are signs that you may want to talk to your loved one about hospice
and palliative care, rather than curative care options:
• Your loved one has made multiple trips to the emergency room, their condition has
been stabilized, but the illness continues to progress significantly, affecting their
quality of life.

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 • They’ve been admitted to the hospital several times within the last year with the same
or worsening symptoms.
• They wish to remain at home, rather than spend time in the hospital.
• They have decided to stop receiving treatments for their disease.

Patient and Caregiver Needs in Late-Stage Care

As your loved one enters late-stage or end-of-life care, their needs can change,
impacting the demands you’ll now face as their caregiver. This can include the following
areas:
1. Practical care and assistance. Perhaps your loved one can no longer talk, sit, walk,
eat, or make sense of the world. Routine activities, including bathing, feeding,
dressing, and turning may require total support and increased physical strength on
your part as their caregiver. You can find support for these tasks from personal care
assistants, a hospice team, or physician-ordered nursing services.
2. Comfort and dignity. Even if your patient’s cognitive and memory functions are
depleted, their capacity to feel frightened or at peace, loved or lonely, and sad or
secure remains. Regardless of where they’re being cared for—at home, in a hospital,
or at a hospice facility—the most helpful interventions are those which ease pain and
discomfort and provide the chance for them to experience meaningful connections to
family and loved ones.
3. Respite Care. Respite care can give you and your family a break from the intensity of
end-of-life caregiving. It may be simply a case of having a hospice volunteer sit with
the patient for a few hours so you can meet friends for coffee or watch a movie, or it
could involve the patient having a brief inpatient stay in a hospice facility.
4. Grief support. Anticipating your loved one’s death can produce reactions from relief
to sadness to feeling numb. Consulting bereavement specialists or spiritual advisors
before your loved one’s death can help you and your family prepare for the coming
loss.

End-of-Life Planning
When caregivers, family members, and loved ones are clear about the patient’s
preferences for treatment in the final stages of life, you’re all free to devote your energy to
care and compassion. To ensure that everyone in your family understands the patient’s
wishes, it’s important for anyone diagnosed with a life-limiting illness to discuss their feelings
with loved ones before a medical crisis strikes.
✓ Prepare early. The end-of-life journey is eased considerably when conversations
regarding placement, treatment, and end-of-life wishes are held as early as possible.
Consider hospice and palliative care services, spiritual practices, and memorial
traditions before they are needed.
✓ Seek financial and legal advice while your loved one can participate. Legal
documents such as a living will, power of attorney, or advance directive can set forth
a patient’s wishes for future health care so family members are all clear about their
preferences.
✓ Focus on values. If your loved one did not prepare a living will or advance directive
while competent to do so, act on what you know or feel their wishes are. Make a list of
conversations and events that illustrate their views. To the extent possible, consider
treatment, placement, and decisions about dying from the patient’s vantage point.
✓ Address family conflicts. Stress and grief resulting from your loved one’s
deterioration can often create conflict between family members. If you are unable to
agree on living arrangements, medical treatment, or end-of-life directives, ask a
trained doctor, social worker, or hospice specialist for mediation assistance.
✓ Communicate with family members. Choose a primary decision maker who will
manage information and coordinate family involvement and support. Even when
families know their loved one’s wishes, implementing decisions for or against
sustaining or life-prolonging treatments requires clear communication.
✓ If children are involved, make efforts to include them. Children need honest, age-
appropriate information about your loved one’s condition and any changes they
perceive in you. They can be deeply affected by situations they don’t understand, and
may benefit from drawing pictures or using puppets to simulate feelings, or hearing
stories that explain events in terms they can grasp.

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 Common Symptoms in End-of-Life Care
Symptom How to provide comfort

Drowsiness Plan visits and activities for times when the patient
is most alert.

Becoming unresponsive Many patients are still able to hear after they are no
longer able to speak, so talk as if your loved one can
hear.

Confusion about time, place, Speak calmly to help re-orient your loved one.
identity of loved ones Gently remind them of the time, date, and people
who are with them.

Loss of appetite, decreased Let the patient choose if and when to eat or drink.
need for food and fluids Ice chips, water, or juice may be refreshing if the
patient can swallow. Keep your loved one’s mouth
and lips moist with products such as glycerin swabs
and lip balm.

Loss of bladder or bowel Keep your loved one as clean, dry, and comfortable
control as possible. Place disposable pads on the bed
beneath them and remove when they become soiled.

Skin becoming cool to the Warm the patient with blankets but avoid electric
touch blankets or heating pads, which can cause burns.

Labored, irregular, shallow, Breathing may be easier if the patient’s body is

or noisy breathing turned to the side and pillows are placed beneath
their head and behind their back. A cool mist
humidifier may also help.

Providing Emotional Comfort

As with physical symptoms, a patient’s emotional needs in the final stages of life also
vary. However, some emotions are common to many patients during end-of-life care. Many
worry about loss of control and loss of dignity as their physical abilities decline. It’s also
common for patients to fear being a burden to their loved ones yet at the same time also fear
being abandoned.
As a late-stage caregiver, you can offer emotional comfort to your loved one in several
different ways:
✓ Keep them company. Talk to your loved one, read to them, watch movies together,
or simply sit and hold their hand.
✓ Refrain from burdening the patient with your feelings of fear, sadness and
loss. Instead, talk to someone else about your feelings.
✓ Allow your loved one to express their fears of death. It can be difficult to hear
someone you love talk about leaving family and friends behind, but communicating
their fears can help them come to terms with what’s happening. Try to listen without
interrupting or arguing.
✓ Allow them to reminisce. Talking about their life and the past is another way some
patients gain perspective on their life and the process of dying.
✓ Avoid withholding difficult information. If they’re still able to comprehend, most
patients prefer to be included in discussions about issues that concern them.
✓ Honor their wishes. Reassure the patient that you will honor their wishes, such as
advance directives and living wills, even if you don’t agree with them.
✓ Respect the patient’s need for privacy. End-of-life care for many people is often a
battle to preserve their dignity and end their life as comfortably as possible.

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 At the End-of-Life
The end-of-life period—when body systems shut down and death is imminent—
typically lasts from a matter of days to a couple of weeks. Some patients die gently and
tranquilly, while others seem to fight the inevitable. Reassuring your loved one it is okay to
die can help both of you through this process. Decisions about hydration, breathing support,
and other interventions should be consistent with your loved one’s wishes.
✓ Saying Goodbye
o Although this is a painful time in so many ways, entering end-of-life care does
offer you the opportunity to say goodbye to your loved one, an opportunity
that many people who lose someone suddenly regret not having.
o If you wonder what to say to your loved one, palliative care physician Ira
Byock in his book, The Four Things That Matter Most, identifies the things
dying people most want to hear from family and friends: “Please forgive me.”
“I forgive you.” “Thank you.” “I love you.”
✓ Don’t wait until the last minute to say goodbye. No one can predict when that last
minute will come so waiting for it puts a huge burden on you.
✓ Just talk, even if your loved one appears unresponsive. Hearing is the last sense
to shut down, so even when your loved one appears comatose and unresponsive,
there is a strong likelihood they can still hear what you are saying. Identify yourself
and speak from the heart.
✓ You don’t have to speak to say goodbye. Touch can be an important part of the last
days and hours, too. Holding your loved one’s hand or giving them a kiss can bring
comfort and closeness between you.
✓ You can say goodbye many different times and in many different ways. You don’t
have to formally issue a goodbye and say everything all at once. You can do it over
days. Don’t worry about repeating yourself; this is about connecting with your loved
one and saying what you feel so you are less likely to have regrets later about things
left unsaid.
After your loved one has passed away, some family members and caregivers draw
comfort from taking some time to say their last goodbyes, talk, or pray before proceeding
with final arrangements. Give yourself that time if you need it.

Caring for Yourself

As impossible as it may seem, taking care of yourself during your loved one’s final
stages is critically important to avoid burnout. Research suggests that spousal caregivers are
most likely to experience despair rather than any kind of fulfillment in their caregiving role.
But whatever your circumstances, it’s important to seek the support you need to adjust, gain
acceptance, and eventually move on.

NURSING ROLES AND RESPONSIBILITY

Staff have many responsibilities in end of life care which will range from having a
sensitive conversation with an individual about their care and preferences, recognizing any
changes in condition and offering compassion and support to the patient and those important
to them. This will require a broad variety of skills and an awareness of the values which
underpin this behavior. Compassionate care has to be at the forefront of all nursing care but
is even more fundamental in the provision of caring for dying people and those close to them.
You will have many responsibilities in end of life care, which will range from speaking
with and listening to individuals and those close to them about their care and preferences,
observing, discussing and recording any changes in conditions and offering compassion and
support. This will require a broad range of skills and an awareness of the values which
underpin this behavior. When providing end of life care, ensure you:
✓ treat people compassionately
✓ listen to people
✓ communicate clearly and sensitively
✓ identify and meet the communication needs of each individual
✓ acknowledge pain and distress and take action
✓ recognize when someone may be entering the last few days and hours of life
✓ involve people in decisions about their care and respect their wishes
✓ keep the person who is reaching the end of their life and those important to them up
to date with any changes in condition

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 ✓ document a summary of conversations and decisions
✓ seek further advice if needed
✓ look after yourself and your colleagues and seek support if you need it

ETHICAL DECISION MAKING PROCESS

Ethical decision-making refers to the process of evaluating and choosing among
alternatives in a manner consistent with ethical principles. In making ethical decisions, it is
necessary to perceive and eliminate unethical options and select the best ethical alternative.
Healthcare providers and physicians have to consider patient’s perspective and
preferences. Patient’s family members when implied with the task of making appropriate
treatment choices or end-of-life care choices for the incapacitated patient should put aside
their self-interest and judge the situation and come to a decision in the patient’s best interest.
This act of working towards achieving greatest good for the patient by family members and
by the physician can be termed under “Virtue theory” of ethics.
Physicians have to judge the situation and provide appropriate treatment prognosis
so that patients’ can make an autonomous choice of treatment preferences or patients’ family
can make these choices for them and work towards act of beneficence for the patient. While
carrying out this act of beneficence, the physician has to provide information about the
treatment, especially in case of futile treatment so as to avoid any undue harm to the patient.
In case of futile treatments, healthcare providers also have to consider the allocation of
limited resources available to manage the case scenario so as to avoid inequity. Hence,
healthcare providers also have to consider the aspect of equitable and distributive justice in
cases where expensive treatment provided to the patient during end-of-life situation may be
futile, and utilize lot of resources, leading to unequal distribution of limited medical and
technological resources. Additionally, they have to address the issues of unnecessary and
unequal distribution of resources by withdrawing or withholding the useless treatment.
The process of making ethical decisions requires:
✓ Commitment: The desire to do the right thing regardless of the cost.
✓ Consciousness: The awareness to act consistently and apply moral convictions to
daily behavior.
✓ Competency: The ability to collect and evaluate information, develop alternatives,
and foresee potential consequences and risks

Good Decisions Are Both Ethical and Effective

Ethical decisions generate and sustain trust; demonstrate respect, responsibility,
fairness and caring; and are consistent with good citizenship. These behaviors provide a
foundation for making better decisions by setting the ground rules for our behavior.
Effective decisions are effective if they accomplish what we want accomplished and
if they advance our purposes. A choice that produces unintended and undesirable results is
ineffective. The key to making effective decisions is to think about choices in terms of their
ability to accomplish our most important goals. This means we have to understand the
difference between immediate and short-term goals and longer-range goals.

SELF-STUDY GUIDE QUESTIONS

1. Discuss the issues in Sexuality and Human Reproduction.
2. Explain Dignity in Death and Dying.
3. Describe the Nursing Roles and Responsibility.
4. Discuss the Ethical Decision Making Process.

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 UNIT 3
BIOETHICS AND RESEARCH

Bioethics includes medical ethics, which focuses on issues in health care; research
ethics, which focuses issues in the conduct of research. In this unit, you will learn the role of
ethics in research.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. discuss principles of ethics in research;
2. explain ethical issues in evidenced-based practice; and
3. identify ethico-moral obligations of the nurse in evidence-based practices.

PRINCIPLES OF ETHICS IN RESEARCH

NUREMBERG CODE
During World War II the Axis Powers did a great deal of human experimentation. Both
Imperial Japan and Nazi Germany subjected human beings to torturous ordeals in order to
obtain data that might prove useful in their war effort. When the Allies were victorious in
Asia, the U.S. government made a secret deal with Japanese scientists. In return for use of
Japanese data, the United States would shield these scientists from prosecution. This was not
the case in Europe. Distrust between the Soviet Union and the Allies forced much of the
aftermath of the Nazi regime into the public eye. Many Nazi scientists were openly tried for
war crimes. These trials were held in Nuremberg, Germany—at the time one of the only cities
in the country with a standing court building.
Issued by the Nuremberg Military Tribunal in 1947, the Nuremberg Code is a 10-point
statement meant to prevent future abuse of human subjects. It states that, above all,
1. Participation in research must be voluntary.
2. The results of the research must be useful and unobtainable by other means.
3. The study must be rationally based on knowledge of the disease or condition to be
studied.
4. It must avoid unnecessary suffering.
5. The study cannot include death or disabling injury as a foreseeable consequence.
6. Its benefits must outweigh its risks.
7. The study must use proper facilities to protect participants.
8. The study must be conducted by qualified individuals.
9. Participants may withdraw from the study if they wish.
10. Investigators must be prepared to stop the study should participants die or become
disabled as a result of participation.

The Nuremberg Code was created by opining on the testimony of physician witnesses
and was said to represent current thoughts on the topic of human experimentation. Although
intended to refer to this particular trial and never formally adopted by any state or
international agency, the Nuremberg Code has been tremendously influential—becoming the
basis of later documents that are highly relevant to research today.

DECLARATION OF HELSINKI
Organized in 1945, the World Medical Association (WMA) took the place of
l'Association Professionnelle Internationale des Médecins—an international medical
association that had been effectively disbanded during World War II. Physicians from the
WMA were appalled at the atrocities revealed at the Nuremberg Trial and, in 1949, issued a
code of medical ethics to condemn what Nazi doctors had done. This code came to be known
as the Declaration of Geneva for the city in which it was officially adopted. In it, the WMA laid
out general principles to which physicians should hold themselves. For example, “the health
of my patients will be my first consideration.” Despite the noble goals of the Declaration of
Geneva, its vague language did not allow accurate interpretations in the newly emerging field
of medical ethics. To clarify a physician's duties as an investigator, the WMA began
reexamining the issue in 1953. The subject was discussed and debated for several years
before the resulting document, Ethical Principles for Medical Research Involving Human
Subjects, was approved in 1964. Again taking its name from the city in which it was adopted,
this paper became known as the Declaration of Helsinki.

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 Beginning in 1975, the Declaration of Helsinki has been revised several times—most
recently in 2000. Minor clarifications were also added in 2002 and 2004. Its current form
contains 3 sections in 32 separate paragraphs—each on a specific topic.
Section A sets the stage of what human research is and why it is necessary and
stresses the obligation of the physician to prioritize participant health. This section reminds
physicians that special populations involved in research must be closely monitored.
Examples of these special populations are the “economically and medically disadvantaged,”
those who cannot give informed consent (or who may be doing so “under duress”), those who
will not benefit personally from the research, and those for whom “research is combined with
care.”
Section B discusses basic principles for medical research and reaffirms points of the
Nuremberg Code—such as the need for basing a human trial rationally on available evidence.
However, the Declaration of Helsinki expands the Nuremberg principle of voluntarism
significantly. It states that potential subjects should only give consent after being fully
informed of the study's setup, goals, and sources of funding; potential conflicts of interest;
researcher affiliation(s); risks and benefits; and their right to withdraw. Only populations
likely to benefit from the research should be targeted for recruitment, and vulnerable
populations should not be used when other populations are available and appropriate.
Furthermore, populations requiring a third party to give informed consent (because they are
unable) should give assent instead (thereby agreeing to participate even if not able to be fully
informed). In all cases of obtaining consent, a researcher should be mindful of unduly
influencing a patient by way of a clinical relationship.
Section C discusses research combined with medical care and states that research can
only be combined with clinical care if it has the potential to prophylax, diagnose, or treat. In
these cases, subjects must be made aware what aspects of their care are experimental.
Experimental care may be offered to individuals outside a formal research study if standard
care has been ineffective for their condition. Section C also contains the 2 most controversial
statements in the document: Paragraphs 29 and 30.

Paragraph 29 asserts that new treatments should be tested against

standard treatment; thus proscribing the use of placebo-controlled studies when
a known treatment exists. This statement was clarified to allow exceptions in
cases where a placebo is “scientifically” necessary to evaluate a treatment or
when the condition being investigated is “minor” and a placebo does not entail
additional risks to the subject.
Paragraph 30 states that, at study conclusion, all participants should be
assured access to the “best” treatment as identified in the study. It is not the
purpose of this article to debate the pros and cons of these statements, but it
should be obvious that well-intentioned and informed investigators could come
to conclusions different than those allowed by Paragraphs 29 and 30 in the
Declaration of Helsinki.

BELMONT REPORT
In 1974, the National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research was created for the U.S. Department of Health, Education, and
Welfare (DHEW—now known as the Department of Health and Human Services after a
separate Department of Education was established in 1979). The commission's charge was
to identify ethical principles underlying research and develop guidelines for respecting these
principles. Although acknowledging the existence of other codes governing human research,
the commission thought that other codes amounted to lists of regulations that might not allow
the resolution of complex ethical questions. The commission postulated that looking at the
topic more generally would allow recognition of fundamental principles. Researchers could
then appeal to these principles to resolve dilemmas for which other codes have no answer.
The report, issued in 1979, is entitled Ethical Principles and Guidelines for the
Protection of Human Subjects of Research. It came to be known as the Belmont Report, after
the Smithsonian Institution's Belmont Conference Center (where most of the meetings of
the commission took place). The commission concluded that the primary principles
underlying ethical research with human beings are as follows:

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 1. Respect for Persons: This principle acknowledges the dignity and freedom of every
person. It requires obtaining informed consent from research subjects (or their
legally authorised representatives)
2. Beneficence: This principle requires that researchers maximise benefits and
minimise harms associated with research. Research-related risks must be
reasonable in light of the expected benefits.
3. Justice: This principle requires equitable selection and recruitment and fair
treatment of research subjects.

The methods used to recognize these principles are:

1. Informed Consent
Informed consent requires that information be shared with a potential
subject, that he or she comprehend the information given, and that the person
voluntarily agree to participate in the research. Information shared should “generally
include: the research procedure, their purposes, risks and anticipated benefits,
alternative procedures (where therapy is involved), and a statement offering the
subject the opportunity to ask questions and to withdraw at any time from the
research”. The report leaves the assessment of comprehension up to the researcher
but does stipulate that a written or oral test may be required depending on the nature
of the risks involved.
The report notes that there are special classes of potential subjects in whom
comprehension may be limited. These patients include children, the “mentally
disabled,” the terminally ill, and the comatose—who must also be given the
opportunity to assent to the research if they are able (“unless the research entails
providing them with therapy unavailable elsewhere”). However, to protect the
interests of these vulnerable populations, a third party should give consent to the
study. This third party should be someone “most likely to understand the
incompetent subject's situation and to act in that person's best interest.”
Another component of informed consent is the voluntariness of the decision
to participate. The commission recognized that flat-out coercion involving threats of
harm are not the only way to affect a patient's voluntariness—“undue influence” is
also disallowed. This inappropriate influence is offering “excessive, unwarranted,
inappropriate, or improper reward” but also pressure coming from a position of
power “to obtain compliance.” Recognizing a fine line between “justifiable
persuasion” and “undue influence,” the commission notes that denial of clinical
treatment to those not participating in a trial is an example of the latter.
2. Risks and Benefits
Assessment of risks and benefits begins by determining the soundness of the
research design. Next, risk is discussed in both the probability that a harm will occur
and “the severity of the envisioned harm.” Benefits are likewise discussed. It is
pointed out that, compared to risks, benefits are more amenable to generalization.
Studies could benefit a patient group, “society,” and/or “scientific knowledge.”
Recognizing that there is as yet no perfect means of doing so, the committee
recommends that risks and benefits be studied by a “systematic, no arbitrary
analysis.” Caveats are that no “brutal or inhumane treatment of human subjects”
could ever be justified and only risks necessary to achieve the experimental ends
should be tolerated.
3. Selection of Participants
In patient selection, the principle of justice is cited most often. This means,
more or less, treating equals equally—therefore, people with the same illness should
be offered research participation equally (or maybe bear the risks of research
equally?). However, in the interest of fairness, people should not be used for research
simply as a matter of “administrative convenience”. Therefore, classes of people like
prisoners or “the mentally infirm” may be invited to participate in research, only on
certain conditions.

ETHICAL ISSUES IN EVIDENCE-BASED PRACTICE

Ethical issues are part of every health care encounter. Moral principles, such as truth,
fairness, doing the right thing, avoiding harm, and respecting autonomy, lie at the heart of
these ethical concerns. Each patient care encounter includes issues related to the established

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 practices of the discipline, what the patient prefers, concern for quality of life, and contextual
features.
Evidence-based practice is rooted in medicine but has quickly been embraced by the
entire health care community. Evidence-based practice is “the conscientious, explicit, and
judicious use of current best evidence in making decisions about the care of individual
patients”. The process of evidence-based practice involves being aware of the various levels
of existing evidence underlying a given intervention approach and carefully appraising that
evidence as it applies to a specific patient encounter. Typically, the method involves carefully
formulating a clinical question, finding evidence that bears on the question, and evaluating
the evidence without bias and applying it as appropriate to a given patient.
Implementing the process of evidence-based practice has implications for resource
use, for professional credibility, and for improving outcomes. These worthwhile benefits are
often emphasized without sufficient attention to the underlying ethical principles involved.
One can argue that the primary reason for implementing evidence-based practice is a
moral one. Professional caregivers are responsible for practicing in a manner that keeps the
patient’s interest foremost by achieving the greatest good and avoiding harm in the process.
In their pledges to practice ethically, professionals already commit to making decisions that
are right for a given patient at a given time.
“The ultimate question we, as clinicians, are challenged to answer is: What, among the
many things that could be done for this patient, ought to be done? This is an ethical question”.
As with so many endeavors pursued with enthusiasm, the fervor that accompanies
evidence-based practice may cause us to overlook its limitations. We may neglect to apply to
evidence-based practice the fundamental principles of objective analysis that are so central
to the process itself. In our zeal to be objective and informed, we may forget that clinical
decision making, at its core, is an ethical matter, and we may lose sight of the ethical dilemmas
hidden beneath our efforts to produce the most effective medical, rehabilitation, and health
outcomes.

ETHICO-MORAL OBLIGATIONS OF THE NURSE IN EVIDENCE-BASED-PRACTICES

Ethical Considerations in Evidence-Based Practice
Selecting and Using Intervention for a Given Patient
✓ Base decision on best evidence for given patient, condition, and setting
✓ Involve patients in the choice of intervention
✓ Appreciate the importance of research evidence over tradition or expert opinion
✓ Recognize the psychological and resource costs of ineffective intervention
✓ Avoid the use of unethical studies

Participating in or Advocating for Research

✓ Monitor ethical practices in research in which one participates
✓ Assure complete and appropriate informed consent
✓ Advocate for research balancing survival with quality of life
✓ Respect the right of participant autonomy
✓ Involve consumers in strategic decisions about research directions

INTRODUCTION TO GOOD CLINICAL PRACTICE GUIDELINES

The ICH-GCP is a harmonized standard that protects the rights, safety and welfare of
human subjects, minimizes human exposure to investigational products, improves quality of
data, speeds up marketing of new drugs and decreases the cost to sponsors and to the public.
Compliance with this standard provides public assurance that the rights, safety and well-
being of trial subjects are protected and consistent with the principles of the Declaration of
Helsinki, and that the clinical trial data is credible.

Importance of GCP
1. Increased Ethical Awareness
2. Improved Trial Methods
3. Clinical Trial Concept Better Understood
4. Public/Political Concern over Safety Aspects
5. Frauds and Accidents during Trials
6. Growing Research and Development Costs
7. Increasing Competition

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 8. Mutual Recognition of Data
9. New Market Structure

There are 13 core principles of ICH-GCP and they are as follows:

1. Clinical trials should be conducted in accordance with ethical principles that have
their origin in the Declaration of Helsinki, and that are consistent with GCP and the
applicable regulatory requirement(s).
2. Before a trial is initiated, foreseeable risks and inconveniences should be weighed
against anticipated benefit for the individual trial subject and society. A trial should
be initiated and continued only if the anticipated benefits justify the risks.
3. The rights, safety and well-being of the trial subjects are the most important
considerations and should prevail over interest of science and society.
4. The available non-clinical and clinical information on an investigational product
should be adequate to support the proposed clinical trial.
5. Clinical trials should be scientifically sound, and described in clear, detailed protocol.
6. A trial should be conducted in compliance with the protocol that has received prior
institutional review board (IRB)/ independent ethics committee (IEC)
approval/favorable opinion.
7. The medical care given to, and medical decisions made on behalf of subjects should
always be the responsibility of a qualified physician or, when appropriate, of a
qualified dentist.
8. Each individual involved in conducting a trial should be qualified by education,
training, and experience to perform his or her respective task(s).
9. Freely given informed consent should be obtained from every subject prior to clinical
trial participation.
10. All clinical trial information should be recorded, handled, and stored in a way that
allows its accurate reporting, interpretation and verification.
11. The confidentiality of records that could identify subjects should be protected,
respecting the privacy and confidentiality rules in accordance with the applicable
regulatory requirement(s).
12. Investigational products should be manufactured, handled and stored in accordance
with applicable Good Manufacturing Practice (GMP). They should be used in
accordance with the approved protocol.
13. Systems with procedures that assure the quality of every aspect of the trial should be
implemented.

These principles are self-explanatory and, when summarized, simply mean:

All clinical trials should be conducted in accordance with ethical principles, sound
scientific evidence and clear detailed protocols. The benefits of conducting trials should
outweigh the risks. The rights, safety and well-being of trial participants are of paramount
importance and these should be preserved by obtaining informed consent and maintaining
confidentiality. The care must be given by appropriately qualified personnel with adequate
experience. Records should be easily accessible and retrievable for accurate reporting,
verification and interpretation. Investigational products should be manufactured according
to Good Manufacturing Practice.

Participants of GCP in Clinical Trials and Their Respective Responsibilities

Regulatory Authorities Review submitted clinical data and conduct
inspections
The sponsor Company or institution/organization which takes
responsibility for initiation, management and financing of
clinical trial
The project monitor Usually appointed by sponsor
The investigator Responsible for conduct of clinical trial at the trial site.
Team leader.
The pharmacist at trial Responsible for maintenance, storage and dispensing of
location investigational products eg. Drugs in clinical trials
Patients Human subjects

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 Ethical review board or Appointed by Institution or if not available then the
Committee for protection Authoritative Health Body in that Country will be
of subjects responsible
Committee to monitor Overseas Sponsors eg. Drug Companies
large trials

The events that led up to the culmination of the ICH-GCP guidelines brought forth
public awareness that there was a need to control and regulate clinical trials dealing with
drugs and human subjects. The violation of human rights played a large role and that is why
the Declaration of Helsinki and The Nuremberg Code remain as the framework of the present
guidelines. The ICH-GCP guidelines are therefore considered the ‘bible’ of clinical trials, and
have become a global law which safeguards humanity as we know it today.

SELF-STUDY GUIDE QUESTIONS

1. Explain the principles of ethics in research.
2. Discuss the ethical issues in evidenced-based practice.
3. Describe the ethico-moral obligations of the nurse in evidence based practices.

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 UNIT 4
ETHICAL CONSIDERATION IN LEADERSHIP AND MANAGEMENT

Ethical leadership is defined as “leadership demonstrating and promoting

‘normatively appropriate conduct through personal actions and interpersonal relations’. In
other words, this really means that ethical leadership is defined as putting people into
management and leadership positions who will promote and be an example of appropriate,
ethical conduct in their actions and relationships in the workplace. In this unit you will learn
ethical consideration in leadership and management.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. know moral decision making specifically principle of moral discernment, principle
of well-formed conscience and strategies of moral decision making process;
2. define ethical dilemma; and
3. discuss the meaning and service value of medical care it’s allocation of health
resources and issues involving access to care.

MORAL DECISION MAKING

Principle of Moral Discernment
Many people just use discernment as a synonym for “decide”. But discernment is a
richer and deeper concept that, while related and antecedent to “deciding” is distinct from it.
The goal of discernment is to see beyond the mere external dimensions of something, and to
probe to its deeper significance.
The word “discern” comes from the Latin dis – “off, or away” + cernere – “to
distinguish, separate, sift, set apart, divide or distinguish.
Thus, to discern is to distinguish or sort out what is of God, what is of the flesh, world
or even the devil. As such, discernment, in its root meaning is something that ought to precede
decision and aid it.

Principle of Well-Formed Conscience

The Principle of Well-Formed Conscience indicates that people are obligated to
inform themselves about ethical norms, incorporate that knowledge into their daily lives, act
according to that knowledge, and take responsibility for those actions. (Lederer, 1995)

Strategies of Moral Decision Making Process

1. Establish the facts in a situation.
✓ Ask yourself the following questions.
✓ What has happened or what is happening?
✓ When and where did certain events occur?
✓ Who is (or might be) involved in or concerned by the situation?
✓ What do the parties involved have to say about the situation?
2. Decide whether the situation involves legal or ethical issues
✓ Has anyone been harmed by the action or decision of another, and if so, in what
way?
✓ Does the action or the situation contravene an existing law?
✓ Was there a breach of contract?
3. Identify your options and possible consequences
✓ What could I do in this situation?
4. Evaluate your options
✓ Assess the pros and cons of your options.
5. Choose the best option
✓ Ensure that the decisions he/she makes and the actions he/she takes do not
result in harm, physical and other.
6. Implement your decision
✓ Consider the following as you establish an action plan.
✓ Choose your path
✓ Think about what may happen
✓ Identify who needs to know.
✓ Determine if you can deal on your own with the persons involved

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 ✓ Warn, don’t threaten.
✓ think about what you might do next if the chosen plan of action doesn’t work.

Ethical Dilemma (CFI Education Inc., 2021)

An ethical dilemma (ethical paradox or moral dilemma) is a problem in the decision-
making process between two possible options, neither of which is absolutely acceptable from
an ethical perspective. Although we face many ethical and moral problems in our lives, most
of them come with relatively straightforward solutions.
On the other hand, ethical dilemmas are extremely complicated challenges that
cannot be easily solved. Therefore, the ability to find the optimal solution in such situations
is critical to everyone.
Every person may encounter an ethical dilemma in almost every aspect of their life,
including personal, social, and professional.

How to Solve an Ethical Dilemma?

The biggest challenge of an ethical dilemma is that it does not offer an obvious
solution that would comply with ethics al norms. Throughout the history of humanity, people
have faced such dilemmas, and philosophers aimed and worked to find solutions to them.

Approaches to Solve an Ethical Dilemma

The following approaches to solve an ethical dilemma were deduced:
1. Refute the paradox (dilemma): The situation must be carefully analyzed. In some
cases, the existence of the dilemma can be logically refuted.
2. Value theory approach: Choose the alternative that offers the greater good or the
lesser evil.
3. Find alternative solutions: In some cases, the problem can be reconsidered, and new
alternative solutions may arise.

Examples of ethical Dilemma

Some examples of ethical dilemma examples include:
1. Taking credit for others’ work
2. Offering a client a worse product for your own profit
3. Utilizing inside knowledge for your own profit

MEANING AND SERVICE VALUE OF MEDICAL CARE

Allocation of Health Resources
Resource allocation is the process of assigning and managing assets in a manner that
supports an organization’s strategic goals.
Includes managing tangible assets such as hardware to make the best use of softer
assets such as human capital.
In practicing resource allocation organizations must first establish their desired end
goal, such as increased revenue, improved productivity or better brand recognition.

Why is Access to Health Services Important?

Access to health services means “the timely use of personal health services to achieve
the best outcomes.” It requires 3 distinct steps:
1. Gaining entry into the health care system (usually through insurance coverage)
2. Accessing a location where needed health care services are provided (geographic
availability)
3. Finding a heath care provider whom the patient trusts and can communicate with
(personal relationship)

Issues Involving Access to Care

Barriers to health services include:
✓ High cost of care
✓ Inadequate or no insurance coverage
✓ Lack of availability of services
✓ Lack of culturally competent care

These barriers to accessing health services lead to:

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 ✓ Unmet health needs
✓ Delays in receiving appropriate care
✓ Inability to get preventive services
✓ Financial burdens
✓ Preventable hospitalizations
✓ Access to care often varies based on race, ethnicity, socioeconomic status, age, sex,
disability status, sexual orientation, gender identity, and residential location

SELF-STUDY GUIDE QUESTIONS

1. Discuss the principle of moral discernment and principle of well-formed conscience.
2. Explain the strategies of moral decision making process.

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 UNIT 5
GUIDELINES AND PROTOCOL IN DOCUMENTATION AND HEALTH CARE RECORDS

The health care record is a documented account of a client's health history. In this
unit, you will learn the guidelines in documentation.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. know the guidelines and protocol in documentation and health care records.

Incorrect information, or no information at all, may result in serious injury or death

of a patient. Negative legal repercussions are often avoided because of proper documentation
and appropriate communication of patient information.

Documentation of Medical Records

Medical record documentation is required to record pertinent facts, findings, and
observations about a client’s health history including past and present illnesses,
examinations, tests, treatments, and outcomes. The medical record documents the care of the
client and is an important element contributing to high quality care. Medical Records may
serve as a legal document to verify the care provided. The medical record facilitates:
1. The ability of the physician and other healthcare professionals to evaluate and plan
the client’s immediate treatment, and to monitor his/her healthcare over time.
2. Communication and continuity of care among physicians and other healthcare
professionals involved in the client’s care.
3. Accurate and timely claims review and payment.
4. Appropriate utilization review and quality of care evaluations.
5. Collection of data that may be useful for research and education.

Five Factors that Improve the Quality and Usefulness of Documented Information
With documentation of medical records, particular emphasis must be placed on the
five factors that improve the quality and usefulness of documented information.
1. Accuracy
2. Relevance
3. Completeness
4. Timeliness
5. Confidentiality

Standards for Documentation

Documentation in health care records must comply with the following:
1. Be clear and accurate.
2. Legible and in English.
3. Use approved abbreviations and symbols.
4. Written in dark ink that is readily reproducible, legible, and difficult to erase and
write over for paper based records.
5. Time of entry (using a 24-hour clock – hhmm).
6. Date of entry (using ddmmyy or ddmmyyyy).
7. Signed by the author, and include their printed name and designation. In a
computerized system, this will require the use of an appropriate identification system
eg. Electronic signature.
8. Entries by students involved in the care and treatment of a patient / client must be
cosigned by the student’s supervising clinician.
9. Entries by different professional groups are integrated ie. there are not separate
sections for each professional group.
10. Be accurate statements of clinical interactions between the patient / client and their
significant others, and the health service relating to assessment; diagnosis; care
planning;
11. Care or treatment provided and client response; professional advice sought and
provided; observations.

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 12. Be sufficiently clear, structured and detailed to enable other members of the health
care team to assume care of the patient / client or to provide ongoing service at any
time.
13. Written in an objective way and not include demeaning or derogatory remarks.
14. Distinguish between what was observed or performed, what was reported by others
as happening and / or professional opinion.
15. Made at the time of an event or as soon as possible afterwards. The time of writing
must be distinguished from the time of an incident, event or observation being
reported.
16. Be relevant to that patient / client.
17. Only include personal information about other people when relevant and necessary
for the care and treatment of the patient / client.
18. Addendum – if an entry omits details any additional details must be documented
next to the heading ‘Addendum’, including the date and time of the omitted event and
the date and time of the addendum.
19. For hardcopy records, addendums must be appropriately integrated within the
record and not documented on additional papers and / or attached to existing forms.
20. Written in error - all errors are must be appropriately corrected. No alteration and
correction of records is to render information in the records illegible.

Legal Aspects of Documentation of Medical Records

In 2012, the Philippines passed the Data Privacy Act of 2012, it is a comprehensive
and strict privacy legislation which states that “to protect the fundamental human right of
privacy, of communication while ensuring free flow of information to promote innovation
and growth.”
It is also known as the Republic Act No. 10173. This comprrehensive privacy law
also established a National Privacy Commission that enforces and oversees it and is endowed
with rulemaking power.

SELF-STUDY GUIDE QUESTIONS

1. Enumerate the standards of documentation.

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 UNIT 6
ETHICAL ISSUES RELATED TO TECHNOLOGY IN THE DELIVERY OF HEALTH CARE

Technology nowadays is a necessity to healthcare professionals to perform their duty

more effectively and efficiently. In this unit, you will learn the technology in healthcare
delivery that were confined with ethical principles.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. know the data protection and security;
2. discuss the benefits and challenges of technology; and
3. identify current technology issues and dilemma.

DATA PROTECTION AND SECURITY

Data Privacy Act 2012 (RA 10173 Series of 2012)
Republic Act No. 10173, otherwise known as the Data Privacy Act is a law that seeks to
protect all forms of information, be it private, personal, or sensitive. It is meant to cover both
natural and juridical persons involved in the processing of personal information.

Scope of Data Privacy Act 2012

Rule I. Preliminary Provisions
Section 1. Title.
These rules and regulations shall be known as the Implementing Rules and
Regulations of Republic Act No. 10173 known as the Data Privacy Act of 2012, or the “Rules.”

Section 2. Policy.
These rules and regulations further enforce the Data Privacy Act and adopts generally
accepted international principles and standards for data protection, safeguarding the
fundamental right of every individual to privacy while supporting the free flow of information
for innovation, growth and national development. The Rules recognize the vital role of
information and communications technology in nation-building and enforce the State’s
inherent obligation to ensure that personal data in information and communications systems
in the government and in the private sector are secured and protected.

Section 3. Definition of Terms.

Whenever used in this Act, the following terms shall have the respective meanings
hereafter set forth:
• Consent of the data subject refers to any freely given, specific, informed indication of
will, whereby the data subject agrees to the collection and processing of personal
information about and/or relating to him or her. Consent shall be evidenced by written,
electronic or recorded means. It may also be given on behalf of the data subject by an
agent specifically authorized by the data subject to do so.
• Data subject refers to an individual whose personal information is processed.
• Personal information refers to any information whether recorded in a material form
or not, from which the identity of an individual is apparent or can be reasonably and
directly ascertained by the entity holding the information, or when put together with
other information would directly and certainly identify an individual.
• Personal information controller refers to a person or organization who controls the
collection, holding, processing or use of personal information, including a person or
organization who instructs another person or organization to collect, hold, process, use,
transfer or disclose personal information on his or her behalf. The term excludes:
• (1) A person or organization who performs such functions as instructed by another
person or organization; and
• (2) An individual who collects, holds, processes or uses personal information in
connection with the individual’s personal, family or household affairs.
• Personal information processor refers to any natural or juridical person qualified to
act as such under this Act to whom a personal information controller may outsource
the processing of personal data pertaining to a data subject.
• Processing refers to any operation or any set of operations performed upon personal
information including, but not limited to, the collection, recording, organization,
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 storage, updating or modification, retrieval, consultation, use, consolidation, blocking,
erasure or destruction of data.
• Privileged information refers to any and all forms of data which under the Rules of
Court and other pertinent laws constitute privileged communication.
• Sensitive personal information refers to personal information:
(1) About an individual’s race, ethnic origin, marital status, age, color, and religious,
philosophical or political affiliations;
(2) About an individual’s health, education, genetic or sexual life of a person, or to
any proceeding for any offense committed or alleged to have been committed by
such person, the disposal of such proceedings, or the sentence of any court in
such proceedings;
(3) Issued by government agencies peculiar to an individual which includes, but not
limited to, social security numbers, previous or current health records, licenses
or its denials, suspension or revocation, and tax returns; and
(4) Specifically established by an executive order or an act of Congress to be kept
classified.

Scope.
This Act applies to the processing of all types of personal information and to any
natural and juridical person involved in personal information processing including those
personal information controllers and processors who, although not found or established in
the Philippines, use equipment that are located in the Philippines, or those who maintain an
office, branch or agency in the Philippines subject to the immediately succeeding
paragraph: Provided, That the requirements of Section 5 are complied with.
This Act does not apply to the following:
(a) Information about any individual who is or was an officer or employee of a government
institution that relates to the position or functions of the individual, including:
(1) The fact that the individual is or was an officer or employee of the government
institution;
(2) The title, business address and office telephone number of the individual;
(3) The classification, salary range and responsibilities of the position held by the
individual; and
(4) The name of the individual on a document prepared by the individual in the course
of employment with the government;

Penalties
Section 25. Unauthorized Processing of Personal Information and Sensitive Personal
Information.
a) The unauthorized processing of personal information shall be penalized by
imprisonment ranging from one (1) year to three (3) years and a fine of not less than
Five hundred thousand pesos (Php500,000.00) but not more than Two million pesos
(Php2,000,000.00) shall be imposed on persons who process personal information
without the consent of the data subject, or without being authorized under this Act or
any existing law.
(b) The unauthorized processing of personal sensitive information shall be penalized by
imprisonment ranging from three (3) years to six (6) years and a fine of not less than
Five hundred thousand pesos (Php500,000.00) but not more than Four million pesos
(Php4,000,000.00) shall be imposed on persons who process personal information
without the consent of the data subject, or without being authorized under this Act or
any existing law.

Section 26. Accessing Personal Information and Sensitive Personal Information Due to
Negligence.
(a) Accessing personal information due to negligence shall be penalized by imprisonment
ranging from one (1) year to three (3) years and a fine of not less than Five hundred
thousand pesos (Php500,000.00) but not more than Two million pesos
(Php2,000,000.00) shall be imposed on persons who, due to negligence, provided
access to personal information without being authorized under this Act or any existing
law.

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 (b) Accessing sensitive personal information due to negligence shall be penalized by
imprisonment ranging from three (3) years to six (6) years and a fine of not less than
Five hundred thousand pesos (Php500,000.00) but not more than Four million pesos
(Php4,000,000.00) shall be imposed on persons who, due to negligence, provided
access to personal information without being authorized under this Act or any existing
law.

Section 27. Improper Disposal of Personal Information and Sensitive Personal Information.
(a) The improper disposal of personal information shall be penalized by imprisonment
ranging from six (6) months to two (2) years and a fine of not less than One hundred
thousand pesos (Php100,000.00) but not more than Five hundred thousand pesos
(Php500,000.00) shall be imposed on persons who knowingly or negligently dispose,
discard or abandon the personal information of an individual in an area accessible to
the public or has otherwise placed the personal information of an individual in its
container for trash collection.

Section 30. Concealment of Security Breaches Involving Sensitive Personal Information.

The penalty of imprisonment of one (1) year and six (6) months to five (5) years and
a fine of not less than Five hundred thousand pesos (Php500,000.00) but not more than One
million pesos (Php1,000,000.00) shall be imposed on persons who, after having knowledge
of a security breach and of the obligation to notify the Commission pursuant to Section 20(f),
intentionally or by omission conceals the fact of such security breach.

BENEFITS AND CHALLENGES OF TECHNOLOGY

1. Ease of Workflow
• Entering data into a computerizedsystem is much less time-consuming than paper-
based methods, and it reduces the risk of errors in patient data and financial details.
Accessing patient records digitally also allows medical coding experts to work from
home, increasing efficiency and productivity.
2. Better and Safer Data Storage
• Cloud computer technology allows for masses of information to be stored at an
unbelievably low cost, all without the limitations (and expense) of additional
hardware or servers. With an increased reliance on EHR systems, Cloud storage
protects against the loss of sensitive data with strong backup and recovery services.
3. Better treatment and less suffering
4. Improved patient care and worker efficiency
5. Doctors are easier to reach and better at their jobs

Challenges of Technology in Healthcare

1. The Learning Curve
• Ongoing education is vital for medical professionals and healthcare administrators,
but these professionals often juggle busy schedules and may not have the time to
learn the latest technology. Not having a full understanding of new medical
equipment may lead to errors, which is why it’s vital that medical facilities plan
training for new processes or technology.
2. The Cost
• A 2012 report estimated that out of the trillions of dollars spent on healthcare every
year, between 5 and 6 percent goes toward medical devices. At a glance, that may
seem like practically nothing. For hospitals and clinics with limited resources, the cost
can present a significant challenge. An article from a prominent school’s Technology
Review states that many economists agree that healthcare has a troubled financial
outlook largely because of the related costs.
3. Meaningful Use Compliance
• Centers for Medicare and Medicaid Services (CMS) Incentive Programs encourage
healthcare facilities to make meaningful use of electronic health records, but this is
difficult for many facilities to meet. Professionals who do not act in accord with
meaningful use procedures will see a decrease in Medicare reimbursements, which
could significantly increase financial concerns for clinics and hospitals that already
have monetary woes.
4. How Hospitals Can Keep Up
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 • The above listed challenges all boil down to the fact that keeping up with
technological advances is difficult.
• How can hospitals stay in line with technologies.
• Technology is essential to healthcare, but it can also create difficulties. Administrators
and leaders in the industry must work to overcome these challenges so all patients
can benefit from the latest advances in medical technology.

CURRENT TECHNOLOGY ISSUES AND DILEMMA

1. Personalized genetic tests/personalized medicine
Within the last 10 years, the creation of fast, low-cost genetic sequencing has given the
public direct access to genome sequencing and analysis, with little or no guidance from
physicians or genetic counselors on how to process the information.
2. 3-D printing
Scientists are attempting to use 3-D printing to create everything from architectural
models to human organs, but we could be looking at a future in which we can print
personalized pharmaceuticals or home-printed guns and explosives. For now, 3-D printing
is largely the realm of artists and designers, but we can easily envision a future in which
3-D printers are affordable and patterns abound for products both benign and malicious,
and that cut out the manufacturing sector completely.
3. Adaptation to climate change
The differential susceptibility of people around the world to climate change warrants an
ethical discussion. We need to identify effective and safe ways to help people deal with the
effects of climate change, as well as learn to manage and manipulate wild species and
nature in order to preserve biodiversity.
4. Autonomous systems
Machines (both for peaceful purposes and for war fighting) are increasingly evolving from
human-controlled, to automated, to autonomous, with the ability to act on their own
without human input. As these systems operate without human control and are designed
to function and make decisions on their own, the ethical, legal, social and policy
implications have grown exponentially.
5. Human-animal hybrids (chimeras)
So far scientists have kept human-animal hybrids on the cellular level. According to some,
even more modest experiments involving animal embryos and human stem cells violate
human dignity and blur the line between species.
6. Ensuring access to wireless and spectrum
Mobile wireless connectivity is having a profound effect on society in both developed and
developing countries. These technologies are completely transforming how we
communicate, conduct business, learn, form relationships, navigate and entertain
ourselves. At the same time, government agencies increasingly rely on the radio spectrum
for their critical missions. This confluence of wireless technology developments and
societal needs presents numerous challenges and opportunities for making the most
effective use of the radio spectrum. We now need to have a policy conversation about how
to make the most effective use of the precious radio spectrum, and to close the digital
access divide for underserved (rural, low-income, developing areas) populations.
7. Human enhancements
Pharmaceutical, surgical, mechanical and neurological enhancements are already
available for therapeutic purposes. But these same enhancements can be used to magnify
human biological function beyond the societal norm.
8. Patient Privacy and Confidentiality
The protection of private patient information is one of the most important ethical and legal
issues in the field of healthcare. Conversations between a physician and a patient are
strictly confidential, as is information about an individual’s medical condition.
9. Relationships
Sexual relationships between medical practitioners and patients or between medical staff
are strictly forbidden at a healthcare facility. Sexual harassment can be harmful to all
involved, including the facility, so the code of ethics should be explicit about this.
10. End-of-Life Issues
Terminally ill patients may have specific wishes about the way they want their lives to end.
Families may struggle with the decision to end life support for a loved one. Healthcare
practitioners and clinical leaders need to be prepared to handle end-of-life issues as well

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 as problems encountered in dealing with elderly patients who may not be able to make
rational decisions on their own.

SELF-STUDY GUIDE QUESTIONS

1. What is the scope of the Data Privacy Act 2012?
2. Discuss the Benefits and Challenges of Technology.
3. Choose 1 issue on Current Technology. Express your point of view about the chosen
issue.

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 UNIT 7
CONTINUING EDUCATION PROGRAMS ON ETHICO-MORAL PRACTICE IN NURSING

Ethical practice is a foundation for nurses, when dealing with ethical issues daily. In
this unit, you will learn the code of ethics for professional nurses is the basis in their nursing
practice.

Learning Objectives
Upon completion of this unit, I am able to do the following:
1. know the code of ethics for professional nurses.

CODE OF ETHICS FOR PROFESSIONAL NURSES

INTERNATIONAL COUNCIL OF NURSES CODE OF ETHICS
An international code of ethics for nurses was first adopted by the International
Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since,
most recently with this review and revision completed in 2012

Preamble
Nurses have four fundamental responsibilities: to promote health, to prevent illness,
to restore health and to alleviate suffering. The need for nursing is universal. Inherent in
nursing is a respect for human rights, including cultural rights, the right to life and choice, to
dignity and to be treated with respect. Nursing care is respectful of and unrestricted by
considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation,
nationality, politics, race or social status. Nurses render health services to the individual, the
family and the community and coordinate their services with those of related groups.

Elements of the International Council of Nurses (ICN) Code

The ICN Code of Ethics for Nurses has four principal elements that outline the
standards of ethical conduct.
1. Nurses and people
The nurse’s primary professional responsibility is to people requiring nursing care.
In providing care, the nurse promotes an environment in which the human rights,
values, customs and spiritual beliefs of the individual, family and community are
respected. The nurse ensures that the individual receives accurate, sufficient and
timely information in a culturally appropriate manner on which to base consent for
care and related treatment. The nurse holds in confidence personal information and
uses judgement in sharing this information. The nurse shares with society the
responsibility for initiating and supporting action to meet the health and social needs
of the public, in particular those of vulnerable populations. The nurse advocates for
equity and social justice in resource allocation, access to health care and other social
and economic services. The nurse demonstrates professional values such as
respectfulness, responsiveness, compassion, trustworthiness and integrity.
2. Nurses and practice
The nurse carries personal responsibility and accountability for nursing practice, and
for maintaining competence by continual learning. The nurse maintains a standard of
personal health such that the ability to provide care is not compromised. The nurse
uses judgement regarding individual competence when accepting and delegating
responsibility. The nurse at all times maintains standards of personal conduct which
reflect well on the profession and enhance its image and public confidence. The nurse,
in providing care, ensures that use of technology and scientific advances are
compatible with the safety, dignity and rights of people. The nurse strives to foster
and maintain a practice culture promoting ethical behavior and open dialogue.
3. Nurses and the profession
The nurse assumes the major role in determining and implementing acceptable
standards of clinical nursing practice, management, research and education. The
nurse is active in developing a core of research-based professional knowledge that
supports evidence-based practice. The nurse is active in developing and sustaining a
core of professional values. The nurse, acting through the professional organization,
participates in creating a positive practice environment and maintaining safe,
equitable social and economic working conditions in nursing. The nurse practices to

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 sustain and protect the natural environment and is aware of its consequences on
health. The nurse contributes to an ethical organizational environment and
challenges unethical practices and settings.
4. Nurses and co-workers
The nurse sustains a collaborative and respectful relationship with co-workers in
nursing and other fields. The nurse takes appropriate action to safeguard individuals,
families and communities when their health is endangered by a co-worker or any
other person. The nurse takes appropriate action to support and guide co-workers to
advance ethical conduct.

CODE OF ETHICS FOR FILIPINO NURSES

The professional code of ethics for Filipino nurses strongly emphasizes the fourfold
responsibility of the nurse, the universality of nursing practice, the scope of their
responsibilities to the people they serve, to their co-workers, to society and environment, and
to their profession.
The Code of Ethics used by Filipino nurses prior to 1984, was the code promulgated
by the International Council for Nurses. In 1982, the PNA Special Committee developed a
Code of Ethics for Filipino Nurses, but was not implemented.
In 1984, the Board of Nursing adopted the Code of Ethics of the ICN, adding
“promotion of spiritual environment” as the fifth-fold responsibility of the nurse.
In 1989, the Code of Ethics promulgated by the PNA was approved by the Professional
Regulation Commission and was recommended for use. This was approved In October 25,
1990 by the general assembly of the PNA.
In July 14, 2004, a new Code of Ethics for Filipino Nurse was adopted under R.A. 9173
and was promulgated by the BON.
The Code of Ethics for Filipino Nurses embodies ethical principles and guidelines to
be observed, stipulated under seven (7) articles. The ethical principles are stated below.
Article I – Preamble
1. Health is a fundamental right. The Filipino RN, believing in the worth and dignity of
each human being, recognizes the primary responsibility to preserve health at all cost.
This responsibility encompasses promotion of health, prevention of illness,
alleviation of suffering, and restoration of health. However, when the foregoing are
not possible, assistance towards a peaceful death shall be his/her obligation.
2. To assume this responsibility, RNs have to gain knowledge and understanding of
man’s cultural, social, spiritual, psychological, and ecological aspects of illness,
utilizing the therapeutic process. Cultural diversity and political and socio-economic
status are inherent factors to effective nursing care.
3. The desire for the respect and confidence of clientele, colleagues, coworkers, and the
members of the community provides the incentive to attain and maintain the highest
possible degree of ethical conduct.

Article II – Registered Nurses and People

1. Values, customs, and spiritual beliefs held by individual shall be represented.
2. Individual freedom to make rational and unconstrained decisions shall be respected.
3. Personal information acquired in the process of giving nursing care shall be held in
strict confidence.

Article III – Registered Nurses and Practice

1. Human life is inviolable.
2. Quality and excellence in the care of patients are the goals of nursing practice.
3. Accurate documentation of actions and outcomes of delivered care is the hallmark of
nursing accountability.
4. Registered nurses are the advocates of the patients: they shall take appropriate steps
to safeguard their rights and privileges.
5. Registered Nurses are aware that their actions have professional ethical, moral and
legal dimensions. They strive to perform their work in the best interest of all
concerned.

Article IV – Registered Nurses and Co-workers

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 1. The RN is in solidarity with other members of the health care team in working for the
patient’s best interest.
2. The RN maintains collegial and collaborative working relationship with colleagues
and other health care providers.

Article V – Registered Nurses, Society, and Environment

1. The preservation of life, respect for human rights, and promotion of healthy
environment shall be a commitment of a RN.
2. The establishment of linkages with the public in promoting local, national, and
international efforts to meet health and social needs of the people as a contributing
member of society is a noble concern of a RN.

Article VI – Registered Nurses and the Profession

1. Maintenance of loyalty to the nursing profession and preservation of its integrity are
ideal.
2. Compliance with the by-laws of the accredited professional organization (PNA) and
other professional organizations of which the RN is a member is a lofty duty.
3. Commitment to continual learning and active participation in the development and
growth of the profession are commendable obligations.
4. Contribution to the improvement of the socio-economic conditions and general
welfare of nurses through appropriate legislation is a practice and visionary mission.

Article VII – Administrative Penalties, Repealing Clause and Effectivity

The certificate of registration of the RN shall either be revoked or suspended for
violation of any provisions of this Code pursuant to Sec. 23 (f), Art.IV of R.A. No. 9173 and Sec.
23 (f), rule III of Board Res. No. 425, Series of 2003, the IRR.

**Art. IV of R.A. 9173 – Examination and Registration

Sec. 23. Revocation and Suspension of Certificate of Registration/Professional License and
Cancellation of Special/Temporary Permit. – The Board shall have the power to revoke or
suspend the certificate of registration/professional license or cancel the special/temporary
permit of a nurse upon any of the following grounds:
(a) For any of the causes mentioned in the preceding section;
(b) For unprofessional and unethical conduct;
(c) For gross incompetence or serious ignorance;
(d) For malpractice or negligence in the practice of nursing;
(e) For the use of fraud, deceit, or false statements in obtaining a certificate of
registration/professional license or a temporary/special permit;
(f) For violation of this Act, then rules and regulations, Code of Ethics for nurses and
technical standards for nursing practice, policies of the Board and the Commission,
or the conditions and limitations for the issuance of the temporary/special permit;
or
(g) For practicing his/her profession during his/her suspension from such practice;

Provided, however, That the suspension of the certificate of registration/professional

license shall be for a period not to exceed four (4) years.

** Rule III of Board Res. No. 425, Series of 2003, the IRR (Implementing Rules and Regulations
o Same as rule III of Board Res. No. 425, Series of 2003, the IRR except:
(f) For violation of RA No. 9173 and this IRR, Code of Ethics for nurses and Code of
Technical Standards for nursing practice, policies of the Board and the
Commission, or the conditions and limitations for the issuance of the
special/temporary permit; or

For this purpose, the suspension of the Certificate of Registration/Professional License

shall be for a period not to exceed four (4) years.

SELF-STUDY GUIDE QUESTIONS

1. Discuss the International Code of Ethics and the Code of Ethics for Filipino Nurses.

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 REFERENCES
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deontological/
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dilemma/
Chan, V. (2015, June 21). Abortion. Retrieved from Slideshare:
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Christiansen, C., & Lou, J. Q. (2001). Ethical Considerations Related to Evidence-Based
Practice. PubMed, 345-349.
Dayton, D. (2018, December 27). Role of Fidelity in Nursing Ethics. Retrieved from Career
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Fischer IV, B. A. (2006). A Summary of Important Documents in the Field of Research Ethics.
Schizophrenia Bulletin, vol.32 no.1 69-80.
International Council of Nurses. (2012). The ICN Code of Ethics for Nurses. Geneva,
Switzerland. Retrieved from https://www.icn.ch/sites/default/files/inline-
files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
Josephson Institute of Ethics. (2016, May 4). Making Ethical Decisions: Process. Retrieved
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https://blink.ucsd.edu/finance/accountability/ethics/process.html
Lay, J., & Nall, R. (2017, December 22). Everything You Need to Know About Artificial
Insemination. Retrieved from Healthline:
https://www.healthline.com/health/artificial-insemination
Lebeaux, R. (2014, May). Resource Allocation. Retrieved from TechTarget:
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20384716
National Privacy Commission. (2012, August 15). Republic Act 10173. Data Privacy Act.
Metro Manila, Philippines: National Privacy Commission.
NSW Health. (2019, June 30). Health Care Records - Documentation and Management.
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Official Gazette. (2002, October 21). Republic Act No. 9173. Metro Manila, Philippines:
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 Vijayananthan, A., & Nawawi, O. (2008). The importance of Good Clinical Practice guidelines
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 APPENDICES
HEALTH CARE ETHICS (NCM 108)
1st Semester, A. Y. 2024 – 2025

CREDIT UNIT/COURSE CREDIT: Theory : 3 units

TIME DURATION: Theory : 54 hours
(Independent Study 10 – 16 hours)

COURSE DESCRIPTION:
This course deals with the application of ethico-moral concepts and principles affecting care
of the individuals, families, population group and community. It involves discussion of issues
and concerns in varied health care situations. The learners are expected to apply sound
ethical decision-making in varied health scenarios.
COURSE POLICIES:
1. Attendance is mandatory and checked within the first 15 minutes of the designated
class schedule. A student with accumulated 3 absences of the total class meetings
will be dropped from the roll.
2. Maximum participation is expected in all classroom activities.
3. At all instances, respect for classmates and instructors are expected. Observe proper
decorum.
4. Come in complete uniform.
5. Come in proper grooming. Hair must be neat and clean. Dyed hair with bright/blond
colors is not acceptable.
6. Use of cellphones, tablets and other gadgets for social and other purposes not
related to the learning material are strictly prohibited during class.
7. It is expected that all written outputs are submitted on time on the designated dates.
8. All students are responsible for maintaining cleanliness and orderliness of the
classroom.
9. Consultation/Messages time will be from Monday-Friday 8:00 AM – 5:00 PM only.
No consultation/messages will be entertained beyond the scheduled time.
Messages/Inquiry sent beyond the scheduled time will be entertained on the next
day during the official office hours.
10. Anyone violating these policies will be sent to the Guidance Office for disciplinary
action.
11. All general policies of the College of Nursing and the University will also be
implemented as part of the policies for this course.

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COURSE PLAN AGREEMENT FORM

I acknowledge that I received the course plan for HEALTH CARE ETHICS (NCM 108).
I have read the course plan and I understand the policies, instructions, expectations, as well
as the grading system, stated in the course plan of this course.
If I have any questions or concerns, I will contact and consult my instructor for further
clarification. I understand that I am to comply with the course requirements by the end of the
semester. I agree to be prepared and attend classes at each scheduled meeting.

PRINTED NAME: ___________________________________________________ SIGNATURE: _________________

DATE: _______________________________________________________________ CONTACT NO: ________________
Email address: (Please write exactly and legibly)
_________________________________________________________________________________________________________
NAME OF PARENT/GUARDIAN: ___________________________________________________________________
RELATIONSHIP: ____________________________________________________ CONTACT NO: _______________
COMPLETE ADDRESS:
_________________________________________________________________________________________________________

COURSE PLAN AGREEMENT 2024

KRISTHINE ABEGAIL M. GAMIAO, MAN, RN

Health Care Ethics 63
Course Instructor
(NCM 108)
 WEEK LEARNING UNIT/TOPIC REQUIREMENT
1 • Orientation to the NEUST vision, mission, core values Write a 100 words reflection
and tagline; CON goals and objectives; and course paper about the importance
content of university vision, mission,
• Leveling of expectations and discussion of the intended core values and tagline; CON
learning outcomes goals and objectives in the
1. Independent study course.
2. Policy in new normal mode of learning
3. Assessment, evaluation and grading system Rubric on Reflection Paper
4. Requirements
5. Students ethics
2-3 Unit 1. Theories and Principles of Health Ethics Minute paper (write all
A. Ethical Theories you’ve learned in 1minute)
1. Deontology
2. Teleology Rubric on Assignment
3. Utilitarianism
B. Virtue Ethics
1. Virtues Ethics in Nursing
2. Core Values of a Professional Nurse
4-5 C. Ethical Principles Digital scavenger hunt
1. Autonomy Students find or create
• Patient’s Rights media (images, video clips,
• Filipino Patient’s Bill of Rights audio clips) that they think
• Informed Consent best represent course
• Proxy Consent/ Legally Acceptable concepts to share with the
Representative Confidentiality class.
2. Accountability
3. Veracity Rubric on presentation
4. Fidelity
5. Justice
6. Beneficence
7. Non-maleficence
6 D. Other Relevant Ethical Principles Discussion & Impromptu
1. Principle of Double Effect Debate
2. Principle of Legitimate Cooperation
3. Principle of Common Good and Subsidiarity
7-8 E. Principle of Bioethics Think-Pair-Share
1. Principle of Stewardship and Role of Nurses as Posing a short problem,
Stewards scenario, or question to
2. Principle of Totality and its integrity students and giving them the
• Ethico-moral Responsibility of Nurses in time and opportunity to
Surgery complete the following steps.
• Sterilization/ Mutilation
• Presentation of Bodily Issues on Organ Rubric on Think-Pair-Share
Donation
3. Principles of Ordinary and Extraordinary Means
4. Principles of Personalized Sexuality
9 MIDTERM EXAM
10-11 Unit 2. Bioethics and its Application in Various Health Think-Pair-Share
Care Situations Posing a short problem,
A. Sexuality and Human Reproduction scenario, or question to
1. Human Sexuality and its Moral Evaluation students and giving them the
2. Marriage time and opportunity to
• Fundamental of Marriage complete the following steps.
Health Care Ethics 64
(NCM 108)
 • Issues on Sex Outside Marriage
• Issues on Contraception, its Morality, and Rubric on Think-Pair-Share
Ethico-moral Responsibility of Nurses
3. Issues on Artificial Reproduction, its Morality and
Ethico-moral Responsibility of Nurses
• Artificial Insemination
• In-vitro Fertilization
• Surrogate Motherhood
4. Morality of Abortion, Rape and other Problems
Related to Destruction of Life
B. Dignity in Death and Dying
1. Euthanasia
2. Inviolability of Human Life
3. Suicide
4. Dysthanasia
5. Orthothanasia
6. Administration of Drugs to the Dying
7. Advance Directives
8. DNR or End of life Care Plan
C. Nursing Roles and Responsibility
D. Ethical Decision Making Process
12-13 Unit 3. Bioethics and Research Minute paper (write all
A. Principles of Ethics in Research you’ve learned in 1minute)
1. Nuremberg Code
2. Declaration of Helsinki Rubric on Assignment
3. Belmont Report
B. Ethical Issues in Evidenced Based
Practice
C. Ethico-moral Obligations of the Nurse in Evidence
Based Practices
1. Introduction to Good Clinical Practice Guidelines
14 Unit 4. Ethical Consideration in Leadership and Answer self-study guide
Management questions
A. Moral Decision Making
1. Principle of Moral Discernment
2. Principle of Well-Formed Conscience
3. Strategies of Moral Decision Making Process
• Ethical Dilemma
B. Meaning and Service Value of Medical Care
1. Allocation of Health Resources
2. Issues Involving Access to Care
Unit 5. Guidelines and Protocol in Documentation and Answer self-study guide
15
Health Care Records questions
16 Unit 6. Ethical Issues Related to Technology in the Digital scavenger hunt
Delivery of Health Care Students find or create
A. Data Protection and Security media (images, video clips,
1. Data Privacy Act 2012 audio clips) that they think
(RA 10173 Series of 2012) best represent course
B. Benefits and Challenges of Technology concepts to share with the
C. Current Technology Issues And Dilemma class.

Rubric on presentation

17 Unit 7. Continuing Education Programs on Ethico- Answer self-study guide

Moral Practice in Nursing questions
A. Code of Ethics for Professional Nurses
1. International Council of Nurses Code of Ethics
2. Code of Ethics for Filipino Nurses
18 FINAL EXAM

Health Care Ethics 65

(NCM 108)
 GRADING SYSTEM
DESCRIPTION MIDTERM FINAL TERM
Term Examination 40% 40%
Quizzes/Unit Test 25% 25%
Output/Requirement 20% 20%
Attendance 15% 15%
TOTAL 100% 100%
FINAL GRADE = Midterm Grade + (Final Grade x 2)

RUBRIC ON REFLECTION PAPER

CRITERIA POOR FAIR GOOD EXCELLENT POINTS
4 pts 6 pts 8 pts 10 pts
Depth of Writing Writing Writing demonstrates Writing demonstrates
reflection demonstrates a demonstrates a a general reflection on an in-depth reflection on
lack of reflection minimal reflection the selected topic, the selected topic,
on the selected on the selected including some including supporting
topic, with no topic, including a supporting details and details and examples.
details. few supporting examples.
details and
examples.
Required Writing does not Writing includes a Writing includes the Writing surpasses the
components include the few components of required components required components of
required the selected topic. of the selected topic. the selected topic.
components of the
selected topic.
Quality of The information Information relates Information relates to Information relates to
Information has little to do with to the main topic. the main topic. It the main topic. It
the main topic. No details and/or provides 1-2 includes several
examples are given. supporting details supporting details
and/or examples. and/or examples.
Structure & Writing unclear, Writing is unclear, Writing is mostly clear, Writing is clear, concise,
Organization disorganized. and thoughts are concise, and organized and well organized with
Thoughts make not well organized. with the use of the use of excellent
little to no sense. Thoughts are not excellent sentence/paragraph
expressed logically. sentence/paragraph structure. Thoughts are
structure. Thoughts expressed logically.
are expressed
logically.
Timeliness Submit 3 days or 1 Submit 2 days after Submit 1 day after the Submit on time.
week after the the deadline. deadline.
deadline.
Reference: iRubric

Health Care Ethics 66

(NCM 108)
 RUBRIC ON SELF-STUDY GUIDE QUESTIONS

NO NEEDS
ADEQUATE QUALITY EXEMPLARY
CRITERIA ANSWER IMPROVEMENT POINTS
6 pts 8 pts 10 pts
0 pts 4 pts
Content Did not Answers are Answers are not Answers are Answers are
answer the partial or comprehensive or accurate and comprehensive,
question. incomplete. The completely stated. complete. Key accurate, and
key points are not Key points are points are complete. Key ideas
clear. Question addressed, but not stated and are clearly stated,
not adequately well supported. supported. explained, and well
answered. supported.
Organization Did not Organization and Inadequate The Well organized,
Answers are answer the structure detract organization or organization coherently
thought out question. from the answer. development. The is mostly clear developed, and
and structure of the and easy to easy to follow.
articulated. answer is not easy follow.
to follow.
Writing Did not Displays over five Displays three to Displays one Displays no errors
Conventions answer the errors in spelling, five errors in to three errors in spelling,
Spelling, question. punctuation, spelling, in spelling, punctuation,
punctuation, grammar, and punctuation, punctuation, grammar, and
grammar, and sentence grammar, and grammar, and sentence structure.
complete structure. sentence structure. sentence
sentences. structure.
Timeliness Did not Submit 2 days Submit 1 day Submit on Submit ahead of
submit. after the after the time. time
deadline. deadline.

RUBRIC ON ASSIGNMENT PAPER

POOR FAIR GOOD EXCELLENT

Does not meet Assignment Meets Exceeds
CRITERIA
assignment objectives partially assignment assignment POINTS
objectives met objectives objectives
5 pts 10 pts 15 pts 20 pts
Accuracy Little to none of the Some of the answers Most of the All the answer is
answers are correct are correct answers are correct
correct
Completeness Incomplete Nearly complete Almost complete Complete and
(1-2 examples) (3-5 examples) (6-8 examples) informative
(9 or more
examples)
Format Paper lacks many Paper follows most Paper follows Paper follows all
elements of correct guidelines. designated designated
formatting. The format is fair. guidelines. guidelines.
The format is The format enhances
good. the readability of the
paper.
Timeliness Submit 3 days or 1 Submit 2 days after the Submit 1 day Submit on time.
week after the deadline. after the deadline.
deadline.

Health Care Ethics 67

(NCM 108)
 RUBRIC ON PRESENTATION

Poor Average Extraordinary

CRITERIA POINTS
10 point 15 points 20 points
Understanding The artwork shows The artwork is planned The artwork is planned
Demonstration that no understanding of adequately; understanding carefully; understanding of all
instructions and the concepts and some concepts and concepts and instructions is
concepts are instructions. instructions shown. clearly shown.
understood.
Craftsmanship/ The artwork shows The artwork shows The artwork shows outstanding
Skill poor craftsmanship average craftsmanship and craftsmanship, with clear
Neatness, precision, and no attention to attention to detail. attention to detail.
care. detail.
Creativity/ The artwork lacks The artwork demonstrates The artwork demonstrates
Originality evidence of personal an average amount of original personal expression
Inventiveness, expression. personal expression. and outstanding problem-
expression of ideas, solving skills.
and imagination.
Effort The student put forth The student put forth the The student put forth
What it takes to no effort or the effort required to finish the extraordinary effort to
finish the project as project was not project; used class time complete the project as well as
well as possible, completed; class time adequately. possible; used class time
time dedicated to was not used well. extremely well.
the project inside
and/or out of class.
Timeliness Submit 3 days after Submit 1 day after the Submit on time.
the deadline. deadline.

RUBRIC ON THINK-PAIR-SHARE
UNCLEAR DEVELOPING STRONG
CRITERIA POINTS
10 points 20 points 30 points
Viewpoint Viewpoints are unclear Most viewpoints are clear. Viewpoints are clear and
and disorganized. organized.
Supporting Few supporting Many supporting All supporting arguments
Arguments arguments are relevant arguments are relevant are relevant, strong, and
and are unconvincing. and most are convincing. convincing.
Use of Facts & Arguments are either Arguments are supported Arguments are supported
Examples unsupported or rely on with 1-3 pieces of evidence with 3-5 pieces of evidence
Evidence unreliable sources. and are mostly from from credible sources.
examples credible sources.
include quotes,
historic
examples,
statistics.
Presentation Voice is difficult to Voice can usually be Voice can always be heard.
understand. The student understood. The student The student is well
is unprepared to defend needs additional prepared. Well-paced and
the argument. Too short preparation. Some timed.
or too long with pacing problems with pace The structure is evident with
issues. and/or length. a clearly stated thesis,
The structure was Mostly fluent structure points, evidence, and re-
illogical or absent or with some errors statement
confusing to the
audience.
Engagement The student does not The student listens to the The student actively listens
show evidence of opponent, has some to other speakers, makes
listening to others, reads attempt at eye contact, good eye contact, adheres to
without eye contact have mostly follows time time limits, and is respectful
respect for his/her requirements, and uses in tone and language.
opponent, and goes well respectful language most
over or under allowed of the time.
time.

Health Care Ethics 68

(NCM 108)