BIOETHICS

Ethical Principles

RN
 PRINCIPLE OF HUMAN DIGNITY
Basis of Human Dignity

Human rights
- needs and values as it relates to other human beings - it
is universal
- equal among everybody
- not a product of human creativity but inherent to us

Universal Declaration of Human Rights (1948)

– respects the dignity of the human person

PERSON a person is a rational, autonomous being with the

ability to know universal, objectives moral laws & the
freedom to decide to act morally
 SIGNIFICANCE OF BEING A PERSON

• Has an inherent dignity which must be respected

- A person should not be destroyed; uniqueness must not be

altered; genes cant be manipulated; organs removed
without any reason; one cant be cloned

- Has an ultimate destiny- to live with God

- To fulfill this, one has needs that must be met, resources

must help one meet these needs; but he is only a steward

- Lives with other persons in the community

- -Interacts with people; helps them

 HUMAN DIGNITY

 All ethical decisions (made by patients and healthcare givers) must

aim basically and ultimately at human dignity.
 They must protect, defend, enhance and enable the person’s worth.
 They must aim for the maximum and integrated satisfaction of every
person’s needs, as an individual and members of his community.
Human Dignity
 Every human being has an inner worth and inherent dignity. These he
possesses not because of what he has or what he does but because of what
he is:
a human person
 As a human person, he must be respected regardless of the nature of his
health problem, social status, competence, past actions
 Decisions about health must aim at the maximum integrated satisfaction
of his needs: biological, psychological, social and spiritual
 Certain actions may never be done because performing them would
constitute a violation against the person’s digni
 Respect for Person

Every human being has an inner worth and inherent

dignity. These he possesses not because of what he has or
what he does but because of what he is:
a human person
 As a human person, he must be respected regardless of
the nature of his health problem, social status, competence,
past actions
 Certain actions may never be done because performing
them would constitute a violation against the person’s
dignity
Ethical
Principles
 Autonomy

Greek word “autos” meaning self and “nomos” meaning rule/

governance/ law. self- governing or the ability to govern self is dependent
upon many factors such as
o sound mind
o sound body
o full information of the issues
o without force or coercion

“Self Rule”
Having the right to choose/Decide for himself;
An individual has the right to determine for himself
Corollary Principles​- Honesty in our dealings with others and
obligation to keep promises.
- Recognizing patients as persons who are entitled to such basic
human rights such as the right to know, privacy and right to receive
treatment - State of being self-regulating, self-defining and self-
reliant
- Ability of a person to make their own decisions without interference
- freedom to make choices about issues that affect one’s life
- Respect for persons; unique and valuable members of the society
- Free to choose and implement one’s own decision, free from lies,
restraint or coercion
KEY POINTS

This principle assumes rational

thinking on the part of the individual
and may be challenged when the
rights of others are infringed upon by
the individual
 Patient’s Rights
> ​Right to appropriate Medical Care and Humane Treatment
> ​Right to Informed Consent
>​Right to Information
>​Right to Religious Belief
>​Right to Leave
>​Right to Express Grievances
>​Right to Correspondence and to Receive Visitors
> ​Right to be informed of his Rights and Obligations as a Patient
>​Right to Refuse Participation in Medical Research
>​Right to Privacy and Confidentiality
>​Right to Choose Health Care Provider and Facility
 Patient’s Bill of Rights

> ​High quality hospital care

> ​A patient can expect to be treated with respect regardless of race, sex, gender, color,
religion, age, marital status, sexual orientation, disability or other state or condition
>​A patient may choose who she/he spends time with during the course of care
>​Appropriate pain management will be provided to the patient
>​Patients are to be free from restraints and seclusion unless completely medically
necessary
>​Providers will disclose and discuss patient’s condition and provide information about
relevant medical decisions
>​Providers will understand who is to make decisions for the patient if she/he is unable
to > ​Patients can expect access to their medical records at will
>​​Providers will work to obtain information from patients about their condition and
personal state
>​Providers will work to understand the patient’s health care goals and personal values
 PATERNALISM

 Deliberate restriction of people’s autonomy by

health care professionals based on the idea that they
know what’s best for the clients- can be justifiable at
times
 Doing good should take precedence over autonomy
The doctor can decide:
1. Doctor can act as loco-parentis
2. If it is a matter of life and death
3. Court
 Informed Consent Or Enlightened Consent
 It is a patient’s right to exercise freedom to make decisions
for his/her health. Appropriate and necessary information
are required so that medical protocols and management may
be done for his interest.
 To protect the basic need of every human person for
health care and the person’s primary responsibility for his
or her own health,
(1) no physical or psychological therapy may be administered
without the free and informed consent of the patient, or,
(2) if the patient is incompetent, the person’s legitimate
guardian acting for the patient’s benefit and, as far as
possible, in accordance with the patient’s known and
reasonable wishes.
- Autonomy and Respect for person.

- Any procedure to be done on a person may only be

administered with his free and Informed consent. This
gives valid permission for others to act in certain specific
ways.
 Informed Consent Or Enlightened Consent

Informed Consent therefore has 2 main functions:

a. Protective​- to safeguard against intrusion of

integrity.

b. Participative​- to be involved in medical decision

making.
 Informed Consent Or Enlightened Consent

Nursing Responsibilities:

Witness the signing of the consent.

Make sure the patient understands the procedure to be
performed.
The ability to give informed consent depends on:
Adequate ​disclosure​of information;
 Patient ​freedom​of choice;

Patient ​comprehension​of information;

And patient ​capacity for decision making.

By meeting these above requirements, three necessary conditions are

satisfied:
1.​​That the individual’s decision is voluntary
2.​​That this decision is made with an appropriate understanding of the
circumstances;
3. And that the patient’s choice is deliberate in so far as the patient has
carefully considered all of the expected benefits, burdens, risks and
reasonable alternatives.
Legally, adequate disclosure includes information concerning the following:

What information you should give to patients?

1. Diagnosis: Current Medical status
2. Nature and purpose of treatment; procedures available
3. Risks of treatment and benefits
4. Treatment alternatives
1. Prognosis
2. Affordability

Types of consent
a. Admission agreement
b. Blood Transfusion consent
c. Surgical Consent
d. Research Consent
e. Special Consent
 Functions of Informed consent

a. To avoid fraud and duress

b. To encourage self- scrutiny by professionals

c. To foster rational decision making

d. To involve the larger society in the debate

 Proxy Consent/Legally Acceptable Representative

The patient’s family or guardian or representative provides it. This is ​

Proxy Consent​. Decisions by proxy should be based on what the patient
would have chosen had he been competent or if the patient’s preferences
are not known, based on the patient’s interest.

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:

1. The person making the delegation must have the right to consent.
2. The person must be legally and medically competent to delegate the right to consent.
3. The right to consent must be delegated to a legally and medically competent adult.
Depending on the circumstances consent may take ​2 other forms.​

*Presumed- In cases where individuals are brought to the hospital in an unconscious state or
with no decision-making capacity, that the procedures to be performed are necessary and
can’t be postponed until the person has regained consciousness or decision-making capacity.

*Vicarious Consent- For incompetent or incapacitated individuals, this right and duty of the
patient to give consent is to be exercised on her behalf by a surrogate. This is regulated by
individual state and federal laws, following various standards of surrogate decision making,
including substituted judgment and best interests.
 Proxy Consent/Legally Acceptable Representative

Who are incompetent?

- Comatose
- Below 18 yrs old
- Mentally incoherent
Who gives proxy consent?
1. Durable Power of attorney
2. Closest of kin
 Adult- married- spouse, children of major age Below
18- parents, grandparents No spouse- siblings,
uncles/aunts
 Key point
 In securing consent, exhaust the vertical line first before the
horizontal
 Proxy Consent/Legally acceptable representatives

Legally Authorized Representative (LAR): An

individual or judicial, or other body authorized under
applicable law to grant permission on behalf of a
prospective participant in research activities. Surrogate
consent was previously referred to as ​“proxy consent”.​
 Proxy Consent/Legally acceptable representatives
Privacy- ​A state of being private, withdraw from public view or
company. Privacy is justified by the principle of Autonomy. Rights to
privacy are valid claims against unauthorized access that have their basis
in the right to authorize or decline access. These rights are justified by
rights of Autonomous choice expressed in the principle for autonomy. In
this respect, the justification of the right to privacy is parallel to the
justification of the right to give an Informed Consent.
Latin ​“ privatus”​Patient’s right.
Invasion of Privacy – If ​a patient is exposed to the public personally or
thru pictures or recording, the person responsible for his/ her exposure
can be held liable if the patient has not given his authority for the
exposure. Unauthorized exposure even after death may constitute
Invasion of Privacy.​
 PRINCIPLE OF CONFIDENTIALITY

Latin word ​“confidere”​means to trust

Confidentiality
• non disclosure of private or secret information with one is
entrusted
• Requires the non-disclosure of private or secret
information with which one is entrusted
• ICN (2000)- “ the nurse holds in confidence personal
information and uses judgment in sharing this information”
• An important component of autonomy- maintains dignity
and respect for the person
 PRINCIPLE OF CONFIDENTIALITY

Relates to matters of professional ethics. It protects the client/patient

from the unauthorized disclosures of any sort by the professionals
without the informed consent of the client.
The purpose of confidentiality is to ​safeguard t​he clients right with
sanctions for violations of confidentiality.
Clients must be able to assume that their private communications with
the obligation not to divulge information without the client knowledge
and authorization unless it is in the client interest to do so
2 General Situations that may give rise to exceptions exist:

Concern safety of other specific person, the determining

factor in justifying breaking confidentiality is whether there is
good reason to believe, specific individual are placed in
serious danger depending on the medical information at hand.

Concern for Public Welfare in most cases of limited

confidentiality. The health care practitioner is required to
report in certain communicable infectious diseases to the
public health authorities the duty to protect.
Privacy – non exposure of a body part

The following are subjects of Confidentiality and should not

be revealed to anyone except for graver cause:
1. Private Secrets
2. Contractual Secrets
3. Professional Secrets
Privileged Communication  intent to kill self or someone
 a confidential communication that one cannot  communicable disease
be forced to divulge  statuses require the disclosure of certain
 Husband & wife happenings e.g. rape, abuse, incest, other crimes
 priest & penitent  Personal decision
 doctor & patient  Reportable cause
 lawyer & client  Legal case
 To qualify for privileged status,
communication must generally be made in KEY POINTS
private setting (that is, in a context where  The public good outweighs the individual’s right
confidentiality could reasonably be expected).to privacy and confidentiality
 Are there any situations in which a medical  protective privileged ends where the public
professional justified in revealing perils begins
embarrassing or damaging information about  duty to warn is the duty to disclose confidential
a patient to a third party? information to protect identifiable victim and
warn appropriate authority targeted by threat

GRAVE CAUSE
 abuse (child/ elder abuse)
 VERACITY/TRUTH

 truthfulness, document accurately

 Duty to tell the truth
 Fundamental to the development and continuance of
trust among human beings- truth telling, integrity and
honesty

 Truth telling
Definition: a nursing intervention from the Nursing
Interventions Classification (NIC) defined as the use of
whole truth, partial truth, or decision delay to promote the
patient’s self determination and well being.
 VERACITY/TRUTH

Thoughts corresponds to action

“ We should declare what we think and not lie”.
*Lying – ​intention of deceiving
*Lie - ​“intrinsically evil and can never be considered lawful”
*Truth ​– Concealing the ​truth when:

Mental Reservation- ​act of the mind limiting the spoken

phrase.
Not bearing the full sense of the phrase. ​

Example:​Supposed to know but ​not​to tell like- Cancer

patient.
 VERACITY/TRUTH
Mental Evasion-​limiting the right of the patient to know about his
condition.
Avoid in answering questions.
Never, tell a lie but tell them with Mental Reservation and Evasion

*​Conceal the truth when:

you have no right to disclose the truth
*​The person has no right to know the truth ​
Considerations in concealing truth when:
*It must not injure the right of another person to know the truth
*There must be a good reason for concealing the truth
*The intention for concealing the truth must be good
 FIDELITY
 faithfulness, promises and loyalty
 Obligation of an individual to be faithful to commitments to
him/herself and also to others
 Main support for the concept of accountability
 Keeping information confidential and maintaining privacy and trust

It’s keeping one’s promises. The nurse must be faithful and

true to their professional promises and responsibilities by
providing high quality, safe in a competent manner.
 JUSTICE
Latin word ​“justitia”​– ​“jus”​From ​“ justus” ​means lawful and rightful
Fairness; Equal distribution of resources
“Giving each one what is his due”

JUSTICE = EQUITY
EQUITY vs UNIFORMITY

Preferential option for the poor

X​- has a right to his due
Y​- has the obligation not to deprive ​X ​of his due.
Justice also means to treat equals equally X ​and ​Y ​are equal: ​X ​and ​Y ​
should have equal benefits/burdens ​
 JUSTICE
IMPLICATIONS OF THE PRINCIPLES OF JUSTICE
1. each individual should receive what is due to right such as
a. Life
b. Information needed for decision making
c. Confidentiality of private information
2. 2. benefits should be justly distributed among individuals such as
a. minimum health care
b. equal opportunities for scarce resources
3. each individual should share in the burden of health and science such as
c. caring for his own health
d. caring for the health of others
e. participating in health/science progress
VIOLATIONS OF THE PRINCIPLES OF JUSTICE
1. Denying/ withholding a benefit to which a person has a right
2. Distributing a minimum health benefit unequally
3. Imposing an unfair burden on an individual
 JUSTICE
NON VIOLATIONS OF THE PRINCIPLES OF
JUSTICE 1, the patient chooses to give up what is
due
2. unjust outcome results or just process

Distributive Justice
 the aspects of justice that pertains to a fair
scheme of distributing a society’s benefits and
burdens to its members

PROBLEMS OF DISTRIBUTIVE JUSTICE

a. macro-allocation
b. meso – allocation
 4 Different Types of Justice

Commutative Justice- refers to that which is

owed between individuals
Example:in conducting business transactions

Contributive Justice- which refers to what

individuals owe to society for the
common good
 4 Different Types of Justice
Legal Justice- which refers to rights and responsibilities of citizens to obey
and
respect the rights of all the laws devised to protect peace and social order and
Distributive justice- which refers to what society owes to its individual
members.
Example: the just allocation of resources.

Creating a health care policy helps decide how limited resources are to be
distributed . It should consider the principles of equality (distributive justice),
social justice and solidarity.
The policy should state in clear terms the criteria for consideration, rank
ordering, etc. and
this should be made public. The process must be just, though sometimes
outcomes do not
appear Just.
 JUSTICE

A. Utilitarian alternatives
 promotes the highest good that is possible in every situation (the greates good for the
greatest number)
 Principle of Immediate Usefulness
o gives priority to the candidate who is at greater immediate service to the larger
group under the circumstances
 Medical Success Principle
o give priority to those whom treatment has the highest probability of success
 Principle of Conservation
o gives priority to those candidates who requires proportionally smaller amount of
resources and therefore more lives would be saved
 Parental Role Principle
o gives priority to those who have the largest responsibilities to dependents
 Principle of General Social Value
o gives priority to those believed to have the greatest general social worth thus
eading to the good of society
 JUSTICE

B. Egalitarian Alternatives
- restoring the equality of the persons in need
 Principle of Saving No One
= gives priority to no one because not all can be saved
 Principle of medical Neediness
= with the most pressing medical needs
 Principle of General Neediness
= gives priority to the most helpless or generally neediest in an attempt to bring
them as nearly as possible to a level of well being equal to that enjoyed by
others.
 Principle of Queuing the line
= gives priority to those who arrived first
 Principle of Random Selection
= gives priority to those selected by chance or random
 PRINCIPLE OF BENEFICENCE

Beneficence
 Comes from the LT. word “bene” meaning good
and “fiche” meaning to act or do. Beneficentia
 An act of or goodness, kindness, an action done for
the good and benefit of others.

Practice of doing acts of goodness, kindness and charity; suggests acts of Mercy and
Charity.
Is the positive pole of non –maleficence. It means to do good, to
provide a benefit.
“ Do good and do no harm”
 PRINCIPLE OF BENEFICENCE
Action that brings the most benefits and the least burden to those
affected, this is the P​rinciple of Utility.​

X- ​has a duty to benefit ​Y ​provided ​Y​- is at significant risk

X’s ​action is needed; X’s ​action is likely to succeed;

There is No significant risk for ​X​. The benefit to ​Y ​outweighs any harm
for ​X​.

Example:​Do overtime, during emergency, Stay and help or No help at

all.
 PRINCIPLE OF NONMALEFICENCE
 it is related to the following human rights
 Right not to be killed
 Right not to have bodily injury or pain inflicted to oneself
 Right not to have one’s confidence revealed to others

Violations of nonmaleficence
1. Physically harming a person as in suicide, abortion, infanticide, torture and
violence
2. Exposing a person to physical harm as in subjecting a person to unnecessary
treatment or to dangerous procedure without a commensurate important goal.
3. Harming a person’s reputation, honor, property or interests as by revealing
confidential information
KEYPOINTS
4. BOTH the principles of BENEFICENCE and NONMALEFICENCE focus on
doing good to others.
5. BOTH principles attuned to ALTRUISM (doing good)
 PRINCIPLE OF NONMALEFICENCE

Make sure patient is safe and not harmed

“ Do not inflect harm’’ ​means to do No, to prevent, to remove or ​not​to

risk harm.

X​- has a right Not to be harmed;

Y​- has an obligation, Not to harm ​X
Harm maybe physical, mental, psychological, social, financial,
spiritual etc.

Example: ​Hippocratic Oath-​“ I will never use treatment to injure or

wrong the sick”
Other Relevant Ethical Principles