Bioethics

PRELIMS

THEORIES AND PRINCIPLES OF HEALTH CARE ETHICS

- Ethics is the moral principles that govern a person’s behaviour or the conducting of an activity.

- Morals are concerned with the principles of right and wrong behaviour and the goodness or badness of human character.

Ethical Issues in Nursing

Theories of Ethics

- Utilitarianism (Consequentalism)

- Act-utilitarianism
- Rule-utilitarianism

- Deontlogy

Utilitarianism

- Right action is that which has greatest utility or usefulness

- No action is, in itself, either good or bad
- The only factors that make actions good or bad are the outcomes

Act-Utilitarianism

- A person performs the acts that benefit the most people, regardless of personal feelings or the societal constraints such as
laws.

Rule-Utilitarianism

- Seeks to benefit the most people but through the fairest and most just means available. It takes into account the law and is
concerned with fairness.

Deontology (Kantianism)

- The rightness or wrongness of an act depends upon the nature of the act, rather than its consequences.
- People should adhere to their obligations and duties when engaged in decision making when ethics are in play
- A person who adheres to deontological theory will produce very consistent decisions since they will be based on the
individual’s set duties

Virtue Ethics

- Judges a person by his/her character rather than by an action that may deviate from his/her normal behaviour
- One weakness of virtue ethical theory is that it does not take into consideration a person’s change in moral character.

ETHICAL PRINCIPLES

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 - AUTONOMY
- NONMALEFICENCE
- BENEFICENCE
- JUSTICE
- FIDELITY
- CONFIDENTIALITY
- VERACITY
- ACCOUNTABILITY

Autonomy

- The freedom to make decisions about oneself

- The right to self-determination
- Healthcare providers need to respect patients’ rights to make choices about healthcare, even if the healthcare providers do not
agree with the patient’s decision.

INFORMED CONSENT relates to a process by which patients are informed of the possible outcomes, althernatives, and risks of
treatments, and are required to give their consent freely.

It assures the legal protection of a patient’s right to personal autonomy in regard to specific treatment and procedures.

Patients are given the opportunity to autonomously choose a course of action in regard to plans of medical care.

NONCOMPLIANCE – unwillingness of the patient to participate in health care activities

Nonmaleficence

- Requires that no harm be caused to an individual, either unintentionally or deliberately

- This principle requires nurses to protect individuals who are unable to protect themselves

Beneficence

- This principle means “doing good” for others

- Nurses need to assist clients in meeting all their needs:
 Biological
 Psychological
 Social

3 major components:

1. Do or Promote Good
2. Prevent Harm
3. Remove Evil or Harm

Justice

 Every individual must be treated equally

 This requires nurses to be nonjudgmental

DISTRIBUTIVE JUSTICE – fair and equitable distribution of goods and services

Fidelity

 Loyalty
 The promise to fulfill all commitments
 The basis of accountability
 Includes the professionals faithfulness or loyalty to agreements & responsibilities accepted as part of the practice of the profession

Confidentiality

 Anything stated to nurses or health-care providers by patients must remain confidential

 The only times this principle may be violated are:
• If patients may indicate harm to themselves or others
• If the patient gives permission for the information to be shared

Veracity

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  This principle implies “truthfulness”
 Nurses need to be truthful to their clients
 Veracity is an important component of building trusting relationships

Accountability

 Individuals need to be responsible for their own actions

 Nurses are accountable to themselves and to their colleagues

Ethical Dilemmas

 Occur when a problem exists between ethical principles

 Deciding in favor of one principle usually violates another
 Both sides have “goodness” and “badness” associated with them

RELEVANT ETHICAL PRINCIPLES

Principle Of Double Effect

• One act can embrace two effects – an intended good effect and an unintended bad effect
• Morality of the act is governed by the intended effect
• Ethically permissible only if:
- Act is morally good or at least morally neutral
- Only good effect is intended
- Good results outweighs the bad result

Principle of Double Effect

When can the principle of double effect not be invoked?

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.

Principle of Cooperation

 COOPERATION is working with another in the performance of an action.

 The degrees of cooperation may vary according to the gravity or essentiality of the shared act in the performance of an evil
action.
 FORMAL COOPERATION - consists of an explicit intention and willingness for the evil act. The one formally
cooperating categorically wills and intends the evil action.

Ex: 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.

Principle of Common Good and Subsidiarity

• The common good is the "good that comes into existence in a community of solidarity among active, equal agents.“
• Essential to the common good is participation by all in all spheres of society.
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 • PRINCIPLE OF SUBSIDIARITY- means that what an individual, lower or smaller group can achieve within his/her or its
capacity should not be taken away and transmitted to the custody and performance of a higher or bigger group.

Ex: in an effort to control the apparent rapid population growth in the country, the State formulates program on responsible
parenthood which rebounds to the enactment of a law mandating every family to just limit the number of its offspring only to one or
two under pain of penalty. And so, the State through the Department of Health conducts contraceptive programs and distributes
various forms of contraceptive methods to ensure the State-directed number of children every family ought to raise.

Principles of Bioethics

Principle Of Stewardship

• Human life comes from God and no man is the master of is own body.
• Humans are mere stewards or caretakers, with responsibility of protecting and cultivating spiritual bodily functions.
• We are obliged to take care of ourselves.
• STEWARDSHIP refers to the expression of one’s responsibility to take care of, nurture and cultivate what has been entrusted
to him.

“No one can in any circumstance, claim for himself the right to destroy an innocent human being.”

-Donum Vitae

-Donum Vitae is the "Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation" which was issued on
February 22, 1987, by the Congregation for the Doctrine of the Faith.

Principles of Integrity and Totality

• These principles dictate that the well-being of the whole person must be taken into account in deciding about any therapeutic
intervention or use of technology.
• Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified only by a proportionate
benefit to the patient.
• INTEGRITY refers to each individuals duty to “preserve a view of the whole human person in which the values of the
intellect, will, and conscience are highly distinguished”.
• TOTALITY refers to the duty to preserve intact the physical component of the integrated bodily and spiritual nature of
human life, whereby every part of the human body “exists for the sake of the whole as the imperfect for the sake of the
perfect”.
• The whole is greater than any of its parts.

Organ Donation Ethical Issues

- Because these donations require a transplant from one living person to another, a moral dilemma involving the principle of
totality arises. According to this principle, the parts of the body are ordered to the good of that specific body. Therefore, the
surgical mutilation of a donor for the good of the recipient must not seriously impair or destroy bodily functions or beauty of
the donor.

For example, both eyes are necessary for certain visual functions. A living person would seriously impair his ability to see if an eye
were donated to another. Such a sacrifice would detract from the wholeness or full functioning of the donor's body. It would be a bad
means to a good end, and therefore morally wrong.

Principle of Ordinary and Extraordinary Means

• Ordinary means = reasonable hope of benefit/success; not overly burdensome; does not present an excessive risk and are
financially manageable
• Proportionate to the state of the patient
• “Ethically indicated” (Strong 1981 p. 84).
• Extraordinary means = no reasonable hope of benefit/success; overly burdensome; excessive risk and are not financially
manageable
• No obligation to use it/morally optional

Principle of Personalized Sexuality

• Personalized Sexuality is based on an understanding of sexuality as one of the basic traits of a person and must be developed
in ways consistent with enhancing human dignity.
• The gift of human sexuality must be used in marriage in keeping with its intrinsic, indivisible, specifically human teleology.
• It should be a loving, bodily, pleasurable expression of the complimentary, permanent self-giving of a man and a woman to
each other, which is open to fruition in the perpetuation and expansion of this personal communion through the family they
beget and educate.
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FOUNDATIONS OF LAW

Law

 A body of rules of action or conduct prescribed by controlling authority and having binding legal force.
 Minimum standard of expected performance between individuals in a society.

Basic Sources for Modern Law

Fundamental Principles of Law

- Justice and fairness

- Plasticity and change
- Doctrine of Individual Rights and Responsibilities

Lawsuit

- begins when a plaintiff files a complaint or petition with the court that addresses the elements of prima facie case (legally sufficient
to establish a case)

Plaintiff a person who brings an action in a court of law

Defendant a person against whom an action is brought

Steps in Lawsuit

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Public Law

Crimes according to seriousness and level of punishment…

Felony Misdemeanor
More serious breach of Punishabe by less than a
law year of imprisonment in
a jail
Punishable by death or Theft of small amount
improsonment
Murder Disorderly conduct
Rape
Robbery

Private Law

Types of Private Law

Tort Contract Law

A private or civil wrong Breech of contract
or injury
Breach of Contract

- Failure, Without legal excuse, to perform any promise that comprises the whole part of the contract

Basic Objectives of Tort Law

1. Preservation of peace between individuals

2. Determining of fault
3. Compensation for injury

Categories of Torts

• Negligent Tort
• Intentional Tort

Negligent Torts

 Negligence is the unintentional commission or omission of an act that a reasonably prudent person would or would not do
under the same or similar circumstances
 Harm caused by carelessness of a professional health provider
 Malpractice is a type of negligence

Forms of Negligence

Malfeasance – execution of an unlawful or improper act

Misfeasance – the improper performance of an act that leads to injury

Nonfeasance – failure to perform an act, when there is a duty to act

4 Ds of Negligence

• Duty
• Dereliction of Duty
• Direct Cause
• Damage

Legal doctrines associated with medical malpractice...

Res Ipsa Loquitor (the thing speaks for itself) – in order to prove negligence in a personal injury lawsuit, a plaintiff must present
evidence to demonstrate that the defendant's negligence resulted in the plaintiff's injury

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Respondeat Superior (let the master answer) – allow liability assessment against employers for negligent acts committed by their
employees during the course of their work

Intentional Torts

• Assault and Battery

• Assault – committed without physical contact, such as someone verbally cursing and threatening
• Battery – requires physical contact of some sort
• Defamation of Character
• Violation of patient’s right to privacy which results to one person communicates to a second person about a third in
such a manner that the reputation of the person about whom discussion was held is harmed
• Libel – written communication
• Slander – spoken defamation
• False Imprisonment
• Illegal confinement of an individual against his or her will by another individual in a manner that violates the confined
individual’s right to be free from restraint of movement

• Invasion of Privacy
• Right to live one’s life without having one’s name, picture, or private affairs made public against one’s will.

MIDTERMS

REPRODUCTIVE ISSUES

Abortion

 Expulsion of a living fetus from the mother’s womb before it is viable.

 Termination of pregnancy, spontaneously or by induction, prior to viability.
 14-20 before weeks of viability

In the Philippines any form of abortion is illegal

 Article II, 1987 constitution: Under the family code

 Section 12: Recognizes sanctity of life and shall protect and strengthen the family.
 Protect life of mother and the life of the unborn from conception.

Criminalized by the Philippine law: Art. 256, 258(highest prison term on the woman or parents), and 259: RPC imprisonment for
women who undergo abortion, as well as those who assist in the procedure.

 Misoprostol- drug inserted in the vagina used for abortion

 RH Bill/Law- prevention of abortion and management of post abortion complications.
 Intention: Responsible parenthood, family planning
 Address cause of abortion, fetal death, and teenage pregnancy
 Ensures that women needing care for post-abortion complications shall be treated and counseled in humane, non-judgmental
and compassionate manner.”
 but “Abortion remains a crime and is punishable”

Types of Abortion

 Natural abortion(spontaneous/accidental)- unintentional and involuntary

 Direct or Intentional Abortion- induced expulsion of a living fetus
 Therapeutic abortion- induced expulsion of a living fetus in order to save the mother from the danger of death brought on by
pregnancy.
 Eugenic abortion- recommended in cases where certain defects are discovered in the developing fetus.
 Indirect abortion- removal of the fetus occurs as a secondary effect of a legitimate action, which is direct and primary object
of the intention.

Moral Issues

 Euthanasia and impaired infants

 Personhood
 Sanctity of life
 Quality of life

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  Autonomy
 Mercy

Two positions

 Pro-life position- anti-abortion, believes that abortion is murder

 Pro-choice position- believes that the decision to abort is one of personal liberty and thus should be legal
 Has two sub-components:
 Abortion is wrong but it is an individual autonomy
 Abortion is not wrong but depending on the situation

Principle of Double Effect

 Distinguish the intended effect of an action from the other, the unintended effects
 It would be impermissible, to perform an abortion to save a mother from death if the procedure involved the direct killing of
the fetus
 Permissible if the death of the fetus is an indirect cause of the death

Nursing Ethical Dilemma: Ethical Rights and Responsibilities in Abortion

 Nurses are agreeable if medically indicated

 Should respect the choices of the mother for as long as the abortion is legal under the state of law
 Should provide the information of alternative and respecting the patient’s right to freedom from imposition and the right to
receive the utmost care in an environment that provides privacy, culturally appropriate, and specific nursing expertise. (ANA,
2011)
 If abortion is against the personal moral, ethical, and religious values of the nurse, the nurse has the right to refuse to
participate in a voluntary termination of pregnancy
o Except in emergency situations; patient’s needs should not be subjected to coercion, censure, or discipline for
reasons of such refusal
 Should be aware of abortion laws within the state of practice to be more legally binding

Ethical Issues in Assisted Reproductive Technologies

Assisted reproductive technologies (ART)

 All treatments or procedures that include the in vitro handling of human oocytes and human sperm or embryos for the
purpose of establishing pregnancy
 First successful IVF: Louise Brown; 1978

Issues/Concerns

 Rapid development in the field of ART

 “Moral panic” about the changes that ICF brought about
 Continuous ethical dilemmas
 Legislation

Rapid Developments

 Better protocols for ovulation induction

 Success rates
 PGD
o Preimplantation genetic diagnosis (PGD)
o Screening of embryos for specific genetic traits before it is implanted
o “Embryo biopsy”
o Enables couples at risk for certain genetic diseases to determine which of their embryos are affected and which are
not

Moral Panic

 No society has been neutral about reproduction

 Social values
 Morals
 Fears
 Separation of sex from reproduction

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  Reproduction with the involvement of a third party
 Gender issue
 Ethical Issue
 Ideology or religion
o Status of the embryo
o Sanctity of the family’s genetic lineage
 Utilitarian principles
o Best for society
o Best interest of the child

ETHICAL CONCERNS

Autonomy

o Patient’s autonomy (respect for autonomy)

o Reproductive freedom
o Decision based on accurate information
o Issue of success rates
o Eligibility
 All infertile couples
 Only married couples
 Single women without partners
 Gay couples
 Lesbian couples
 Menopausal women
 HIV-positive women or couples

Gamete donor

 Sperm
 Oocyte

Donor anonymity

 Right of autonomy of privacy of the parents

 Right of privacy of the donor
 Right of the child to know his/her origins

Pre-implantation genetic diagnosis (PGD)

o Screening of cells from preimplantation embryos for the detection of genetic and/or chromosomal disorders before embryo
transfer
o Status of the embryo
 Discrimination
 “Designer” babies
 Sex selection
 Destruction of unwanted embryos

Ethical Issues/Risk-benefits

 Welfare of the child

o Medical risks
o Family environment
o Social environment
 Who is making the decisions for the welfare of the child?
o Parents
o Medical personnel
o Society and the law
 Is it one’s best interest to be born?

The issues

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  The outcomes related to their care should be their own wishes
 The decision may involve the choice for:
o Organ and tissue donations
o Advance directives
o Resuscitation

Advanced directives- a general term used to describe the documents that give instructions about future medical care and
treatments

o Living will
o Do not resuscitate order
o Withholding or withdrawing treatments
o Should have proper documentation and consent/waiver

Living will- the lay term used to frequently to describe any number of documents that give instructions about future medical
care and treatments or the wish to be allowed to die w/o heroic or extraordinary measures should the patient be unable to
communicate for self

• No uniformity in laws on living wills and surrogate decision makers

• In some states, the advanced directives go into effect only if a patient is terminally ill and death is imminent
• Due to inconsistencies and limitation, many authorities recommend the use of durable power of attorney over a living will
• What to and what not to do

Durable power of attorney

• A power of attorney is a legal document that gives someone you choose the power to act in your place, in case you become,
mentally incapacitated, you’ll need what are known as “durable” powers of attorney for medical care and finances
• This allows you to name someone as proxy, with the authority to make medical decisions on your behalf should you become
incompetent and unable to make decisions for yourself

DNR (Do not resuscitate)

• A written physician’s order instructing health care providers not attempt CPR
• Often requested by the family
• Must be signed by the physician to be valid must have a witness
• Several types of CPR decisions can be made including:
o Full code
o Chemical code
o DNR or “no code”- avoid use of CPR
o Slow codes- slows process

Orders: Code

 A call for CPR efforts

 Contains all elements of ACLS (advanced cardiac life support; oxygenation, ventilation, cardiac massage, electroshock as
necessary, emergency drugs)

Orders: No code or Code blue

 DNR

 Written order placed in medical chart to avoid the use of CPR efforts

Orders: Slow codes

• Health care teams slows the process of emergency resuscitation so as to appear to be providing the care but in actual fact is only
providing illusion
• Intent is more for family comfort than patient benefit

Orders: Chemical code

• Provides the drugs needed for resuscitation but does not provide the other services
• Emergency drugs only

DNR Guidelines

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 • Should be documented
• Should specify the exact nature of the treatments to be withheld
• Patients, when they are able, should participate in DNR decisions
• Decisions to withhold CPR should be discussed with the health care team
• DNR status should be reviewed on a regular basis

Ethical Issues

- Do DNR patients belong on intensive care units (ICU)?

Withholding or withdrawing treatments

 What is to be done and what is not to be done must be included in clear terms

 Honoring the refusal of treatments that a patient does not desire, are disproportionately burdensome to the patient, or will
not benefit the patient can be ethically and legally permissible

Organ donations

 When it is permissible to remove organs?

 Who should receive them?

 How is it to be financed?

Ethical issues

 Document the gift that an individual executes before death

 Commercialization (exploitation, pay for a service)

 The need to obtain family consent in a time of grief and stress has been a major barrier to organ procurement

Legal and social standing of euthanasia

 Euthanasia is currently conceptualized as an action that aims to end the life of a human being taking into account humanistic
considerations in relation to the person or society

o Quickening of death

o Passive euthanasia- the allowance of deadly process to proceed without intervention

o Active euthanasia- requires action that speeds the process of dying

o Involuntary euthanasia- ignores the individual’s autonomous rights and could potentially bring about the death of an
unwilling victim

o Voluntary euthanasia- done upon patient’s request

 Orthotanasia refers to the art of promoting a humane and correct death

o Usual death/normal death

 Dysthanasia is the term for futile or useless treatment treatment, which does not benefit a terminal patient. It is a process
through which one merely extends the dying process and not life per se

Euthanasia vs. suicide

 A person has committed suicide when:

o Person brings about his/her own death

o Others do not coerce him/her to do the action

o Death is caused by condition arranged by the person for the purpose of bringing about his/her death

 Physician-assisted suicide- allowed in the Netherlands in 2002

o Patient must request the assistance freely and frequently after careful consideration
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 o Physician may act on request only if the patient is terminally ill, with no hope of improvement and in severe pain

 May be actively-assisted

o Physician must consult with another physician and file a coroner (an official who examines a person’s cause of
death)

 Germany

o Does not allow active-assisted suicide—where the physician prescribes and administers the lethal dose

 Does not allow direct participation of the physician

o Allow assisted suicide, so long as the drug is taken without any help

 Belgium

o Legalized physician-assisted suicide

o If an inpatient expresses a desire for euthanasia, prior to becoming comatose, physician may comply with the request

o Include children who with the expressed permission of their parents may receive lethal injection

o The child must be terminally ill and be conscious of their decision

 USA

o Doctors are allowed to prescribe lethal doses of drugs to terminally ill patients to “aid in dying”

 Only 5 states allow physician-assisted suicide

 Oregon (1st state to legalize), Washington, Vermont, Montana, and New Mexico

o Active euthanasia is illegal

o Oregon act: allows a terminally ill patient to obtain a physician’s prescription for a fatal drug

FINALS

CODE OF ETHICS
 Systematic guides for developing ethical behavior
 Answers normative questions of what beliefs and values should be morally accepted

Code of Good Governance

▪ Promulgated by the Professional Regulation Commission on July 23, 2003

▪ States that the hallmark of all professionals is their willingness to accept a set of professional and ethical principles which they will
follow in the conduct of their daily lives.

Code of Good Governance

General Principles

1. Service to Others
2. Integrity and Objectivity
3. Professional Competence
4. Solidarity and Teamwork
5. Social and Civic Responsibility
6. Global Competitiveness
7. Equality of All Professions

Code of Ethics for Filipino Nurses

 Provides direction for nurses to act morally

 Emphasizes the four-fold responsibility of nurses
- To promote health
- To prevent illness

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 - To alleviate suffering
- To restore health
 Emphasizes universality of the nursing practice, scope of responsibility

Code of Ethics for Filipino Nurses

 1982 – PNA (Dean Sotejo) developed a Code of Ethics for Filipino Nurses, approved but was not implemented
 1984 – PRC-BON adopted the Code of Ethics of ICN, added fifth-fold responsibility “promotion of spiritual environment”
 1989 – Code of Ethics promulgated by PNA was approved by PRC-BON

ARTICLE I

PREAMBLE

Sec. 1. Health is a fundamental right of every individual. The Filipino registered nurse 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.

ARTICLE I

Sec. 2. To assume this responsibility, registered nurses have to gain knowledge and understanding of a 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.

ARTICLE I

Sec. 3. The desire for the respect and confidence of clientele, colleagues, co-workers, 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

Sec. 4. Ethical Principles

1. Values, customs, and spiritual beliefs held by individuals 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 II

REGISTERED NURSES AND PEOPLE

Sec. 5. Guidelines to be observed

Registered Nurse must:

 consider the individuality and totality of patients when they administer care;
 respect the spiritual beliefs and practices of patients regarding diet and treatment;
 uphold the rights of individuals; and
 take into consideration the culture and values of patients in providing nursing care. However, in the conflicts, their welfare
and safety must take precedence.

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 6. Ethical Principles

Registered Nurse must:

1. Human life is inviolable.

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 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.

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 7. Guidelines to be observed

Registered Nurse must:

a. Know the definition and scope of nursing practice which are in the provisions of R.A. No. 9173,known as the Philippine
Nursing Act of 2002 and Board Res. No. 425,Series of 2003, the Rules and Regulations Implementing the Philippine Nursing
Act of 2002, (the IRR);
b. Be aware of their duties and responsibilities in the practice of their profession as defined in the Philippine Nursing Act of
2002 and the IRR;
c. Acquire and develop the necessary competence in knowledge, skills and attitudes to effectively render appropriate nursing
services through varied learning situations;
d. If they are administrators, be responsible in providing favourable environment for the growth and development of Registered
Nurses in their charge;
e. Be cognizant that professional programs for specialty certification by the BON are accredited through the Nursing Specialty
Certification Council (NSCC);
f. See to it that quality nursing care and practice meet the optimum standard of safe nursing practice;
g. Ensure that patient’s records shall be available only if they are to be issued to those who are professionally and directly
involved in their care and when they are required by law.
h. Insure that modification of practice shall consider the principles of safe nursing practice;
i. If in position of authority in a work environment, be normally and legally responsible for devising a system of minimizing
occurrences of ineffective and unlawful nursing practice.

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 8. Ethical Principle

4. Registered Nurses are the advocates of the patients: they shall take appropriate steps to safeguard their rights and privileges

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 9. Guidelines to be observed

Registered Nurses must:

a. Respect the Patient’s Bill of Rights in the delivery of nursing care;

b. Provide the patients or their families with all pertinent information except those may be deemed harmful to their well-being
and
c. Uphold the patients’ rights when conflict arises regarding management of their care.

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 10. Ethical Principle

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 III

REGISTERED NURSES AND PRACTICE

Sec. 11. Guidelines to be observed

Registered Nurses must:

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 a. perform their professional duties in conformity with existing laws, rules regulations. measures, and generally accepted
principles of moral conduct and proper decorum.
b. not allow themselves to be used in advertisement that should demean the image of the profession (i.e. indecent exposure,
violation of dress code, seductive behavior, etc.).
c. decline any gift, favor or hospitality which might be interpreted as capitalizing on patients.

ARTICLE III

REGISTERED NURSES AND PRACTICE

Sec. 11. Guidelines to be observed

Registered Nurses must:

a. not demand and receive any commission, fee or emolument for recommending or referring a patient to a physician, a co-
nurse or another health care worker; not to pay any commission, fee or other compensations to the one referring or
recommending a patient to them for nursing care.
b. avoid any abuse of the privilege relationship which exists with patient and of the privilege access allowed to their property,
residence or workplace.

ARTICLE IV

REGISTERED NURSES AND CO-WORKERS

Sec. 12. Ethical Principles

a. The Registered Nurse is in solidarity with other members of the healthcare team in working for the patient’s best interest.
b. The Registered Nurse maintains collegial and collaborative working relationship with colleagues and other health care
providers.
c. maintain their professional role/identity while working with other members of the health team.
d. conform with group activities as those of a health team should be based on acceptable, ethico-legal standards.
e. contribute to the professional growth and development of other members of the health team.
f. actively participate in professional organizations.
g. not act in any manner prejudicial to other professions.
h. honor and safeguard the reputation and dignity of the members of nursing and other professions; refrain from making unfair
and unwarranted comments or criticisms on their competence, conduct, and procedures; or not do anything that will bring
discredit to a colleague and to any member of other professions.
i. respect the rights of their co-workers.

ARTICLE V

REGISTERED NURSES, SOCIETY, AND ENVIRONMENT

Sec. 14. Ethical Principles

1. The preservation of life, respect for human rights, and promotion of healthy environment shall be a commitment of a
Registered Nurse.
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 Registered Nurse.

ARTICLE V

REGISTERED NURSES, SOCIETY, AND ENVIRONMENT

Sec. 15. Guidelines to be observed

Registered Nurses must:

a. be conscious of their obligations as citizens and, as such, be involved in community concerns.

b. be equipped with knowledge of health resources within the community and take active roles in primary health care.

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 c. actively participate in programs, projects, and activities that respond to the problems of society.
d. lead their lives in conformity with the principles of right conduct and proper decorum.
e. project an image that will uplift the nursing profession at all times.

ARTICLE VI

REGISTERED NURSES AND THE PROFESSION

Sec. 16. Ethical Principles

1. Maintainance 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 Registered Nurse 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 a visionary mission.

ARTICLE VI

REGISTERED NURSES AND THE PROFESSION

Sec. 17. Guidelines to be observed

Registered Nurses must:

a. be members of the Accredited Professional Organization (PNA).

b. strictly adhere to the nursing standards.
c. participate actively in the growth and development of the nursing profession.
d. strive to secure equitable-economic and work conditions in nursing through appropriate legislation and other means; and
e. assert for the implementation of labor and work standards.

ARTICLE VII

ADMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY

Sec. 18.

The Certificate of Registration of Registered Nurse 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.

ARTICLE VII

ADMINISTRATIVE PENALTIES, REPEALING CLAUSE AND EFFECTIVITY

Sec. 19.

The Amended Code of Ethics promulgated pursuant to R. A. No. 877 and P.D. No. 223 is accordingly repealed or superseded by the
herein Code.

Sec. 20.

This Code of Ethics for Nurses shall take effect after fifteen (15) days from its full and complete publication in the Official Gazette or
in any newspapers of general circulation. Done in the City of Manila, this 14th day of July, 2004.

ETHICS IN GENETICS

Genetics

 Branch of biology concerned with the study of genes, genetic variation, and heredity in organisms

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Three Main Reasons Why Genetics is Ethically Interesting

1. Genetic information often identifies risks of medical conditions that don’t yet affect the patient
- The ‘at risk’ patient
2. Genetic information is about families as well as individuals
- As such, it sometimes doesn’t fit well into our usual individualistic ways of thinking about consent, confidentiality, etc.
3. Genetic research is commercially driven to a very substantial degree
- This raises questions about whether it is legitimate to allow genes to be ‘owned’ and what people should expect in return
for participating in genetic research

Case Study: Huntington’s Disease

 One day a woman’s father comes home and starts ranting and raving. She has never seen him like this. His limbs begin
moving in strange ways, and he begins to have seizures. Finally, the doctors have the diagnosis: Huntington’s disease. Now
she founds out that, because her father’s disease is the result of a dominant gene, she has a fifty-fifty chance of getting it
herself.

Case Study: Huntington’s Disease

 A disease which causes deterioration of nerve cells in the brain

 Slowly destroys the affected individual's ability to walk, think, swallow, talk, ...
 Normally begins affecting people when they are between 30 and 50 years old
 Death (due to pneumonia, heart failure or other complications) usually occurs between 10 and 25 years after symptoms first
appear

Genetics for Philosophers

 Our chromosomes (which contain our genes) come in pairs.

 We inherit one chromosome from each pair from each of our parents
 The paired chromosomes, while similar, are not identical
 About 1 in 10,000 people are thought to carry a mutation linked to Huntington’s Disease

Inheriting Huntington’s

 Huntington’s is an example of a dominant genetic condition

– i.e., you only need to inherit one copy of a gene for Huntington’s in order to be almost certain to contract the
condition at some point
 If one of your parents carries a mutation linked to Huntington’s, you have a 50% chance of having inherited such a gene
yourself.

Testing for Huntington’s

 Huntington’s is caused by having an enlarged gene on chromosome 4

 Since the early 90’s a very reliable genetic test for such an enlargement has existed
 Even if you presently show no signs of Huntington’s, it can tell you with great reliability whether you carry a gene that
makes it extraordinarily likely that you will develop Huntington’s.
 There is no cure

Assessing Purdy’s Argument

 “if it is true that sufferers [from Huntington’s] live substantially worse lives than do normal persons, those who might
transmit it should not have children.”
 Response: this is a pretty big ‘if’
– It seems to require making judgments about what sort of live is worth living that are deeply troubling
 Nonetheless, thinking about this issue should allow you to appreciate why genetics raises some distinct ethical questions.

Some Issues Raised by Genetic Testing

1. Risks of being tested

2. Problems posed by public conceptions of genetics
3. Problems with confidentiality & consent
4. ‘Commodifying’ our genes

1. Risks of Being Tested

▪ Psychological
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 – If positive for a ‘bad’ mutation:
 Burden of knowing you have the predisposition, particularly if no treatment is available
 Genetic determinism: possible overestimation of likelihood of actually becoming afflicted
– The situation with Huntington’s is not typical
– If negative:
 Evidence of ‘survivor guilt’ in some cases
 Possible over-confidence
– E.g., thinking you won’t get breast cancer because your test for BRCA1 & 2 came out OK

More Risks of Being Tested

 Practical
– Employment
– Life insurance
– Health Insurance (more important in US)
 Is it fair for companies to take genetic information into account when making hiring decisions or decisions about whether to
insure a person?
 Do these risks justify being paternalistic regarding who is given a genetic test, as DeGrazia suggests (pp. 474-490)?
- ‘Traditionally,’ tests have not been given without genetic counselling, although this is likely to change.
- Recall the Rule of Justified Paternalism

2. Popular Beliefs about Genetics

 Genetic Determinism: The common misconception that all genes work like the gene for Huntington’s, i.e., the idea that
having a particular gene will guarantee having a particular trait
- For the most part, having a particular gene mutation will just increase your chance of developing some trait, not
guarantee it.
– Furthermore, most ‘genetic conditions’ are the result of a number of different gene mutations (as well as interactions
with the environment)
 We are unlikely to discover ‘the gene makes you good at math’

3. Confidentiality & Consent

 ▪ In medical ethics, a great deal of importance is placed on the idea of individual informed consent
– One aspect of this is that your personal health information is not supposed to be released without your consent
– But the nature of genetic information sometimes gets in the way of this
– Finding out genetic information about you also reveals genetic information about the people you’re related to

Case: Confidentiality & Huntington’s

 Suppose there is a known history of Huntington’s in your family, but you don’t want to know whether you personally carry a
mutation for Huntington’s.
 Your son does, however. He gets tested and discovers that he has a mutation for Huntington’s.
 This almost guarantees that you also carry such a mutation.
 We have discovered personal information about you without your consent
– How should we deal with this?
– Should we put restrictions on who your son can reveal this information to?

Confidentiality & Duty to Warn

 Most ethicists agree that, while confidentiality is important, there are situations in which confidentiality can be broken
 The most common example involves a duty to warn
– E.g., a psychiatrist who is told by one of his patients that the patient plans to kill his wife tomorrow
 Is there a genetic duty to warn?
– Must we warn family members who are at risk?
– Should we warn employers if a person possesses a genetic mutation that may someday pose a threat?
 E.g., the bus driver at high genetic risk of heart failure

Case Study: BRCA 1 & 2

 About 5-10% of breast cancer is thought to be hereditary

 It has been discovered that those women with particular mutations in the BRCA 1 or 2 gene are at an elevated risk of
contracting breast cancer
– Without these mutations: 2% by age 50, 7% by age 70

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 – With the mutations: 33-50% by age 50, 56- 87% by age 70
– Note: information is from Myriad Genetics’ Website

Myriad Genetics & BRCA

 Myriad Genetics (Utah, USA) holds patents on BRCA 1 & 2

 They have recently been insisting that only they (or companies they have a licensing agreement with) may perform testing for
the BRCA 1& 2 mutations.
 The government of Ontario has refused to obey, preferring to perform its own test, which it claims is both cheaper and more
accurate

4. Commodifying Genes

 The Myriad example raises a number of questions regarding the commercialization of genetic research
– Is gene patenting ethically acceptable?
– If our genes are a valuable commercial resource, should we be paid for them?
– Are genes property or person?

Newfoundland & Labrador

 Questions about commercial research are particularly relevant in Newfoundland and Labrador
 Most of the present population of the province can trace their ancestry back to settlers in the 1800s or earlier
– Some argue that Newfoundland has a ‘homogeneous’ gene pool that is very valuable for genetic research
– We have an elevated rate of some genetically influenced conditions (e.g., psoriasis)
 For these reasons, Newfoundland had been described as "something of a motherlode to the drug development industry"
(National Post, 2000).

Should You Be Paid for Your DNA?

 There has been some local debate about whether individuals should be paid for providing their DNA to researchers
– One former professor at MUN suggested $50,000 (US) per donation

A Recent Report

 Policy Implications of Commercial Human Genetic Research in Newfoundland and Labrador

– Pullman & Latus, 2003
 Argues that human DNA should be viewed as neither property nor person, but something in between
– Payments may sometimes be OK, but not individual ones.
– In keeping with our general approach to health care as a public good, payment should go to improve health care &
research
– Gene patenting should be reconsidered
 ▪ This by no means settles the issue

So what was the point of all this?

 Genetics provides a good final example for this course:

– New developments in health care almost invariably raises new ethical problems
– New developments often cast old problems in new light
– Health ethics will never run out of problems

But ...

 ‘All you’ve done is raise questions and problems. What was the point of that?’
 Answer #1: Sometimes these problems don’t have clear solutions.
– Sometimes making people sensitive to problems is the best solution we can hope for
– E.g., while we may not be able to stop a genetic test on Mary’s son from revealing information about Mary, but by
being aware we can at least try to minimize this problem
 Answer #2: Ethics is hard
– Progress does occur, but it’s very slow because these are difficult problems.
– The least we can do is subject these issues to a serious public debate.

RIGHTS AND RESPONSIBILITIES

Patient Reponsibilities

1. Providing Information

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 2. Complying with instructions
3. Informing the physician of refusal to treatment
4. Paying hospital charges
5. Following hospital rules and regulations
6. Showing respect and consideration

Nurses’ Bill of Rights

1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care.
2. Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally
authorized scopes of practice.
3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics
for Nurses and its interpretive statements.
4. Nurses have the right to freely and openly advocate for themselves and their patients without fear of retribution.
5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional
responsibilities.
6. Nurses have the right to a work environment that is safe for themselves and their patients.
7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively in all practice
settings.

Responsibilities of the Nurse to the Physician

Sec 28 (a) of RA 9173 states that: It shall be the duty of the nurse to:

A. Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and
innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care,
comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral, topical and
parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of
perineal laceration, special training shall be provided according to protocol established;
-Reports results of therapies

▪ If any medical orders were not carried out:

– Report to physician
– Document
– Explore patient’s reason

▪ Familiarize themselves with various routines and methods of Physicians

Responsibility of the Nurse to their Colleagues

- Get along smoothly

- Adjust to the organization and know its policies and procedures
- Establish good working relationship
- Constructive criticism
- Nurses who are cranky, too sensitive, who “backbite”, who do not see any good in their colleagues, are the type of nurses who
will not be happy in their work

Responisbility of the Nurse to Themselves

- Continuous learning
- Self respect
- To look neat and attractive

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