HEALTHCARE ETHICS NCM 108

MODULE 2
Bioethics and its Application in Various Health Care Situations

1.Human Sexuality and its Moral Evaluation

Sexual ethics or sex ethics (also sexual morality) is the study of ethics in relation to human sexuality, and sexual
behavior. Sexual ethics seeks to understand, evaluate, and critique the conduct of interpersonal relationships and sexual
activities from social, cultural, and philosophical perspectives. Sexual ethics involve issues such as gender
identification, sexual orientation, consent, sexual relations, and procreation. Sex has historically been an issue of great
importance to people in cultures all over the world, and as such is a pertinent topic of discussion and study. As sex is a
social practice that varies widely in the ways that it is understood, performed, and discussed, there is much to be said for
a critical and comprehensive study of sexual ethics and norms.
Historically, the prevailing notions of what was deemed as sexually ethical have been tied to religious values. More
recently, the feminist movement has emphasized personal choice and consent in sexual activities.
Viewpoints and historical development:
Religion: Many cultures consider ethics and morality to be intertwined with religion. Some acts that might be considered
ethical or unethical from a religious standpoint include adultery, contraception, homosexuality, masturbation,
promiscuity, various paraphilias and prostitution.
Christianity: Christian denominations generally hold that sexual morality is defined by natural law, the Bible, and
tradition. In many cases, the Bible contains direct commandments or statements about specific sexual acts.
Marriage and procreation are key factors in Christian sexual ethics, particularly in the teachings of the Catholic
Church. Catholicism teaches that there is a universal human nature established by God, and that which disrupts God's
natural plan for human beings is inherently wrong. This teaching stipulates procreation as the natural purpose of
sexuality, and thus sexual activity not aimed toward procreation is prohibited. In Humanae vitae, the most recent
Catholic encyclical, permanent monogamous marriage is stated as the only appropriate context for the fulfillment of
moral sexuality.
St. Thomas Aquinas and St. Augustine were some of the key figures in honing Christian ethics. Augustine underlined
fidelity, offspring, and sacrament as the core aspects of sexual morality
Age of consent is also a key issue in sexual ethics. It is a controversial question of whether or not minors should be
allowed to have sex for recreation or engage in sexual activities such as sexting. The debate includes whether or not
minors can meaningfully consent to have sex with each other, and whether they can meaningfully consent to have sex
with adults. In many places in the world, people are not legally allowed to have sex until they reach a set age. The age of
consent averages around the age of 16.Some areas have 'Romeo and Juliet' laws, which place a frame around teenage
relationships within a certain age bracket, but do not permit sexual contact between those above or below a certain age.
2. 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.
As the philosopher Michel Foucault has noted, such societies often create spaces or heterotopias outside themselves
where sex outside marriage can be practiced. According to his theory, this was the reason for the often unusual sexual
ethics displayed by persons living in brothels, asylums, onboard ships, or in prisons. Sexual expression was freed of social
controls in such places whereas, within society, sexuality has been controlled through the institution of marriage which
socially sanctions the sex act. Many different types of marriage exist, but in most cultures that practice marriage,
extramarital sex without the approval of the partner is often considered to be unethical. 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.
Individuals and societies
Most societies disapprove of a person in a position of power to engage in sexual activity with a subordinate. This is often
considered unethical simply as a breach of trust. When the person takes advantage of a position of power in the
workplace, this may constitute sexual harassment, because subordinates may be unable to give proper consent to a
sexual advance because of a fear of repercussions.
Child-parent incest is also seen as an abuse of a position of trust and power, in addition to the inability of a child to give
consent. Incest between adults may not involve this lack of consent, and is, therefore, less clear-cut for most observers.
Many professional organizations have rules forbidding sexual relations between members and their clients. Examples in
many countries include psychiatrists, psychologists, therapists, doctors, and lawyers. In addition, laws exist against this
kind of abuse of power by priests, preachers, teachers, religious counselors, and coaches.
Public health
In countries where public health is considered a public concern, there is also the issue of how sex impacts the health of
individuals. In such circumstances, where there are health impacts resulting from certain sexual activities, there is the
question of whether individuals have an ethical responsibility to the public at large for their behavior. Such concerns
might involve the regular periodic testing for sexually transmitted diseases, disclosure of infection with sexually
transmitted diseases, responsibility for taking safer sex precautions, ethics of sex without using contraception, leading to
an increased level of unplanned pregnancies and unwanted children, and just what amount of personal care an
individual needs to take in order to meet his or her requisite contribution to the general health of a nation's citizens.
Public decency
Legal and social dress codes are often related to sexuality. In the United States, there are many rules against nudity. An
individual cannot be naked even on their own property if the public can see them. These laws are often considered a
violation to the constitution regarding freedom of expression. It is said that common sense needs to be used when
deciding whether or not nudity is appropriate. Nevertheless, Hawaii, Texas, New York, Maine, and Ohio allow all women
to go topless at all locations that let men be shirtless. In California it is not illegal to hike in the nude, however it is
frowned upon. Also, in state parks it is legal to sunbathe in the nude unless a private citizen complains then you are to
be removed from the premise by force if the individual doesn't comply. Breastfeeding in public is considered wrong and
mothers are encouraged to either cover themselves in a blanket or go to the restroom to breastfeed their newborn.
There are no actual laws that prohibit the action of breastfeeding in public except two places in Illinois and Missouri.
Homosexuality
In ancient Athens, sexual attraction between men was the norm. In the Levant, however, persons who committed
homosexual acts were stoned to death at the same period in history that young Alcibiades attempted to seduce Socrates
to glean wisdom from him. As presented by Plato in his Symposium, Socrates did not "dally" with young Alcibiades, and
instead treated him as his father or brother would when they spent the night sharing a blanket. In Xenophon's
Symposium Socrates strongly speaks against men kissing each other, saying that doing so will make them slavish, i.e.,
risk something that seems akin to an addiction to homosexual acts.
Most modern secular ethicists since the heyday of Utilitarianism, have constructed systems of ethics whereby
homosexuality is a matter of individual choice and where ethical questions have been answered by an appeal to non-
interference in activities involving consenting adults. However, Scanlon's system, notably, goes in a slightly different
direction from this and requires that no person who meets certain criteria could rationally reject a principle that either
sanctions or condemns a certain act. Under Scanlon's system, it is difficult to see how one would construct a principle
condemning homosexuality outright, although certain acts, such as homosexual rape, would still be fairly
straightforward cases of unethical behavior.
Source:
https://en.wikipedia.org/wiki/Sexual_ethics#:~:text=Sexual%20ethics%20or%20sex%20ethics,%2C%20cultural%2C%20a
nd%20philosophical

3. Issues on Contraception, its Morality, and Ethico-Moral Responsibility of Nurses

WHAT IS INFORMED CHOICE AND VOLUNTARISM (ICV)?
The quality of care in family planning (FP) requires that the rights of FP clients are safeguarded by service providers at all
times. The rights of FP clients, especially the right to information and choice, must be honored through appropriate FP
counseling. Clients must be able to make voluntary and informed choices based on accurate, balanced, and complete
information. The Department of Health (DOH) AO 2011-0005 defines Informed Choice and Voluntarism (ICV) as “A
standard in the delivery of FP services, ensuring that clients freely make their own decision based on accurate and
complete information on a broad range of available modern FP methods, and not by any special inducements or forms
of coercion or misinterpretation.” Healthcare providers are responsible for ensuring that an FP client makes a voluntary
and informed choice. This factor is considered as one of the pillars that guide FP program implementation.
Medical ethics and contraception
What ethical issues do doctors or other medical professionals face when giving contraceptive advice?
Their primary concern should always be the welfare of the patient concerned.
This goes hand in hand with respecting the autonomy of the patient: the doctor must respect the patient's right to make
their own decisions, which means the doctor should provide the method the patient prefers unless there is a medical
reason not to do so.
The doctor should make sure the patient gets the information and advice they need to be able to choose wisely.
It's important to realize that the doctor has rights too. Organizations such as the British Medical Association recognize
that a doctor has the right to claim a conscientious objection to prescribing contraception and emergency contraception.
However, in such a case the doctor should refer the patient to another source of treatment and advice.
Methods
The principle of informed consent requires a doctor to make sure that the patient is aware of, and has genuinely
understood the hazards and benefits of various methods of contraception.
For each method of birth control the patient needs to know:
 Reliability of the method
 Ease of use of the method
 Potential side-effects
 Health risks
Doctors should explain the methods available, and help patients weigh the advantages and disadvantages of the
methods so as to make the best choice for their situation.
Doctors must make sure that that patients are able to use the chosen method properly and can recognize and cope with
side effects.
Doctors provide continuing support for their patients' birth control needs.
Doctors should outline the emergency contraception options that are available if there is a problem.
Where the method is sterilization the doctor must ensure that the patient is aware that it is unlikely to be reversible.
Personal views
Where the doctor has strong ethical or religious views on birth control they have two choices:
Make the patient aware of their views and give the patient an opportunity to consult someone else
Disregard their own views and give unbiased medical advice
It is unethical for a practitioner to give medical advice influenced by a non-medical factor without disclosing this to the
patient.
This poses problems not just for doctors who disapprove of contraception itself, but also for doctors who while willing to
provide birth control to married couples, believe it is wrong to help unmarried people avoid the consequences of sexual
immorality.
An additional moral issue for doctors is whether or not they need to warn patients seeking contraception outside
marriage (or at least a settled relationship) of the dangers of sexually transmitted diseases.

Confidentiality
Doctors have an obligation to maintain patient confidentiality.
This has come under pressure in cases where teenagers seek help with contraception from a doctor and make it clear
that they do not wish their parents to know about it. British Medical Association report recommends:
 that children of under 16 must be entitled to expect that both the existence and the content of a consultation in
connection with pregnancy or contraception will normally remain secret
 that in the case of any departure from this rule doctors should be liable to justify their action.
 The duty of confidentiality owed to a person under 16 is as great as that owed to any other person.
o Regardless of whether or not the requested treatment is given, the confidentiality of the consultation
should still be respected, unless there are convincing reasons to the contrary.
 Any competent young person, regardless of age, can independently seek medical advice and give valid consent
to medical treatment.
o Competency is understood in terms of the patient's ability to understand the choices and their
consequences, including the nature, purpose and possible risk of any treatment (or non-treatment).
 Parental consent to that treatment is not necessary.
 It is obviously preferable for young people to have their parents' support for important and potentially life-
changing decisions. Often, however, young patients do not wish parents to be informed of a medical
consultation or its outcome and the doctor should not override the patient's views.
 Establishing a trusting relationship between the patient and doctor at this stage will do more to promote health
than if doctors refuse to see young patients without involving parents.
Can doctors ever break confidentiality over contraception?
Yes, they can, but only in very limited circumstances.
In the UK all the following conditions must be met:
 the patient does not have sufficient understanding to appreciate what the advice or treatment being sought
may involve
 the patient cannot be persuaded to involve an appropriate person in the consultation
 the doctor believes breaking confidentiality is essential to the best medical interests of the patient
There is one other situation in which confidentiality can be breached in this context, and this is where the health, safety
or welfare of someone other than the patient would otherwise be at serious risk.
This is likely to arise in cases where the doctor suspects, with good reason, that the patient and other people may be
suffering from sexual abuse or exploitation.
As a result of the criminal abortion law and the discriminatory environment in the Philippines, women are left without a
means to control their fertility, exposed to unsafe abortions, and made vulnerable to abuse in the health system.

Source: http://www.bbc.co.uk/ethics/contraception/ethics_contraception_1.shtml#h1
An Ethical Perspective on Reproductive Technologies
Post Date: 07/17/1999
Author: Daniel S. McConchie
Reproductive Ethics

The inability to have a child is a true burden. Would-be parents often ask both God and themselves why their innate
desire to have children continues to be unfulfilled. This kind of self-examination reflects how deeply emotional and
traumatic infertility can be. Sometimes a couple may even keep the situation secretive to avoid embarrassing
themselves in front of family and/or friends.
Sadly, this response only serves to heighten the pain that many couples experiencing infertility feel. 15% of couples in
the United States cannot have children after one year of sexual relations. As a result, clinics specializing in aiding the
reproductive process have sprung up all over the country. Couples spend many thousands of dollars to increase
their chances of having a child.
There are several reproductive technologies which are currently in use, including fertility drugs, artificial insemination, in
vitro fertilization (IVF), use of a surrogate mother, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer
(ZIFT), and intracytoplasmic sperm injection (ICSI). Although these technologies are all different from each other, they all
raise certain ethical issues which should concern anyone considering them. The issues as developed here should be
nuanced by the fuller explanations in the book Sexuality and Reproductive Technology.
Care of Multiple Embryos
A crucial issue in reproductive technologies is the safety of the embryos whether they are inside of a mother's body or in
a laboratory. Because human life begins at conception, all embryos should be treated with the utmost care. For
example:
A couple using IVF should decide ahead of time how many embryos to implant and attempt to create only that number
of embryos. If more than the ideal number of embyros are created, the extras may be implanted with the others or
frozen (to be implanted later)--whichever option poses less risk to the lives of the mother and embryos. No embryos
should ever be discarded.
Only a limited number of embryos should be implanted following in vitro fertilization. Such an approach will decrease
the chance that too many embryos will implant, thereby risking the lives of all the embryos and/or the mother.
A couple considering fertility drugs should research the options carefully. Some drugs may cause multiple eggs to
mature rather than merely putting the body back into a normal, healthy, fertile state. Potentially harmful multiple
pregnancies can result. One drug, clomiphene citrate, does not carry the risk of multiple pregnancies that some of the
other fertility drugs now available do. Also, the multiple pregnancy risk can be minimized with the use of ultrasound to
monitor the maturing egg(s). With monitoring, multiple pregnancies can be avoided.
Selective reduction (abortion of some implanted, developing embryos so the others have a better chance to survive) is
not an ethical option. However, selective reduction should not be necessary if an appropriate number of embryos are
implanted in the first place.
A couple should only consider implantation procedures whose percentage of success is equal to or greater than that of
unassisted natural implantation. Otherwise, embryos are being placed at greater risk than is normally the case in human
reproduction.
Use of Donor Eggs/Sperm
It is not advisable to use donor eggs and/or sperm in any reproductive technologies for a variety of reasons:
Who are the parents? Are they the ones whose genetic material (sperm and egg) combine to form the child or the
people who raise the child? This question might be a simple one for the parents caring for the child, but how simple is
that question from the viewpoint of the child? Sometimes, legal battles even result between the sets of parents involved
in one child's life.
Should children know that one or both of his or her (rearing) parents did not provide the egg or sperm which brought
them into being? Should children have access to the donor(s) (genetic parents)? Should genetic parents have visitation
rights?
A distinctive imbalance may be introduced into a marriage where donor eggs or sperm are used in place of one parents
eggs or sperm. There is the possibility of resentment from the partner whose eggs or sperm were not used. ("You take
care of her! She's your child.") Accusations of unfaithfulness can result because, in a real, genetic sense, one of the
spouses has had a child with another person. Emotional attachment to the "mystery person" can also develop in the
spouse who genetically had the child with the donor.
These and other difficulties flow from violating the "one flesh" model of marriage in Scripture, in which children are
literally to be the result of the two married parents (and their eggs and sperm) becoming "one flesh".
Surrogate Motherhood
The most common form of surrogacy involves inseminating the surrogate with the husband's sperm--generally because
the wife cannot carry a child through pregnancy. Such an arrangement should be avoided because a donor egg is
involved, as explained above. Even when a donor egg is not involved--e.g., when the husband's sperm and wife's egg are
joined in vitro--the bonding problems discussed below generally make such an agreement unwise. Particularly
problematic are commercial arrangements in which surrogates receive payment for producing a child beyond expenses
they incur. Like the selling of organs, such arrangements wrongly commercialize the body. In fact, financial contracts
essentially entail the purchasing of the baby and imply an unacceptable form of ownership of human beings. Less
problematic are altruistic surrogacies such as rescue surrogacies where a woman acts to save an embryo that would
otherwise be destroyed.
Bonding
Whenever donor eggs/sperm or a surrogate are used, the question of bonding can affect all parties involved. Bonds can
develop between child and genetic parent(s), between surrogate mother and child, and between the genetic parents.
The risk that inappropriate bonds will be created through the reproductive process is very real and can cause many
problems. On many occasions, surrogate mothers have sued the genetic parents for custody after the baby was born or
for the right to abort a malformed fetus even though the genetic parents wanted the child to live.
Financial Implications
Undergoing reproductive treatments is very costly. In vitro fertilization costs between $10,000 and $20,000. Surrogacy
can cost between $20,000 and $40,000. And these treatments do not guarantee that a child will result. In fact, clinics
average only 20-40% live birth success rates. However, these success rates are most likely this high due to the
implantation of multiple embryos and selective abortion which is very problematic ethically. Following ethical guidelines
that protect human life from conception would probably make the percentage much lower.
Prudence
One serious consideration should be the prudence of seeking to have a child with reproductive technologies when the
costs and/or risks are so great. There are two primary concerns:
The money could go towards meeting another great need. It can be difficult to imagine anything more important than
the creation of life. However, we also have a responsibility to be concerned about those people already in the world
today. There are people in many parts of the world without adequate medical care. For example, it costs just pennies
per person to inoculate them against many of the world's greatest killers.
Adopting a child is often an option for people to consider. It's true that it is difficult to adopt in some countries, but
international adoption is gaining popularity because of the number of orphaned children and speed with which the
adoption process can often be completed. There are many children in the world in need of a home. In Cambodia, many
children have been orphaned through years of war. In China where the government allows parents to have only one
child, many female babies are left with orphanages by parents who want a boy. In Bulgaria, a reported average of 90% of
the many children in orphanages will become criminals unless they are adopted. Those who are able should investigate
the possibility of international adoption before ruling it out.
Conclusion
Many people experience a very natural urge to be parents. Some are seeking to satisfy this urge using reproductive
technologies without fully understanding all their implications. Before using technological methods of reproduction, it is
wise to study in-depth the available options, understand the ethical issues involved, and above all, seek the will of God
before moving ahead.
Source: https://cbhd.org/content/ethical-perspectives-reproductive-technologies

THE ROLE OF THE NURSE IN REPRODUCTIVE AND GENETIC TECHNOLOGIES

Source: https://cna-aiic.ca/~/media/cna/page-content/pdf
fr/ps58_role_nurse_reproductive_genetic_technologies_march_2002_e.pdf

Facts on Abortion in the Philippines: Criminalization and a General Ban on Abortion

The Center for Reproductive Rights works nationally and internationally to expand access to reproductive healthcare for
women around the world. We have conducted years of investigative research into the status of reproductive rights in
the Philippines. The facts are as follows:
 For over a century, abortion has been criminalized in the Philippines. The criminal provisions on abortion do
not contain any exceptions allowing abortion, including to save the life of the pregnant or to protect her
health. Abortion was criminalized through the Penal Code of 1870 under Spanish colonial rule, and the criminal
provisions were incorporated into the Revised Penal Code passed in 1930under U.S. occupation of the
Philippines. The criminalization of abortion has not prevented abortion, but instead has made the procedure
unsafe and potentially deadly for the over half a million women each year who try to terminate their
pregnancies. In 2008 alone, the Philippines’ criminal abortion ban was estimated to result in the deaths of at
least 1,000 women and complications for 90,000 more.
 Physicians and midwives who perform abortions in the Philippines with the consent of a pregnant woman
may face up to six years in prison under the Revised Penal Code. These criminal punishments are
 supplemented by separate laws that prescribe sanctions for a range of medical professionals and health
workers such as doctors, midwives, and pharmacists for performing abortions or dispensing abortifacients such
as the Medical Act, the Midwifery Act, and the Pharmaceutical Act. According to these laws, these practitioners
may have their license to practice suspended or revoked if caught engaging in abortion-related activities.
Women who undergo abortion for any reason may be punished by imprisonment for two to six years.
 Because of the lack of access to safe abortion, Filipino women with life threatening pregnancies have no
choice but to risk their lives, either through unsafe abortion or through continuation of high-risk pregnancies.
Poor women are particularly vulnerable to unsafe abortion and its complications, as they face barriers in
obtaining effective means of family planning and lack access to reproductive health services. Common physical
complications that arise from the use of such crude and dangerous methods include hemorrhage, sepsis,
peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs.
 The criminal abortion ban has stigmatized the procedure in the medical community, so that women face
tremendous barriers and significant abuse when they seek treatment for abortion complications. Filipino
women who seek treatment for complications from unsafe abortion have repeatedly reported that the stigma
around abortion means that healthcare workers are unwilling to provide care or only treat women after
“punishing” women who have undergone abortions by threatening to report them to the police, harassing
women verbally and physically, or delaying care. Filipino women who have undergone unsafe abortions for
health reasons report that healthcare workers have not been sympathetic to their situation, but instead
continue to abuse and threaten them.

Source: https://reproductiverights.org/sites/crr.civicactions.net/files/documents/pub_fac_philippines_1%2010.pdf

Abortion: The destruction of life

- Sahin Aksoy, MD.
Eubios Journal of Asian and International Bioethics 7 (1997), 53-54.

Abortion is the intentional destruction of the fetus in the womb, or any untimely delivery brought about with the intent
to cause the death of the fetus (1). As it is evident in definition, it is the intention to terminate the life of a living being
which has made abortion a controversial issue. Hippocrates (d. 322 B.C.) wrote in his oath: "I will not give to a woman a
pessary to cause abortion" (2). The history of abortion goes to that far back, perhaps further. How can abortion which
contradicts such basic imperatives of medical practice, like 'Do not harm' or 'Respect human life', be so deep rooted in
history of that practice? What made (and still makes) health professionals carry out abortions on such a scale?
Abortion has always been discussed by doctors, philosophers, lawyers and theologians from different perspectives. Here
I shall go over some of these arguments, and try to come to a conclusion about the ethics of abortion. Actually, as
Dunstan observes; we shall be considering the ethics of a practice already very widespread, and likely to become more
so in all regions of the world, developed and developing. At least fifty million abortions are carried out annually
worldwide, and, for example in France and Japan, half of all pregnancies end in abortion. It was recorded that, one and
half million abortions are performed in USA each year, one-third of them on teenagers between 12 and 17 years old .
Therefore, it is rather difficult to discuss the moral acceptability of something which has already been so widely
accepted. Mason states that; "The significant feature is not so much the total number of abortions but, rather, the
steady escalation in numbers over the years. The figures indicate that there must be an increasing public acceptance of
abortion as a natural way of life". Dunstan commenting on this fact writes: "Abortion is now being more widely legalized
and practiced because that is what people want -an indication for medical intervention for the destruction of life
unknown in our ethics before".
Two principal kinds of indications have been defined for 'termination of pregnancy'. The first, called 'medical
indications', are: 1) The continuance of the pregnancy would involve risk to the life of the pregnant woman, or of injury
to the physical or mental health of the pregnant woman or any existing children of her family, greater than if the
pregnancy were terminated. 2) There is a substantial risk that if the child were born it would suffer from such physical or
mental abnormalities as to be seriously handicapped.
The second kind of indications, the so-called 'social indications', are more complex and vary between cultures and
epochs. Examples are: pregnancies resulting from extra-marital relations, from rape of incest, unwanted or unplanned
pregnancies, pregnancies at too young or too old an age, expecting a baby of 'wrong' sex -the information being
provided by recent medical technology. We may note that it is primarily 'social reasons' of this sort that lead parents to
seek abortion.
Writers on the abortion issue have concentrated most on two matters: first the 'rights' of the fetus and the mother, in
particularly the property right of the woman on her body; second, the question of the 'personhood' of the prenate.
Judith Jarvis Thomson is one of the pioneers among writers who approach the issue from the perspective of the 'rights'
of the fetus and the mother. She has no difficulty recognizing the 'personhood' of the fetus. She says every person has a
right to life, so the fetus has a right to life. However, she believes that the mother has a right to decide what shall
happen in and to her body.
The people in first group are not very many. They follow the Roman Catholic teaching, which maintains: "We cannot be
absolutely certain when animation takes place, or when the conceptus or the fetus is a human person; but it may well
be precisely at the moment of conception. This being so, it would be seriously wrong to destroy the fertilized ovum even
then, because one might be killing a human person". According to this strict line, abortion is impermissible even when
the mother's life is in danger or the pregnancy is the result of an indecent event, like rape or incest.
The second position is held by those who advance the 'personhood' argument. Harris, is one of those writers who
suggest that: "A person is a creature capable of valuing its own existence. And non-persons or potential persons cannot
be wronged in this way because death does not deprive them of anything they can value. If they cannot wish to live,
they cannot have that wish frustrated by being killed".
The third position which may be defined as 'moderate' maintains that abortion should not be allowed after a certain
stage of pregnancy and only if particular circumstances justify it. For instance, it is a very common view that abortion
should be permitted in order to save the mother's life. Some people believe that abortion is also morally permissible
when pregnancy is the result of rape or incest, and when a severe fetal abnormality has been diagnosed, or if the
potential mother is too young. It is also argued that pregnancy and delivery pose a risk to the life of a pregnant woman,
even a healthy one. At the turn of the century the risk of the mother dying at delivery was about 1:200, and it declined
to 1:10 000 today, but not zero. Therefore, abortion may be viewed as the prerogative of all pregnant women as long as
the risk of abortion is lower than the combined risk of pregnancy and delivery.
For all the debate, the suggestions and counter-suggestions and alternatives, it seems likely that abortion will remain
the dilemma it has been for centuries. However, we must bear in mind the fundamental fact that abortion is termination
of the life of a living being. We must approach ending the life of a prenate as cautiously and sensitively as we would
ending the life of any other being, and we should not end the life of any living being unnecessarily and without very
good reason.
In religious perspective, the earthly existence of a person ends when soul departs from the body. At the other end of
this 'silent journey' the human person begins when the soul joins the body. We do not know very much about when and
how of the soul's departure, but there are clear statements in the Qur'an ) and hadith (Prophet Muhammad's sayings)
about the time and the process of ensoulment. There is also detailed explanation in Aquinas's works and some other
religious texts. All the scientific (anatomical and physiological) and metaphysical (religious and spiritual) arguments tell
us that, if there is a time between conception to birth at which prenate 'enters humanity', 'becomes a person', 'becomes
morally important' or however we call it, it is most likely to be at some time in the eighth week . In sum: even at the very
beginning of its existence we owe respect to the unborn, but after eight weeks’ time to terminate its life should be
defined as morally unacceptable. (Source: https://www.eubios.info/EJ72/EJ72M.htm)
Abortions
Abortion laws provide specific guidelines for nurses about what is legally permissible. In 1973, when the Roe v. Wade
and Doe v. Bolton cases were decided, the Supreme Court of the United States held that the constitutional rights of
privacy give a woman the right to control her own body to the extent that she can abort her fetus in the early stages of
pregnancy. In 1989, the Supreme Court's decision in Webster v. Reproductive Health Services upheld a Missouri law
banning the use of public funds or facilities for performing or assisting with abortions. In 1992, President Clinton
rescinded the Rust v. Sullivan 1991 decision, dubbed the "gag rule," that prevented health care providers from
discussing abortion services with clients in nonprofit agencies. The Supreme Court and state legislatures
continue to struggle with the issue of abortion. Many statutes also include conscience clauses, upheld by the Supreme
Court, designed to protect nurses and hospitals. These clauses give hospitals the right to deny admission to abortion
clients and give health care personnel, including nurses, the right to refuse to participate in abortions. When these rights
are exercised, the statutes also protect the agency and employee from discrimination or retaliation.
B.Dignity in Death and Dying
1. Euthanasia and Assisted Suicide
Euthanasia, a Greek word meaning "good death," is popularly known as "mercy killing." Active euthanasia involves
actions to about the client's death directly, with or without client consent. An example of this would be the
administration of a lethal medication to end the client's suffering. Regardless of the caregiver's intent, active euthanasia
is forbidden by law and can result in criminal charges of murder. A variation of active euthanasia is assisted suicide, or
giving clients the means to kill themselves if they request it (e.g., providing providing pills or a weapon). Some countries
or states have laws permitting assisted suicide for clients who are severely ill, who are near death, and who wish to
commit suicide. Although some persons may disagree with the concept, in January 2006, the U.S. Supreme Court ruled
to uphold the assisted suicide regulations in the state of Oregon. In any case, the nurse should recall that legality and
morality are not the same thing. Determining whether an action is legal is only one aspect of deciding whether it is
ethical. The questions of suicide and assisted suicide are still controversial in our society. The American Nurses
Association's position statement on assisted suicide (ANA, 1995) states that active euthanasia and assisted
suicide are in violation of the Code for Nurses.Passive euthanasia, more commonly referred to now as withdrawing
or withholding life-sustaining therapy (WWLST), involves the withdrawal of extraordinary means of life support,
such as removing a ventilator or withholding special attempts to revive a client (e.g., giving the client "no code" status)
and allowing the client to die of the underlying medical condition. WWLST is both legally and ethically more acceptable
to most persons than assisted suicide (Ersek, 2005). ( source: Kozier and Erb’s Fundamentals of Nursing 8th Edition
Volume 1 by Berman, Snyder, Kozier and Erb pages 88-92)

Faced to this context, it is paramount to distinguish euthanasia ("to kill after being asked to, to accelerate death"),
assisted suicide ("to help committing suicide") and disthanasia ("slow death with lots of suffering"), from orthothanasia
("natural, correct death"). The first two concepts are interpreted as crimes in our country, regulated by article 121 of the
penal code as homicides. The search for these means is closely related to fear of pain, loneliness or family
abandonment, and by rejection of the coldness and impersonality permeating the assistance to many of our end-of-life
counterparts. So, we once more understand the mandatory indication of palliative, correct and safe care in a society
which shall not fail to the point of having its participants asking for the right of dying because they are not cared for.
Palliative care is a powerful alternative to the proposals of legalizing euthanasia or assisted suicide.

Disthanasia seems to have free flow through our hospitals and goes unnoticed. In fact, it is a useless treatment,
cultivated by a Western society which values saving the life at any cost and submits patients to therapies which, in
summary, do not prolong life, but rather the death process. Cure is impossible, expected benefit is meanest, the effect is
noxious. It is the therapeutic obstinacy or the medical futility.
Among this number of concepts emerges orthothanasia which, differently from euthanasia is sensitive to the death
humanization process and to pain relief. It does not tolerate disproportionate treatments, does not incur in abusive
delays, it faces death at the right time, without falling in the disthanasia trap. It generates the possibility of discussing
with people the difference between curing and treating, between maintaining life when this is the right procedure or
signaling death when it time arrives. Death then may be understood as part of life, offering experiences which may be
enriching and unforgettable. However, in spite of this clarity, orthothanasia in our country has generated much
discussion. It is an atypical approach according to the Penal Code because it is not the cause of death, since the dying
process has been already installed. On the other hand, it is advocated after the irreversibility of a pathological condition.
The Federal Council of Medicine has regulated with Resolution 1805/06, the medical approach faced to the desire of the
patient or legal representative of limiting or withdrawing procedures and treatments prolonging the life in terminal
phase, in cases of severe or incurable diseases. This resolution was suspended by request of the Public Prosecutor's
Office in 2007. The medical class resented but finally the Public Prosecutor's Office request was considered groundless
putting a full stop in the action and bringing back the practice of orthothanasia, which is a landmark in the valuation of
human beings autonomy and well-being. ( source: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-
00132011000100001)

2.Inviolability of Human Life

This springs from the religious belief that life, any human form, is of infinite value as it is a sacred & precious gift from
the Almighty Creator. Its worth outweighs everything in the world. It can never be sacrificed by whatever means or for
whatever reasons.
The practice of sometimes weighing the value of life against another in difficult cases (as in the case of whose life is
more important: the baby or that of the mother)? Is not correct. No one’s life is more important or valuable than others.
All lives are of finite worth (that is, unquantifiable) that we simply cant weigh one as against the other. Each individual
life is in itself incalculable or immeasurable.
This principle applies to every human life, including life of the unborn (fetus) that is still in the process of developing in
the womb of the mother. The unborn, even in the earliest stages of growth does have all the basic natural right to life
that be protected from any harm.

Source: Nursing Ethics for Students and Practitioners by Ambong Fernandez

HOSPICE CARE
Nursing care involves the support of the general well-being of our patients, the provision of episodic acute care and
rehabilitation, and when a return to health is not possible a peaceful death. Dying is a profound transition for the
individual. As healthcare providers, we become skilled in nursing and medical science, but the care of the dying person
encompasses much more. Certain aspects of this care are taking on more importance for patients, families, and
healthcare providers.
Hospice care provides comprehensive physical, psychological, social, and spiritual care for terminally ill patients. Most
hospice programs serve terminally ill patients from the comforts and relaxed surroundings of their own home, although
there are some located in inpatient settings. The goal of the hospice care team is to help the patient achieve a full life as
possible, with minimal pain, discomfort, and restriction. It also emphasizes a coordinated team effort to help the patient
and family members overcome the severe anxiety, fear, and depression that occur with a terminal illness. To that end,
hospice staffs encourage family members to help and participate in patient care, thereby providing the patient with
warmth and security and helping the family caregivers begin the grieving process even before the patient dies.
Everyone involved in this method of care must be committed to high-quality patient care, unafraid of emotional
involvement, and comfortable with personal feelings about death and dying. Good hospice care also requires open
communication among team members, not just for evaluating patient care but also for helping the staff cope with their
own feelings.
Recent studies have identified barriers to end-of-life care including patient or family member’s avoidance of death, the
influence of managed care on end-of-life care, and lack of continuity of care across settings. In addition, if the dying
patient requires a lengthy period of care or complicated physical care, there is the likelihood of caregiver fatigue
(psychological and physical) that can compromise the care provided.
The best opportunity for quality care occurs when patients facing death, and their family, have time to consider the
meaning of their lives, make plans, and shape the course of their living while preparing for death.
Source: https://nurseslabs.com/4-end-of-life-care-hospice-care-nursing-care-plans/

AN ACT

RECOGNIZING THE FUNDAMENTAL RIGHT OF ADULT PERSONS TO DECIDE THEIR TREATMENT WITHHELD OR
WITHDRAWN IN INSTANCES OF A TERMINAL CONDITION OR PERMANENT UNCONSCIOUS CONDITION OWN HEALTH
CARE, INCLUDING THE DECISION TO HAVE LIFE-SUSTAINING
Be it enacted by the Senate and the House of Representutives of the Philippines in
Congress assembled:.
SECTION 1. Title. - This Act shall be known as the “Natural Death Act of 2005.”
SECTION 2. Declaration of Policy. - It is the policy of the State to value the dignity of
every person and guarantees full respect for human rights.
SECTION 3. Dejnition of Terms. -For purposes of this Act:
(a) “Adult person” means a person who has attained the age of majority, and who has the capacity to make health care
decisions.
(b) “Attending physician” means the physician selected by, or assigned to, the patient who has primary responsibility for
the treatment and care of the patient.
(c) “Directive” means a written document voluntarily executed by the declarer
(d) “Health facility” means a hospital or a nursing home, a home health agency or hospice agency, or a boarding home.
(e) “Life-sustaining treatment” means any medical or surgical intervention that uses mechanical or other artificial
means, including artificially provided nutrition and hydration, to sustain, restore, or replace a vital function, which, when
applied to a qualified patient, would serve only to prolong the process of dying. “Life-sustaining reatment” shall not
include the administration of medication or the performance of any medical or surgical intervention deemed necessary
to alleviate pain.
(f) “Physician” is a person licensed by the Professional Regulation Commission to practice medicine.
(9) “Permanent unconscious condition” means an incurable and irreversible condition in which the patient is medically
assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma
or a persistent vegetative state.
(h) “Qualified patient” means an adult person who is a patient diagnosed in writing to have a terminal condition by the
patient’s attending physician, who has personally examined the patient, or a patient who is diagnosed in writing to be in
a permanent unconscious condition in accordance with accepted medical standards by two physicians, one of whoni is
the patient’s attending physician, and both of whom have personally examined the patient.
(i) “Terminal condition” means an incurable and irreversible condition caused by injury, disease, or illness, that, within
reasonable medical judgment, will cause death within a reasonable period of time in accordance with accepted medical
standards, and where the application of life-sustaining treatment serves only to prolong the process of dying.

SECTION 4. Directive to Withhold or Withdraw Lqe-Sustaining Treatment. -

(1) Any person of legal age and sound mind may execute a directive directing the withholding or withdrawal of life-
sustaining treatment in a terminal condition or permanent unconscious condition. The directive shall be signed by the
declarer in the presence of two witnesses who:
(a) are not related to the declarer by blood or marriage;
(b) would not be entitled to any portion of the estate of the declarer upon declarer’s decease under any will of the
declarer or codicil thereto then existing or, at the time of the directive, by operation of law then existing;
(c) shall not be the attending physician;
(d) shall not be an employee of the attending physician or a health facility in which the declarer is a patient; or
(e) have no claim against any portion of the estate of the declarer upon declarer’s decease at the time of the execution
of the directive.
(2) The directive shall be duly notarized.
(3) The directive, or a copy thereof, shall be made part of the patient’s medical records retained by the attending
physician, a copy of which shall be forwarded by the custodian of the records to the health facility when the withholding
or withdrawal of lifesupport treatment is contemplated. The directive may be in the following form, but in
addition may include other specific directions:

HEALTH CARE DIRECTIVE

Directive made this __ day of (month, year).
1 , having the capacity to make health care decisions,
willfully and voluntarily make known my desire that my dying shall not be artificially prolonged
under the circumstances set forth below, and do hereby declare that:
(a) If at any time I should be diagnosed in writing to be in a terminal condition by the
attending physician, or in a permanent unconscious condition by two pliysicians, and where the
application of life-sustaining treatment would serve only to artificially prolong the process of my
dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die
naturally. I understand by using this form that a terminal condition means an incurable and
irreversible condition caused by injury, disease, or illness, that would within reasonable medical
judgment cause death within a reasonable period of time in accordance with accepted medical
standards, and where the application of life-sustaining treatment would serve only to prolong the
process of dying. I further understand in using this form that a permanent unconscious condition
means an incurable and irreversible condition in which I am medically assessed within reasonable
medical judgment as having no reasonable probability of recovery from an irreversible coma or a
persistent vegetative state.
(b) In the absence of my ability to give directions regarding tlie use of such lifesustaining
treatment, it is my intention that this directive shall be honored by my family and
physician(s) as tbe final expression of my legal right to refuse medical or surgical treatment and I
accept the consequences of such refusal. If another person is appointed to make these decisions
for me, whether through a durable power of attorney or otherwise, I request that the person be
guided by this directive and any other clear expressions of my desires.
(c) If I am diagnosed to be in a terminal condition or in a permanent unconscious
condition (check one):

0 I DO want to have artificially provided nutrition and hydration.

0 I DO NOT want to have artificially provided nutrition and hydration
(d) If I have been diagnosed as pregnant and that diagnosis is known to my physician this directive shall have no force or
effect during the course of my pregnancy.
(e) I understand the full import of this directive and I am emotioiially and mentally capable to make the health care
decisions contained in this directive.
(f) I understand that before I sign this directive, I can add to or delete from or otherwise change the wording of this
directive and that I may add to or delete from this directive at any time and that any changes shall be consistent with
Philippine law to be legally valid.
(g) It is my wish that every part of this directive be fully implemented. If, for any reason, any part is held invalid, it is my
wish that the remainder of my directive be implemented.
Signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Residence Address ....................
....................................
...............
The declarer Itas been personally known to me and I believe him or her to be capable of
making health care decisions.
Witness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(ACKNOWLEDGMENT)
(3) Prior to withholding or withdrawing life-sustaining treatment, the diagnosis of a terminal condition by the attending
physician or the diagnosis of a permanent unconscious state by two physicians shall be entered in writing and made a
permanent part of the patient’s medical records.
(4) A directive executed in another political jurisdiction is valid to the extent permitted by Philippine law. SECTION 5.
Revocation of Directive. -.
(1) A directive may be revolted at any time by the declarer, without regard to declarer’s mental state or competency, by
any ofthe following methods:
(a) By being canceled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarer or by some person in
declarer’s presence and by declarer’s direction.
(b) By a written revocation of the declarer expressing declarer’s intent lorevoke, signed, and dated by the declarer. Such
revocation shall become effective only upon communication to the attending physician by the declarer or by a
person acting on behalf of the declarer. The attending physician shall record in the patient’s medical record the time and
date when said physician received notification of the written revocation.
(c) By a verbal expression by the declarer of declarer’s intent to revoke the directive. Such revocation shall become
effective only upon communication to the attending physician by the declarer or by a person acting on behalf of the
declarer. The attending physician shall record in the patient’s medical record the time, date,mand place of the
revocation and the time, date, and place, if different, of when said physician received notification of the revocation.
(2) There shall be no criminal or civil liability on the part of any person for failure to act upon a revocation made
pursuant to this section unless that person has actual o rconstructive knowledge of the revocation.
(3) If the declarer becomes comatose or is rendered incapable of communicating with the attending physician, the
directive shall remain in effect for the duration of the comatose condition or until such time as the declarer’s condition
renders declarer able to communicate with the attending physician.

SECTION 6. Liability of Health Care Provider or Facility. - Any physician or healthcare provider acting under the direction
of a physician, or health facility and its personnel who participate in good faith in the withholding or withdrawal of life-
sustaining treatment from a qualified patient in accordance with the requirements of this chapter, shall be immune from
legal liability, including civil, criminal, or professional conduct sanctions, unless otherwise negligent.

SECTION 7. Procedures by Physician. - Prior to the withholding or withdrawal of lifesustaining treatment from a qualified
patient pursuant to the directive, the attending physician shall make a reasonable effort to determine that the directive
complies with Section 4 of this Act, and, if the patient is capable of making health care decisions, that the directive and
all steps proposed by the attending physician to be undertaken are currently in accord with the desires of
the qualified patient.

SECTION 8. Effects of Carrying out Directive.

(1) On Insurance. -
(a) The withholding or withdrawal of life-sustaining treatment from a qualified patient pursuant to the patient’s directive
in accordance with the provisions of this chapter shall not, for any purpose, constitute a suicide or a
homicide.
(b) The making of a directive pursuant to Section 4 shall not restrict, inhibit,or impair in any manner the sale,
procurement, or issuance of any policy of life insurance, nor shall it be deemed to modifv the terms of an existing policy
of life insurance. No policy of life insurance shall be legally impaired or invalidated in any manner by the withholding or
withdrawal of life-sustaining treatment from an insured qualified patient, notwithstanding any term of the policy to the
contrary.
(c) No physician, health facility, or other health provider, and no health car service plan, insurer issuing disability
insurance, self-insured employee welfare benefit plan, or nonprofit hospital service plan, shall require any person to
execute a directive as a condition for being insured for, or receiving, health care services.
(2) On Cause of Death. - The act of withholding or withdrawing life-sustaining treatment, when done pursuant to
adirective described in Section 4 and which results in the death of the declarerchain of proximate cause between the
conduct of anyone that placed the declarer in a
terminal condition or a permanent unconscious condition and the death of the declarer.
SECTION 9. Criminal Conduct, Penalties. -
(1) Any person who willfully conceals, cancels, defaces, obliterates, or daniages the directive of another without such
declarer’s consent is guilty of a gross misdemeanor.
(2) Any person who falsifies or forges the directive of another, or willfully conceals or withholds personal knowledge of a
revocation, as provided in Section 4, with the intent to cause a withholding or withdrawal of life-sustaining treatment
contrary to the wishes of the declarer, and thereby, because of any such act, directly causes lifesustaining
treatment to be withheld or withdrawn and death to thereby be hastened, shall
be subject to prosecution for murder as defined in Article 248 of the Penal Code.
SECTION 10. Mercy Killing or Physician-Assisted Suicide Not Authorized. - Nothing in
this Act shall be construed to condone, authorize, or approve mercy killing or physician-assisted
suicide, or to permit any affirmative or deliberate act or omission to end life other than to permit
the natural process of dying.
SECTION 11. Discharge So That Patient May Die At Home. - If a qualified patient
capable of malting health care decisions indicates that he or she wishes to die at home, the patient
shall be discharged as soon as reasonably possible. The health care provider or facility has an
obligation to explain the medical risks of an immediate discharge to the qualified patient. If the
provider or facility complies with the obligation to explain the medical risks of an immediate
discharge to a qualified patient, there shall be no civil or criminal liability for claims arising from such discharge.
SECTION 12. Directive’s Validity Assumed. - Any person or health facility may assume
that a directive complies with this Act and is valid.
SECTION 13. Separability Clause. - If any provision of this Act is held invalid or
unconstitutional, the remainder of the Act or the provision not otherwise affected shall remain
valid and subsisting.
SECTION 14. Repealing Clause. - Any law, presidential decree or issuance, executive
order, letter of instruction, administrative rule or regulation contrary to or inconsistent with the
provisions of this Act is hereby repealed, modified or amended accordingly.
SECTION 15. EffecfiiiifJ)C lause. - This Act shall take effect fifteen (15) days after its
publication in at least two newspapers of general circulation.
Source: http://legacy.senate.gov.ph/lisdata/34342743!.pdf