In Partial Fulfillment of the Requirements

for NCM 108

Portfolio in Bioethics

Prepared by:
KENT FERRY D. FUENTES
Bachelor of Science in Nursing
2-3

Presented to:
CAROL JOY P. REMANESES, RN, MHSS
Classroom Instructor

February 2021
 Ethical Theories
Case Study 1: Karen is 5-year-old girl who is a member of a tribe living in Sahara Desert. It is the
practice of her tribe that at the age of 3-5 years old, girls undergo circumcision (Female Genital
Mutilation) wherein the clitoris, labia majora and minora are scraped and removed by a shaman with
the use of sharp edges of stone without anesthesia.
With all the list of countries practicing this ritual, can it be justified? How will you judge this practice
using 8 ethical thoughts/theories and its corresponding principles?
1) Ethical relativism
2) Situation Ethics
3) Pragmatism
4) Kant’s Ethics
Include the applicable ethical
principles applicable
Supports Opposes
Countries that still perform this
practice claim that FGM is rooted
in local culture and this traditional
ritual is passed on from one
generation to another. In
addition, preservation of culture
and cultural identity are the
underlying impetus for continuing
the said practice therefore,
performing FGM is ethically right
because it’s part of their moral
belief. Besides, this practice is
linked to perceptions of women
and girls regarding sexual purity
and is a way of testing or to
establish their marriageability.
As with many longstanding
traditions, it may be argued that
the procedure holds strong ties
within the community. In fact,
women from the communities
who must undergo female genital
cutting and advocate for its
continuance do not see the
procedure as a violation or
aberration. Moreover, since it’s a
social practice that is strongly
anchored in cultural beliefs,
norms, custom and tradition,
women participating in female
genital cutting believe that this
procedure translates into
conforming to the standards for
the role of a woman.
In addition to the pressures
exerted by the tradition, there are
three main reasons for the
continuation of FGM, which are
women’s sexuality, social
pressure and religion. That is
why in most practicing societies,
undergoing female genital cutting
is a prerequisite for marriage, a
requirement for social
acceptance, and is often justified
under the pretext of adherence to
religious practices. Therefore,
performing FGM is a legitimate
action because it’s one way of
conforming to the rules within
their society.
Categorical Imperative-
Although this practice is legal in
some communities, this does not
mean that the international
community has accepted the

5) Ross Ethics
Include the applicable ethical
principles applicable
6) Utilitarianism
7) Rawl’s Theory of Justice
Include the applicable ethical
principles applicable
8) Natural Law Ethics
Include the applicable ethical
principles applicable
Ethical Theories
Case Study 2: Sandra grew up in a dysfunctional family. His father was a drunkard, gambler and
womanizer. He abuses his mother almost every day. She was also sexually abused by her father since
practice as a meaningful cultural
expression. This only means that
the practice cannot be
universalized as it brings harm
and may cause unintended health
problems for women who
undergone the procedure.
Ross Ethics- As with many
traditions, female genital cutting
has become a distinct part of
many of the cultures where the
practice continues. In other
words, these communities are an
exception since it abides with
their cultural practice. Thus, in
some cases including women
who have undergone the
procedure, lenient constitutions
allow their respective community
to continue their cultural
expressions.
Rule Utilitarianism- Cutting
practices became associated
with the ideals of virginity and
chastity, which is why women in
these communities are required
to take part in the said ceremony.
Furthermore, they firmly believe
that circumcision confers full
social acceptability and
integration into the community
upon the females. However, if
they refuse to do so, a woman
will be viewed as a disgrace to
her family and a disreputable
member of her society.
Principle of Justice- FGM is
deemed as a representation of
gender inequalities in a certain
society. This is evidenced by
male-dominated societies who
lend themselves to the
continuation of the practice for
the purposes of maintaining the
ideals of virginity and purity for
women without much concern for
the same in men.
Principle of Totality- The term
female genital mutilation can
describe all procedures which
involve partial or total removal of
the external female genitalia or
other injury to the female genital
organs whether for cultural or any
other non-therapeutic reasons.
This means that the procedure
supports the idea that cutting
allows for women’s sexuality to
be controlled by reducing their
sexual fulfilment and in that way
creating the appearance of
virginity.
Supports Opposes
she was 3 years old. At the age 10, her father beat his mother endlessly. To protect her mother and to
stop the abuses they both endured, she stabbed her father 100 times. Her father died due to stab
wounds while her mother died due to internal bleeding

Sandra’s lawyer justified her action as self-defense to protect herself and her mother against her
father’s brutality. It was a case of self-defense. Prosecution however said, it was premeditated and
done out of rage and revenge because of the abuses she received from her father thus a case of
murder was filed.

How will you justify Sandra’s actions? Can you consider it as a wrongful act, why?

1) Ethical relativism
2) Situation Ethics
3) Pragmatism
4) Kant’s Ethics
Include the applicable ethical
principles applicable
5) Ross Ethics
Include the applicable ethical
principles applicable
Child abuse, sexual and domestic The higher court will recognize
violence are among the most her action as a crime since she
destructive experiences afflicting intentionally killed her own father.
women and children. In Sandra’s Sandra’s appeal will be hardly
case, she did the action on acknowledged because in the
purpose since she and her eye of law, negative emotions will
mother was in a life-threatening never be an excuse for ending
situation. Thus, in a lawyer’s point someone’s life. As a result, she
of view, Sandra’s action is clearly may be punished for committing
an act of self-defense because all parricide.
she wanted was to end the agony
that they’ve been enduring for a
long time.
Legalism- Since Sandra is a Situationism- Sandra’s action
minor; she will not be may be her way to protect herself
incarcerated because her case is and her mother but that doesn’t
considered under juvenile exempt her from the fact that
delinquency. At a very young what she did was unlawful by
age, she already experienced brutally killing her own father.
horrendous acts repeatedly which Also it is evident that her
resulted to the execution of such emotions clouded her moral
atrocious crime. judgement that is why she was
not able to think of another way
on how to deal with their
situation. Nonetheless, it’s still
her father no matter what
happens and she should have
come up with better solutions like
calling for help from their
neighbourhood or ask the
assistance of the authorities for
her to avoid committing such
merciless act.
Instrumentalism- Sandra
believed that the best option to do
was to put her father’s life to end.
It reflects that this is her idea on
escaping a life of torment and
terror which triggered her
negative emotions to manifest. In
other words, she surrendered to
the wrong in able to attain the
freedom that she wanted to have.
Categorical Imperative-
Sandra’s father thinks that he has
the superiority inside their home
and can do whatever he wants as
long as it gives pleasure and
satisfies his needs. His mentality
made him forget the duty of a
father, that he must protect his
family at all cost but then what he
did was totally the opposite.
Duty of Justice- When Sandra
killed her father; it made her feel
that justice was served for all the
pain and suffering they’ve been

6) Utilitarianism
7) Rawl’s Theory of Justice
Include the applicable ethical
principles applicable
8) Natural Law Ethics
Include the applicable ethical
principles applicable
Ethical Theories
Case Study 3: Jasmine and Greg is married for 10 years and they don’t have a child yet. Someone
offered to find them a child for adoption in return they have to pay him P50, 000.00. Desperate to have
a child, they accepted the offer. Now their adopted son is living comfortably and happy.
If you look at the government side, what Jasmine and Greg engaged in criminal act which is Child
Trafficking which punishable by the law.
If you are the nurse, how will you justify their actions? Will you oppose their actions despite it will
brought them happiness?
1) Ethical relativism
2) Situation Ethics
through. Although she committed
a sinful act and because of the
fact that revenge is not part of the
justice system, it’s still justifiable
under the law because they have
legal basis for a given
circumstances.
Act Utilitarianism- Despite the
fact that intentionally killing
someone is ethically wrong;
Sandra’s case is an exception.
What she did was not only for
herself but also for the sake of
her mother even though it
seemed impossible because of
the differences in age.
Fair equality of opportunity and
equal distribution of socio-
economic inequalities- The
incident should have been
avoided if her father tried to
change his bad behaviours and
started a new life. He could be a
better man and establish a
healthy relationship with his wife
and child by giving them the
proper treatment that they
deserve.
The Double Effect Principle- The Principle of the
Her action has a good purpose Inviolability of Life- Since God
however the consequences has the complete control over life;
contradict with each other. She Sandra’s action is morally
killed her father because their unacceptable because she have
lives are at stake and she had no no right to end a person’s life.
choice and on the other way This is because life is sacred and
around, she was able to free only God has the absolute power
themselves from further abuses of taking back the borrowed life of
and has the chance to start a new a particular person.
beginning.
Supports Opposes
The couple’s action was clearly
an act of child trafficking because
they did not undergo legal
process of adopting the baby. It is
punishable by law since they
chose to violate it out of
desperation.
Although the adoption was illegal,
their wish of becoming real
parents came true. The action
may be viewed as ethically wrong
but the intention was good and
genuine since they want to take
care of the child. They only took
the opportunity because they
want the child to grow having a

3) Pragmatism
4) Kant’s Ethics
Include the applicable ethical
principles applicable
5) Ross Ethics
Include the applicable ethical
principles applicable
6) Utilitarianism
7) Rawl’s Theory of Justice
Include the applicable ethical
principles applicable
8) Natural Law Ethics
Include the applicable ethical
principles applicable
Ethical Theories
mother and a father and
experience the life of having a
family.
Both parties benefit each other
because the baby completed
their life since they’re not capable
of producing an offspring. In
return, they completed the child’s
life because they filled in the
roles as parents by giving a
complete family to the child.
Act is done from a sense of
duty- The couple felt the need
that they’re responsible on taking
care of the child by giving him
home and a comfortable life.
Although they have no
experience on parenting, their
inner desire of raising the child is
all they wanted and the motive is
good since it’s their choice to
take charge of the child’s welfare.
Ross Ethics- The rule may be
set aside and the couple’s action
can be justified since the wrong
act originated from a good
motive. It can be considered
since their purpose was to take
full responsibility of the child and
did not intend to violate the law
because they don’t want to let the
opportunity slip of finally
becoming real parents.
The Principle of Utility- Having
a child will make any parents
happy because they will have a
new source of happiness. In the
couple’s case, the amount of
happiness they felt was priceless
because after how many years,
they finally receive a blessing in
their life. It’s an answered prayer
for them since they’re longing of
having a child and has the
chance of fulfilling the parents’
duty.
Rawl’s Natural Duties- Child’s
welfare would be the couple’s
primary obligation since they’ve
decided to adopt it. This only
means that it cannot be reversed
and they have taken full
responsibility on providing
parental care.
The Double Effect Principle-
Unintentionally breaking the rule
isn’t bad at all for its outcome
gave benefit to the couple. Their
good motive resulted to a good
and bad consequence since their
wish of becoming parents was
granted and at the same time,
their poor moral judgement made
them violate the law.
Supports Opposes
Case Study 4: Esther was gang raped and got pregnant. She had 2 options
Option 1 is going through the pregnancy but gave up her child for adoption. She doesn’t want to abort
the child but she had to let go of it so not to remind him of her painful past.
Option 2: undergo early termination of pregnancy or induced abortion so to set her free from reminders
of her painful past.
Either which of the options she will use, if you are the nurse on duty during pregnancy testing, how will
you justify her actions?
1) Ethical relativism
2) Situation Ethics
3) Pragmatism
4) Kant’s Ethics
Include the applicable ethical
principles applicable
5) Ross Ethics
Include the applicable ethical
principles applicable
6) Utilitarianism
The life inside her womb isn’t the
one to blame and should be
given the chance to live. If she
doesn’t want to keep it, at least
her conscience will not haunt her
for killing an innocent child. Also,
judging her situation in a moral
perspective, it could be simply
implied that the definition of
rightness and wrongness of an
action varies from person to
person.
Esther’s dark past plays a major
role on determining the best
possible options for her which
ended up on choosing a side
between pro-life or pro-choice.
This would be tough for her but
no matter what side she’ll
choose, her decision can still be
considered as morally acceptable
because she’s doing it for her
own sake.
Progressivism- Her situation will
measure the strength of her
resolve since each option has its
heavy consequences. If Esther
feels like either of the two choices
is the solution to forget her
painful past then I have to
respect her decision without
prejudice. After all, it’s part of her
growth as a person in terms of
effective decision-making.
Categorical Imperative- Esther’s
option has its own reasonable
purpose and as a nurse, focusing
only to the nature of the problem
wouldn’t be enough to help the
client. This is because my duty
does not rely on the situation
alone but also to respect the
worth, dignity, and rights of the
client.
Duty of Beneficence- As a
nurse, helping the client on
weighing the benefits of each
choice will give additional support
to her decision. This will provide
her insights for her to be able to
come up with a judgement that is
favourable to her situation.
Act Utilitarianism- Esther
believes that what she’s doing is
for her to restore the sanity that
she wants. Therefore, if she
choose any option of her choice

7) Rawl’s Theory of Justice
Include the applicable ethical
principles applicable
8) Natural Law Ethics
Include the applicable ethical
principles applicable
that will help her forget the painful
past she have been through then
her decision was right.
The Double Effect Principle-
Esther’s two options were set for
a good cause because she only
aims to free herself from the
nightmare of her past. However,
this will result to two contradicting
outcomes by which the good
effect is that she can let herself
engage in the process of moving
on and healing. In contrast, it
would be an evil act because her
selfishness will be the root cause
for taking away the child’s chance
to live and the experience of a
parent’s care and love.
Rawl’s Natural Duties- It
contradicts to what Esther will be
doing because if she chooses the
first option, it would appear that
she gave up her responsibility of
being a mother and may bring
probable danger to her child
because she cannot guarantee
that her child will be in good
hands with regards to foster care.
On the other hand, if she
chooses the second option, it will
end up on harming the child thus
committing a sin and may cause
health complications to her well-
being.
The Principle of Inviolability of
Life- Since life is valuable and
sacred; it only means that God
has the only right of taking it
back. And we, humans, don’t
have the authority of ending
someone else’s life because all of
us owe that gift from the Almighty
since he’s the only one who has
the complete control and
dominion over life.

Ethical Theories Supports Opposes

Case Study 5: Honor Killing

Ayesaa, a girl from affluent family in Afghanistan not only passed the University Admission
Examination but acquire a scholarship as well. She went to Sweden to pursue her education. While
she was in the University, she got married to her Swedish boyfriend. When her family heard about the
news, the male members of the family got ballistic . . . her oldest brother bought a plane ticket to
Sweden and plan to kill his younger sister. The reason, to avenge and redeem the name of their family
in their community. However, one of closest friend in Afghanistan sent a cryptic message to her
revealing the plan of her family. For her and her husband’s protection, she asked for asylum to
Swedish government. The Swedish government, in response to her request and to protect them, they
were put into government Victim/Witness Protection Program and banned to enter Sweden territory all
her family members up the 5th degree of family relations.

How can you justify the Honor Killing of women in Muslim communities? How about opposing it as in
immoral act and cannot be justified?

1) Ethical relativism In an honour culture, like in In an instance, Ayesaa and her

Muslim communities, reputation
management is the most
important social ethic,
superseding all other values that
is why killing a woman due to an
honour’s defiance is ethically
acceptable. In Ayesaa’s case,
she brought disgrace to her
family by secretly marrying a
foreign man knowing the fact that
she came from a Muslim family.
Therefore, the intent of the eldest
husband lives in a non-Muslim
country where honour killing is
not practiced. Perpetrating the
said action would be completely
pointless and is considered a
crime since it’s against the norms
and standards of Sweden. This
only reflects that the plan of her
eldest brother is ethically
erroneous since it’s beyond the
context of the country’s law given
the fact that Sweden has a

2) Situation Ethics
3) Pragmatism
4) Kant’s Ethics
Include the applicable ethical
principles applicable
5) Ross Ethics
Include the applicable ethical
principles applicable
6) Utilitarianism
7) Rawl’s Theory of Justice
Include the applicable ethical
principles applicable
brother on killing Ayesaa and her different set of rules.
husband is a lawful act because
it lies within their society’s
cultural lens and is the only way
to reclaim the family’s honour.
Ayesaa’s family believed that Since she knew the plan
their honour got stained because beforehand, seeking the help
of her shameful act. Since her from the Swedish government
honour is intimately connected would be the best option for
with her family, it is necessary for Ayesaa and her husband. This
the eldest brother to end will give them protection as well
Ayesaa’s life for she violated the as saving themselves from being
principle of their community and oblivious to their impending fates.
also to protect the family’s
honour. This only means that
cultural beliefs and values seem
to have an amazing power,
capable of overriding the most
visceral urges of human nature
and being dishonoured in an
honour culture is often
considered a fate worse than
death.
This belief contradicts the
instinctive love of a parent for a
child and the protective affection
of a brother for a sister. Because
of Ayesaa’s action of marrying by
her own choice, this is enough
reason to trigger an attack on her
life. Therefore it only proves that
honour is more valuable than a
close kin’s life in which death is
the only way and the fairest cover
for her shame.
Act done from a sense of duty-
Choosing dignity and honour
over someone who shares the
same blood with you was never
been right. If this is the motive of
her eldest brother then it’s
considered as morally wrong
because he failed to fulfil his duty
as a brother to protect her sister.
Prima Facie Duty- The rules
must be followed and must
always prevail in honour families.
That is why it’s her eldest
brother’s obligation to protect the
honour that gives them the
benefits disregarding the fact that
Ayesaa is part of their family. It
only shows that he values his
duty and loyalty to his family and
to their community.
Act Utilitarianism- In this case,
Ayeesa wanted to be happy and
experience the freedom of
making her own decisions. She
overrules the law because she
believed that she has the
authority to control her life and is
willing to take the risk in order to
achieve what her heart desires.
An erroneous theory is
tolerable in the absence of a
good one- Their family will not
be criticized if ever Ayesaa and

8) Natural Law Ethics
Include the applicable ethical
principles applicable
her husband got killed due to the
fact that their community values
the honour more over life.
Instead, the action would be
praised because they were able
to get rid of the person who
stained the honour and will not
make their image bad to the eye
of the public.
The double effect principle-
The purpose of Ayesaa’s brother
is good because this is their way
of restoring the honour and this
may result to two consequences.
One is that he was able to get rid
of the couple and free their family
from the threat of shame.
Meanwhile, committing such
unlawful act in a non-Muslim
country will get him into the jail
and will receive retribution from
the high authority.

PRINCIPLE OF TOTALITY AND ITS INTEGRITY

In its simplest form, the principle of totality holds that under certain circumstances it is morally permissible to
sacrifice the good of a part for the sake of the whole. However, Pope Puis XII rejects this argument as erroneous by
appealing to the “essential difference between a physical organism and a moral organism.” He stated “The organs of
the body exist solely for the sake of the body while each human person does not exist for the sake of the whole of
humanity. Instead, each human person has intrinsic worth and thus cannot be coercively sacrificed for the sake of
the whole”. This is meant to serve the integral good of the person by creating a harmonious relationship between the
physical and spiritual elements.

To emphasize this point, some authors have referred to it as the principle of “Totality and Integrity.” Fr. Benedict
Ashley, one such author, states the principle as follows: “Except to save life itself, the fundamental functional
capacities which constitute the human person should not be destroyed, but preserved, developed, and used for the
good of the whole person and of the community.”

In medical ethics, this principle of totality is an important principle because it promotes authentic human good. This
may require at times the sacrifice of a physical part for the integral good of the person, but it also serves to limit the
activities that may be performed on a person.
 ETHICO-MORAL RESPONSIBILITY OF NURSES IN SURGERY

Perioperative nurses often find ethical decisions difficult to make, but necessary when caring for surgical patients in
practice. Perioperative nurses need to be able to recognize ethical dilemmas and take appropriate action as
warranted. They are responsible for nursing decisions that are not only clinically and technically sound but also
morally appropriate and suitable for the specific problems of the particular patient being treated. The technical or
medical aspects of nursing practice answer the question, “What can be done for the patient?” The moral component
involves the patient's wishes and answers the question, “What ought to be done for the patient?”

BIOETHICAL PRINCIPLES

According to the ANA, the term ethical refers to reasons of individuals have for the decisions they make about how
they ought to act. The term moral overlaps the term ethical, but it is more aligned with an individual's personal
beliefs and cultural values. 4 Underlying nurses' ethical actions are the principles of bioethics, which have a great
deal of influence on perioperative nursing practices. These principles include:

• Autonomy (e.g., an individual's self‐determination), which is the principle that encompasses respect for
others, and allows individuals to make voluntary, uncoerced decisions about life situations;

• Beneficence, which is the principle of doing good, benefiting, or acting in the best interests of the patient—
health care providers strive to do this for their patients;

• Nonmaleficence, which is the principle that directs health care providers to do no harm—it often is not
enough to do good for a patient, nonmaleficence also must be considered proportionally when heath care decisions
are being made;

• Justice, which is the principle that treats individuals according to what is fair or owed to them (i.e., patients
expect to be treated fairly and to receive equal care);

• Fidelity, which is the principle of keeping promises, as patients expect health care providers will keep their
promises to maintain the confidentiality and privacy of patient information; and

• Veracity, which is the principle of truth telling—patients expect health care providers to be truthful about
their care.

RESPECT FOR PEOPLE

Provision 1 in the Code of Ethics for Nurses with Interpretive Statements reads: The nurse, in all professional
relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every
individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health
problems.

This provision clarifies that perioperative nurses should have respect for human dignity, especially in the context of
their relationships with patients and taking into account the nature of patients' health problems. Nurses also should
respect human dignity in their relationships with their colleagues and others in the health care setting. This provision
also addresses the right of patients and nurses to self‐ determination. In terms of behavior, the overall concept
expressed is respect for people.

SUPPORTING PATIENT RIGHTS AND CHOICES

Perioperative nurses are obligated morally to respect the dignity and worth of individual patients. Perioperative
nursing care must be provided in a manner that preserves and protects patient autonomy and human rights. Nurses
have an obligation to be knowledgeable about the moral and legal rights of their patients and to protect and support
those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account both individual
rights and interdependence in decision making.

Perioperative nurses preserve and protect their patients' autonomy, dignity, and human rights with specific nursing
interventions, including supporting a patient's participation in decision making, confirming informed consent, and
implementing facility advance directive policies. Perioperative nurses explain procedures and the OR environment
before initiating actions, and they respect patients' wishes in regard to advance directives and end ‐of‐life choices.
Perioperative nurses help patients make choices within their scope of care as applicable. They also provide patients
with honest and accurate answers to their questions, especially related to perioperative teaching, and formulate
ethical decisions with help from available resources (eg, ethics committee, counselors, ethicists).

Patients have the right to self‐determination (i. e., the ability to decide for oneself what course of action will be taken
in various circumstances). The nurse, as a moral agent for the patient, must be ready and able to advocate for the
patient's rights and needs whenever necessary while providing care. Assuming such a stance involves acting on
ethical principles and values. Nurses must be prepared to identify advocacy issues and take action on them as
needed. The nurse‐patient relationship not only allows the nurse to support the patient, but it also supports the nurse.
Nurses can empower patients by providing opportunities for them to make autonomous decisions about their health
care. They can support patient empowerment through education about appropriate administrative protocols (e. g.,
patients' rights, hospital policies, procedures) that best meet individual patient's needs.

When dealing with informed consent, the nurse's role is to validate that the patient has been given the information
and understands as much as is possible about the surgical intervention. The nurse's assessment includes determining
whether the patient has any additional questions that might require another discussion with the physician. The nurse
also assesses the level of decision making the patient is able to demonstrate. The principle of autonomy provides for
patients to make decisions freely, even if those decisions are against medical advice. The criterion that must be met
is that the patient is an adult who is capable of making decisions and has been given the information necessary to
make an autonomous choice. Even if a surgeon and nurse believe that surgery is in the best interest of the patient,
the patient has the right to refuse the procedure at any time, regardless of whether he or she signed a surgical consent
form. Nurses ethically should support patients in their choices, regardless of whether they agree with the patient's
decision.

Nursing assessment and care also applies to situations in which patients identify advance directive choices or
decisions related to do‐not‐resuscitate orders. It is the nurse's role to ensure that surgical team members are aware of
a patient's wishes in these matters. It is important that all team members and the patient discuss and identify a plan
of care before beginning the surgical procedure.

RESPECT FOR OTHERS

Not only must nurses recognize the individuality of their patients, they also must recognize the individuality of their
colleagues and others. Nurses must be able to interact with a variety of other professionals and ancillary providers in
the perioperative environment. Treating others with professionalism and respect enhances the performance of the
health care team. Perioperative nurses are obligated to treat all persons in a just and fair manner, regardless of
disability or economic, educational, cultural, religious, racial, age, and lifestyle differences. Just as nurses have the
right not to be abused or harassed in the workplace, so must they treat others in the workplace with respect and
compassion. The nurse recognizes the contributions of each member of the health care team and collaborates to
achieve quality patient care. In addition, there may be times when a perioperative nurse is told to get the patient's
signature on a consent form. Nurses must realize that they are not being asked to provide informed consent for the
patient. In cases such as these, the nurse merely is acting as a witness to the identity of the patient and to the patient's
signature on the consent form. If a nurse is present at the time the patient signs the consent, it is a good opportunity
to once again assess the patient's level of understanding and see if he or she wishes to further discuss the proposed
intervention with the physician.

TREATING PATIENTS EQUALLY

Perioperative nursing care should be provided in a nonprejudicial manner that preserves and protects patient free
will, choice, and human rights. When providing patient care, nurses must take into consideration a patient's values,
religious beliefs, and lifestyle choices. These choices and beliefs influence nursing practice to the extent that they
represent factors the nurse must understand, consider, and respect in tailoring care to personal needs and maintaining
an individual's self‐respect and dignity. The nurse does not have to agree with or condone the choices and beliefs of
the patient, but he or she should not allow any such disagreement to preclude appropriate patient care. Perioperative
nurses may need to plan for appropriate substitute nursing care if their personal beliefs conflict with required care;
this respects the patient's health care decisions.

The principle of justice dictates that all patients receive the same care regardless of personal attributes. A wealthy
patient should receive the same perioperative care as a patient from a lower economic status. Privacy and
confidentiality are to be maintained too, regardless of the personal characteristics of the patient. Perioperative nurses
apply ethical principles by using standards of nursing practice consistently to all patients regardless of disability or
economic, educational, cultural, religious, racial, age, or lifestyle differences. Ethical perioperative nursing behavior
also is demonstrated by refraining from making derogatory comments about patients, family members, significant
others, colleagues, and other associates.

AGE‐SPECIFIC CARE

As a part of respect for individuals, perioperative nurses must act ethically with regard to age‐specific care and
treatment. For example, sometimes it is difficult for nurses to adequately assess pain in patients. As a result, they
subjectively decide what is best for the patient based on their depth of knowledge and individual assessment skills;
thus, some nurses may be more aggressive than others when managing pain. Nurses often use the principle of best
interests, which allows them to act as most reasonable people would act in similar circumstances. This principle is
used most often in cases in which patients cannot speak for themselves or cannot accurately relate their feelings to
the nurse, such as in the case of pediatric patients.

It often is necessary to consult with a pediatric patient's parents when obtaining assessment data. A nurse acting with
the best interests of the patient in mind must consider individual patient needs, parental preferences where
applicable, and professional standards of practice. In essence, the good of pain management has to be balanced with
the potential for harm to minimize or eliminate any harm that may result. In this role, the nurse becomes the parental
surrogate, advocating for the child, assessing pain, and providing timely and effective relief. Understanding pain
management across the life span, therefore, becomes an integral part of the ethical practice of nurses. With an
understanding of the ethical principles and responsibilities inherent to nursing practice, perioperative nurses will be
able to more effectively manage preoperative, intraoperative, and postoperative pain.

THE CHANGING FACE OF CULTURE

Culturally competent care has been defined as “…a complex integration of knowledge, attitudes, and skill that
enhances cross‐cultural communication and appropriate and effective interaction with others.” In many instances,
nurses provide care across cultures, so it becomes an ethical imperative for them to develop culturally competent
caring. To effectively care for patients from other cultures, nurses must be conscientious observers and perceptive
listeners and assessors. Acquiring information about a patient's culture and gaining further personal insight provides
nurses with an increased understanding of culture and values as they relate to providing culturally competent care
from both the patient's and the nurse's perspective.

Examples of this in perioperative practice occur when a nurse provides language interpreters for spiritual comfort
and care, regardless of the patient's health status. Sometimes perioperative nurses can allow family members to be
present at various times during the surgical experience to alleviate anxiety on the part of a patient from a different
culture. Sometimes all that is necessary is allowing a patient to bring an important cultural or religious item (eg, a
talisman, rosary) into surgery. The item often can be put in a plastic bag so the patient still can have contact with it
even as sterility is maintained in the OR.

THE PERIOPERATIVE NURSING DATA SET

Respect for persons is evidenced in the information presented in the Perioperative Nursing Data Set (PNDS). A
patient's value system, lifestyle, ethnicity, and culture are considered, respected, and incorporated into the
perioperative plan of care as appropriate. To do this, perioperative nurses assess, identify, and report a patient's
philosophical, cultural, and spiritual beliefs or values. This information is incorporated into the plan of care and
disseminated as appropriate. Additionally, perioperative nurses identify cultural and value components related to
pain and provide pain control, while also considering such cultural factors and value manifestations as stoicism,
meditation, and alternative therapies.

Perioperative nurses contact appropriate health care team members as necessary for patient care. They preserve and
protect patients' autonomy, dignity, and human rights by supporting patient participation in decision making,
implementing advance directives as appropriate, and confirming consent. Comparable levels of care must be
provided, regardless of the setting in which the care is given. Nurses must provide care in a nondiscriminatory and
nonprejudicial manner. Perioperative nurses provide care that respects the worth and dignity of patients regardless of
the diagnosis, disease process, procedure, or projected outcome. Nurses provide patients with information and
explain the patient self‐determination act in instances such as organ procurement, do‐not‐resuscitate orders,
informed consent, and advance directives. Nurses also impart patient status reports to the patient's family members if
the patient has

indicated it is acceptable to do so. Patient consent and permission to release information are of the utmost
importance when the goal is respect for the individual.
 STERILIZATION/MUTILATION

STERILIZATION

Sterilization is a permanent method of contraception, suitable for people who are sure they never want children or do
not want any more children. Sterilization is available for both women and men and there are a few different types of
procedure, they do all have the same ending though, no babies and no going back. According to the teaching of the
Church, sterilization is an intrinsically evil act insofar as it attacks the moral good of the person.

FEMALE STERILIZATION
The most common forms of female sterilization are the surgical and non-surgical techniques. Both methods
completely stop the chance of a sperm meeting an egg in the womb, but the way they do it are slightly different.

Surgical Techniques: One way is by tying and cutting the tubes and this is called tubal ligation. The fallopian tubes
can also be sealed using an instrument with an electrical current or closed with clips, clamps, or rings so that the
sperm cannot meet the egg. A medical device is put inside the fallopian tube through the vagina with a special
catheter. Sometimes, even a small piece of the tube is removed.

Non-Surgical Technique: blocks the tubes up so nothing is getting in or out. A small flexible, metal insert is put
into the fallopian tubes through the vagina with a special catheter. The device works by causing scar tissue to form
around the coil. This blocks the fallopian tubes and stops you from getting pregnant.

MALE STERILIZATION

Male sterilization is often referred to as a vasectomy, and is a surgical procedure in which the sperm-carrying ducts
are cut and the operation can be carried out under local anesthetic. After the procedure, a man can still ejaculate, but
there is no sperm present. It affects a man’s fertility potential but has no effect on his libido or the ability to have
sexual intercourse.

ADVANTAGES OF STERILIZATION

 It lasts forever
 Highly effective
 It doesn’t interrupt sex
 It isn’t affected by other medications
 Suitable for everyone who never wants to have a child (or does not want any more children) and wants a
permanent contraceptive option
 Hormone free

DISADVANTAGES OF STERILIZATION

 It lasts forever
 It may cause pain, bleeding, infection or other complications after surgery
 It may cause tubal pregnancy
 You may need general anesthesia
 Rarely, there can be a failure in which the Fallopian tubes reopen, or closure is incomplete
 Sterilization is sometimes reversible, although the procedure is complicated and rarely successful
 It requires a healthcare provider to do it
 Does not protect against HIV infection (AIDS) and other sexually transmitted infections (STIs)

Direct sterilization is a sterilization that “of itself” and “of its own nature and condition, has the sole immediate
effect of rendering the generative faculty incapable of procreation.” With direct sterilization, sterility is chosen either
as an end (sterility is the goal) or as a means (sterility is sought to bring about another goal, i.e., the health of a
woman). Direct sterilization is “absolutely forbidden” in Catholic institutions, because it is not “oriented to the
integral good of the person.” Catholics should never choose a sterilization procedure that is “direct.” To do so freely
and knowingly is a mortal sin.

Indirect sterilization is morally permissible. Here surgery, or drug or radiation therapy, is not intended to destroy
the functioning of a healthy organ or to prevent the conception of children. Rather, the direct intention is to remove
or to combat a diseased organ; unfortunately, the surgery or therapy may "indirectly" result in the person being
sterilized.
But are there any surgical or medical interventions that could be classified as indirect sterilization? The answer is
yes, under certain circumstances. For example:

1. A woman with an ectopic pregnancy in one fallopian tube followed by an ectopic in the remaining tube
could have the second (medically necessary) salpingectomy, even though this last procedure will render her
sterile.
2. A male patient with testicular cancer could have his testicles removed for curative purposes, even though
he is sterile as a result.

The Distinction Between Direct and Indirect Sterilizations

“Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health-
care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a
present and serious pathology and a simpler treatment is not available.”

The first sentence defines direct sterilization as a morally unacceptable procedure since, in choosing it, the
physician/patient have the sole intent of sterility or the direct suppression of the basic human good of fertility. Its
second sentence defines indirect sterilization: a procedure who’s direct, that is, intended effect is to cure or alleviate
a present and serious pathology and whose indirect, only tolerated, effect is sterility. Thus, an indirect sterilization is
morally acceptable since the physician/patient who chooses it directly intends the therapy or cure-a moral good-and
only tolerates the bad effect of sterility.

A revised understanding of the principle of totality could be applied to sterilization. Perhaps even in sterilization,
according to Nolan, the discussion should not be confined to the organs in question and their relationship to the
organism, but rather the good of the whole man and his relationship to his family, community and the larger society
must be taken into account.

For instance, if a woman is diagnosed with a cancerous uterus, the performance of a hysterectomy is perfectly
legitimate and moral. The direct effect is to remove the diseased organ and preserve the health of the woman’s body;
the indirect effect is that she will be rendered sterile and never be able to bear children again. The same would be
true if one of a woman’s ovaries or if one of a man’s testes were cancerous or functioning in a way that is harmful to
overall bodily well-being. The caution in this discussion to uphold the morality is that the operation is truly
therapeutic in character and arises from a real pathological need.

MUTILATION

Despite global and local attempts to end female genital mutilation (FGM), the practice persists in some parts of the
world and has spread to non‐traditional countries through immigration. FGM is of varying degrees of invasiveness,
but all forms raise health‐related concerns that can be of considerable physical or psychological severity. Female
genital mutilation (FGM), the practice of cutting or otherwise damaging the genitalia of young women and girls, is a
cultural tradition in some third-world countries.' Although the practice is widespread in parts of the world, many
women and girls participate unwillingly. After all, FGM has severe short- and long-term health consequences both
for the women who undergo it and for their future children.

The classification of FGM by the World Health Organization

It seems appropriate to briefly and preliminarily consider the classification of FGM by the WHO: FGM, often
referred to as female circumcision, comprises all procedures entailing partial or total removal of the external female
genitalia or other injury to the female genital organs for cultural, religious or other non‐therapeutic reasons.
Different types of FGM practiced today include:

1. Type I—excision of the prepuce, with or without excision of part or all of the clitoris;
2. Type II—excision of the clitoris with partial or total excision of the labia minora;
3. Type III—excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening
(infibulation);
4. Type IV—pricking, piercing or incising of the clitoris or labia; stretching of the clitoris or labia;
cauterization by burning of the clitoris and surrounding tissue;
5. Scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts);
6. Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of
tightening or narrowing it; and any other procedure that falls under the definition given above.

In addition, FGM often includes "sewing shut the victim's vaginal opening so that only a small hole remains through
which urine and menstrual fluid may pass.

Even considering the clearly invasive nature of these procedures, the number of negative health consequences that
female genital mutilation causes is staggering. Negative health consequences can result from any of the four types of
FGM, although the first three types are more likely to produce serious consequences. In the short term, all four types
cause excessive bleeding, severe pain, and emotional trauma (family or tribe members usually hold a girl down for
the procedure and then bind her legs together for several weeks as she heals). In addition, all types of FGM can
cause shock, difficulty in urinating, infections (including human immunodeficiency virus (HIV), unintended labia
fusion, and death.

Long-term health consequences often include "chronic pain, infections [to the genitalia], decreased sexual
enjoyment, and psychological consequences, such as post-traumatic stress disorder. “Long-term health
consequences can also include keloids (excessive scar tissue), reproductive tract infections, sexually transmitted
infections, HIV, a reduced quality of sexual life and painful sexual intercourse, a need for later surgery, urinary and
menstrual problems, and infertility.

In conclusion, the unquestionable psychophysical “harmfulness” of FGM is a certain and fundamental acquisition of
medical science and has been documented in several studies in medical literature.6 The ethical dimension of this
phenomenon has caused great interest, raising,7,8,9,10 at the international level, strong and unanimous expressions
of condemnation towards a practice that is harmful both to the physical and psychological health of the girls and the
women who have undergone these procedures and also to their dignity and sexual freedom.

ISSUES ON ORGAN DONATION

Organ Donation is the removal of the tissues of the human body from a person who has recently died, or from a
living donor, for the purpose of transplanting.

 Organ and tissues are removed in procedures similar to surgery.

 People of all ages may be organ and tissue donors.
 In numerical terms, donation from dead donors far outweigh donations by living ones.
 The laws of different countries allow either the potential organ donor to consent or dissent to the donation
during his or her life time, or allow the potential donors relatives to consent of dissent.
 Due to cultural issues and different legislative possibilities, the number of donations per million people
varies substantially in different countries.

Short History about Organ Donation

Organ transplantation is certainly one of the “miracles” of modern medicine. The impossible dream of replacing a
dead or dying vital organ, such as a kidney or a heart, with a living one became a reality on December 23, 1954,
when Drs. Joseph Murray and John Merrill of Peter Bent Brigham Hospital transplanted a kidney from one
monozygotic twin to another. Rejection was prevented by their genetic similarity, and the recipient lived another 8
years. Many years of experimental transplants, mostly on animals and occasionally on humans, led to this
miraculous moment of success. Many obstacles remained, particularly the problems of transplanting organs between
persons who were not genetically identical. Still, the era of transplantation had begun and was everywhere hailed as
an extraordinary leap in medicine and surgery.

Principles of Biomedical Ethics

Beneficence: act in the best interest of the patient. Non-maleficence: first, do not harm, “primum non cere”.
Autonomy: respect for a person’s choice. Justice: fairness and equality. General guiding principles in organ and
tissues donation: should be voluntary and altruistic, free and consented; respect for donor’s and recipient’s
autonomy; confidentiality and protection of donor’s and recipient’s data; equitable opportunities and fairness in
allocation; prohibition on making the human body and its parts a source of financial gain; physicians who determine
brain death occurrence should not be directly involved in organ removal from the donor.

Organs and Tissues which can be Donated

 Organs that can be procured include: heart, intestines, kidneys, lungs, liver, and pancreas. These are
procured from a brain-dead donor or a donor where the family has consent for donation after cardiac death,
known as Non-heart beating donation.
 The following tissues can be procured: bones, tendons, cornea, heart valves, femoral veins, great saphenous
veins, small saphenous veins, pericardium, skin grafts, and the sclera. These are the only procured after
someone has died.
 Organs that can be donated from living donors include part of the liver or pancreas and the kidney.

ORGAN TRANSPLANTATION: APPLICATION OF ETHICAL PRINCIPLES

The ethical and legal issues related to organ and tissue procurement and transplantation are often discussed in light
of such principles as autonomy, benevolence, non-maleficence, free and informed consent, respecting the dignity,
integrity and equality of human beings, fairness, and the common good.

Ethical Issue Regarding the Donor

From the Deceased

 Such a donation can greatly benefit others and cannot harm the donor who is dead. Not to offer such a
donation can be a sign of indifference to the welfare of others. To donate, however, is not considered
obligatory. Transplantation is against some people's consciences for religious or other reasons.

 In any case proper respect should always be shown human cadavers. Although they are by no means on par
with a living human body/person, they once bore the presence of a living person. The probably dying
potential donor should be provided the usual care that should be given to any critically ill or dying person.

 Deprived of life or of the essential integrity of their bodily functions. No organs may be removed until the
donor's death has been authenticated by a competent authority other than the recipients.

The Catholic Health Association of Canada (CHAC)

 Considers transplantations of brain cells (presuming irreversible cessation of all brain functions of the
donor) in order to restore functions lost through disease as permissible "as long as the unique personal
identity and abilities of the recipient are not compromised in any way."

The German Bishops' Conference and the Council of the German Evangelical Church

 Consider the transplant of "reproductive glands" as unethical, "since it intervenes in the genetic
individuality of the human being.) This does not seem to exclude transplanting all sexual body parts, but
the gonads. Any child that resulted following an ovary or testicle transplant would have the dead donor and
not the living recipient as its biological mother or father. This would violate the rights of the child.

From Living Persons (Adults, Mentally Disabled, Minors)

 Transplants between living persons raise the question whether it can ever be ethical to mutilate one living
person to benefit another.

 Before transplants of organs such as kidneys were performed, many Catholic theologians considered this
unethical between living persons. They thought it violated the Principle of Totality, which allowed the
sacrifice of one part or function of the body to preserve the person's own health or life (i.e. a part could be
sacrificed for the sake of the whole body), but did not allow one person to be related to another as a means
to an end.

From Anencephalic Infants

 Anencephalic infants are born with a major portion of the brain absent. If born alive they die within a few
days, although in rare cases some survive for weeks or months.

 According to the widely accepted criteria of death as irreversible cessation of all brain functions, they are
living human beings/persons. To increase the likelihood of procuring viable organs from them, some would
like to redefine death in terms of partial brain death so that they could be considered dead or for them to be
exempt from the total brain death criteria, or to consider them non-persons.

From Human Fetuses

 Some argue that transplanting fetal brain tissue would require the fetus to be still alive, that is, the tissue
would not be good for transplant purpose.

ETHICAL ISSUES ON ORGAN DONATION AND TRANSPLANTATION

Ethical Issue Regarding Recipient

  Another moral issue involving the recipient is free and informed consent. A competent person who could
possibly benefit from receiving a transplant should be adequately informed regarding the expected benefits,
risks, burdens and costs of the transplant and aftercare, and of other possible alternatives.

 Guardians should respect the wishes, if known and reasonable, of incompetent persons in their care. No
unfair influence should be put on someone to be a transplant recipient.

Ethical Issues Regarding Allocation of Limited Resources

 A "first come, first serve" basis, where there is equal chance, is fair provided that the need and benefit are
approximately the same among potential recipients.

 Some argue in favor of using criteria such as social worth, and merit or demerit, to select or prioritize
potential recipients.

 Many, however, criticize these and other criteria such as ability to pay, race, religion, gender, and age, as
involving unfair discrimination. They are said to violate the equal dignity of all human beings.

Ethical Issues Regarding Procurement of Organ and Tissues

Buying and Selling Human Organs and Tissues

 Some argue in favor of allowing human organs and tissues to be bought and sold to increase the supply and
to respect people's autonomy. Others argue against such saying that to treat the human body and its parts as
commodities violates human dignity.

 Paying for organs can constitute unjust moral pressure on the donor. It could invalidate any free consent or
a contract.

 Equity would be violated with ability to pay rather than medical need determining the distribution of organ.

Media Publicity

 Sometimes an organ or tissue is procured for a person by publicizing their need through the media. This
could bypass the regular transplant channels and their selecting recipients for an available organ on the
basis of greatest need and greatest likelihood benefit, first come first serve.

Organ donation and transplantation still presents many ethical challenges and dilemmas, both at personal and
community level, even within the medical community. The various aspects of ethical, cultural and religious nature
should not be a barrier to the act of organ donation and transplantation – all of these are issues to be solved.
Applying ethical principles, transparency, identifying and fighting the main concerns with the utmost
professionalism can bring changes in the attitude towards organ donation.

Involvement of medical staff with specific professional training, promoting interpersonal communication among
community members, campaigns aiming to create a more accurate perception of the entire medical act, the legal and
ethical framework are essential elements for a good development of the whole process of organ donation and
transplantation.

PRESERVATION OF BODILY FUNCTIONAL INTEGRITY

Integrity refers to each individual’s duty to “preserve a view of the whole human person in which the values of the
intellect, will, conscience and fraternity are pre-eminent. The functional integrity of the person may be sacrificed to
maintain the health or life of the person when no other morally permissible means is available. It is a philosophical
concept that is closely connected with autonomy and dignity. It concerns the integrity of the human person, and the
personality. The human person has a private sphere which can be described as the sphere of integrity. This sphere of
integrity has at the same time a spiritual and a corporeal dimension: the psychical and physical integrity. The
spiritual dimension can be expressed by the concept of the zone of the "untouchable", developed by the Danish
philosopher Logstrup.

In the Principle of Totality and Integrity, the body is seen as a temple for the Holy Spirit, how nothing should be
done to that body which hurts or denigrates its overall, and draws a line between the human condition and its animal
commonality. Totality directs that anatomical completeness must not be sacrificed without proportional justification.
Integrity focuses on maintaining basic human capacities and provides a hierarchical ordering of higher functions
over lower functions for use in decision making.

An infringement of bodily integrity (BI) is defined as any penetration into a bodily orifice, breaking of the skin, or
alteration of a person’s physical form. A violation of a person’s right to BI is any infringement of their BI that
wrongs them. An autonomous person is wronged by an infringement of their BI if they did not consent to it. If a
person is incapable of consenting because they are temporarily non-autonomous – as in the case of an intoxicated
adult or a pre-autonomous child – the infringement should be delayed until the individual becomes
autonomous and can make their own decision. It is only when the infringement cannot be delayed without putting
the person into a situation, they would be even less likely to consent to (if they were autonomous) that the
infringement does not wrong them. Given the seriousness of violating anyone's right to BI, and especially that of the
most vulnerable persons, the appropriate likelihood-of-consent for proceeding with a BI infringement on a child is
argued to be at or near the ‘medically necessary’ threshold.

Suppose you are a healthy adult, minding your own business, and a stranger comes along and cuts you with a knife.
Not badly – just a little slice out of your arm, let’s say – but enough to draw blood. If you did not consent to this, it
seems obvious that this stranger has seriously wronged you. In fact, you might say you have a right against other
people intentionally cutting you (or otherwise crossing your physical boundaries) without your consent, no matter
how mildly. This is sometimes expressed as a right to ‘bodily integrity. Let’s say that bodily integrity (BI) refers to
the physical state of being all in one piece, unbroken, undivided, intact. So, skin puncturing of any kind would
negate this. What about borderline cases, like if I jam my finger in your ear? I’d have entered your bodily sphere, in
some sense, and if you don’t want my finger there, I am most likely wronging you in some way. But it isn't clear
whether I am actually infringing on your ‘bodily integrity’ as we have defined it. So, let’s just stipulate that any
intentional (or negligently accidental) penetration into a bodily orifice, breaking of the skin, or alteration of your
physical form, counts a BI infringement.

Now we have to draw a distinction: ‘merely’ infringing on someone’s BI is not necessarily the same thing as
violating their right to BI. This is because not all infringements of a person’s BI wrong them, and if you have not
wronged someone (we’ll suppose) you also have not violated their rights. Consent is what lets you decide about
something that will primarily affect your own embodied self, typically based on what you take to be in your best
interests. But you might also decide to do something that is plausibly not in your best interests, such as donating one
of your kidneys to a sibling. Either way, though, the choice should be yours. We would not want to live in a world
where others had a right to interfere with our bodies based on what they thought was in our best interests, without
first asking our permission. This is why consent, rather than best interests, is built into the two conditions from
before for when someone can infringe on your BI without wronging you, and so avoid violating your right to BI: (1)
you consent to the infringement, or (2) you can’t consent, because you are temporarily non-autonomous (TNA), but
you would consent if you were able.

Bodily Integrity as a Barrier to Organ Donation

Bodily integrity remains a central issue for organ transplantation. The process of removing an organ from one body
and resettling it into another body necessarily requires transgressing the physical integrity of the human body. This
process raises different psychological and moral issues with respect to ideas about how we should treat our bodies or
the bodies of our loved ones. On the one hand, ideas about the physical integrity of the body play an important role
in decision-making by individuals and their families as to their willingness to participate in organ donation
programs. For this reason, it is an important consideration to take into account when understanding those factors that
can limit the potential supply of available organs for transplantation. On the other hand, ideas of the physical
integrity of the body also play an important role in setting constraints on what is viewed as permissible in relation to
possible policies or intervention practices aimed at increasing the general availability of donor organs.

Bodily Integrity as an Empirical Barrier to Donation

Bodily integrity can act as a barrier to organ donation in so far as people are psychologically disposed to reject
interventions they view as transgressing the physical integrity of their body or the body of their loved ones. This is
so even when they are thinking about their bodily integrity after death. For this reason, one’s personal future
intention to donate posthumously or one’s actual family decisions in favor of posthumous donation are less likely to
occur because of how transgressing the physical integrity of the body acts as a countervailing consideration.

In conclusion, the different perspectives on integrity clearly establish the close connection between integrity,
personal identity and character. As early as in Plato's ethical theory integrity meant basic moral virtue and human
character. The psychical and physical aspects of integrity confirm this comprehensive definition and relates the right
to privacy, revealed by integrity, to the concepts of autonomy and dignity.
 PRINCIPLE OF ORDINARY AND EXTRAORDINARY MEANS

A number of claims made in recent discussions about Catholic teaching and the use of life-sustaining treatments
raise important and very serious theological, philosophical, and medical questions that have received almost no
direct attention or examination. For the field of Catholic health care ethics, with its keen interest in the work of grace
in the world, these observations point to one fundamental reality about the traditional distinction between ordinary
and extraordinary means: both sides of this distinction serve to call attention to the role of grace amidst serious
illness.

A Spanish Dominican theologian, Franciso De Vitoria (1486-1546), offered the first explicit treatment from the
Catholic tradition about one’s obligation to prolong life by providing food and medicinal drugs. However, it was
Domingo Bañez (1528-1604) who introduced the terms ‘ordinary’ and ‘extraordinary’ into the discussion of morally
obligatory and morally optional means of preserving life. In a short time after this terminology was introduced, the
distinction became firmly established in both the Catholic moral tradition and secular contexts of medical practice.
This distinction still operates today and is often used as a rule of thumb by health professionals.

The distinction between ordinary and extraordinary means is used both by physicians and moral theologians, but
such a use does not mean that their notions of "ordinary" and "extraordinary" are exactly the same. It may happen
that the notions overlap, but they are not necessarily co-extensive: a means may be "ordinary" for the physician, in
the sense of usual, standard medical practice, but considered "extraordinary" by the moral theologian, and
conversely.

Ordinary means are all medicines, treatments, and operations, which offer a reasonable hope of benefit and which
can be obtained and used without excessive expense, pain, or other inconvenience. Such treatments would normally
be considered morally obligatory. In ordinary means, there are four features to be considered:

1. Media communia, common means, what in the common judgment of men is necessary for the preservation
of life: food, water, clothing, housing, medicines, the recourse to a physician. 
2. Secundum proportionem status, the introduction of a certain subjective judgment in the means by
comparison to one’s station in life. There are means that might be judged excessive for a common man,
but which are not excessive for the president of the nation or for a distinguished scientist, not because of
the absolute value of a human life, which is identical in each case, but simply because of the relative
importance of that life for the common good.
3. Medicina non difficilia, the medicines or means that are not difficult to obtain or use. For instance, the
medicines that are easily found in any pharmacy, or the treatment available in every hospital, or the one
that is considered standard medical practice. In a word, it means that the medicines or treatment do not
impose a great burden of expense, difficulty, inconvenience or pain.
4. Spes salutis, the hope of a beneficial result

Extraordinary means are all medicines, treatments, and operations, which cannot be obtained and used without
excessive expense, pain or other inconvenience, or which, if used, would not offer a reasonable hope of benefit. In
extraordinary means, there are five features to be considered:

1. Quædam impossibilitas, not the physical impossibility of using them because of their unavailability, but
the moral impossibility of using the available means. This includes any kind of impossibility that arises in
the individual regarding the means of preservation of his own life.
2. Summus labor, media nimis dura, the overwhelming and extremely difficult effort to use or to
procure these means.
3. Quidam cruciatus, ingens dolor. If the use of the means provokes such intense and constant pain that one
cannot endure it, those means become extraordinary to that person, even if they are objectively ordinary.
4. Sumptus extraordinarius, media pretiosa. This means that the expense is outrageous, to the extent of
reducing the patient, or the person entrusted with his care, to poverty.
5. Vehemens horror, an intense and overwhelming emotion of horror provoked by the use of those means.

CASE SCENARIO: Same Treatment May Yield Two Moral Outcomes

The following example, concerning use of a ventilator, illustrates how a procedure can result in two different
outcomes – both of which are moral, depending on the patient’s condition.

Assisting a patient’s respiration for a short time as they recover from pneumonia, for example, is most often
considered ordinary care. However, for a patient in the final stages of lung cancer to be put on a ventilator may
 offer little hope of recovery and may be unduly burdensome, simply prolonging the patient’s imminent death.
Under these latter circumstances, the ventilator’s use would be considered an extraordinary means.

The question of whether a means of preserving life is an ordinary or an extraordinary means does not depend
upon the specific procedure or treatment to be given, but requires a fact-specific analysis that considers the
patient’s condition and prognosis, the rationale for the procedure or treatment, and the extent of the benefit that
may be reasonably expected from such treatment. us, the identical treatment in different circumstances may
be morally considered ordinary or extraordinary, depending on such factors.

THE PRINCIPLE OF PERSONALIZED SEXUALITY

(Francisco)

The gift of sexuality must be used in keeping with the intrinsic human teleology. 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 Catholic church has an obsession with sexual morality. The reason for the
emphasis on sexual morality in the teaching of the church is because this element of human character leads so
often to a loss of dignity and an inability to pursue the truly fulfilling goals of human life.

In the Jewish tradition, which is based on the first chapters of genesis, human sexuality is always seen in
relation to the family as the basic community into which we are born and educated and on which the larger
community is built. Hence, sexuality is not only a private matter, although it involves most intimate of
relationships. It also concerns the common good of society and requires its public support and defense as the
basic social institution.

The Meaning of Human Sexuality

"Prudential personalism," the moral method espoused and employed by Frs. O'Rourke and Ashley, situates
beginning-of-life ethical concerns in the context of the twofold meaning of human sexuality. As Frs. O'Rourke
and Ashley are careful to point out, human sexuality first provides the basis of the human capacity for love,
friendship, and community. As they tell us, "Our capacity for affection, communication, and sympathy in all
relationships is rooted in our physical and psychic sexuality."3 The second sense of human sexuality is that of
human reproduction. Here, their stated concern is primarily with "ethical questions about genital activity within
marriage." Together these two meanings of human sexuality form the basis for five major values:

1. Sensual pleasure and satisfaction

2. More profoundly, the completion of the human person through an intimate and personal union of love.
3. The social necessity for the procreation of children and their education so as to expand the human
community and ensure its continuation beyond the death of individual members
4. Even more broadly, the basis of all relationships that constitute the network of human society (as discussed
above)
5. Symbolically, a sacramental mystery that stands for the creative love of God for all creatures and their
loving response

These five values can be summed up in the "Principle of Personalized Sexuality," which states that "God made us
sexual not only for the survival of our species, but for the complete expression of a married person's mutual self-
giving love that finds its complete fulfillment not just in orgasm but in children.

The Principle of Human Sexuality may be stated as follows:

1. The gift of human sexuality must be used in marriage in keeping with its intrinsic, indivisible, specifically
human teleology.
2. 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.

Generally recognized values:

1. Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic tensions.
2. Sex is a search for the completion of the human person through an intimate personal union of love expressed by
bodily union.

3. Sex is a social necessity for the procreation of children and their education in the family so as to expand the
human community and guarantee its future beyond the death of individual.

4. Sex is a symbolic (sacramental) mystery, somehow revealing the cosmic order.

For secular humanists, reasonable uses of sex:

1. Use sex purely for the sake of pleasure apart from any relation to love or family.

2. Use it to reproduce (making test-tube babies) without any reference to pleasure or love.

3. Expression of unselfish love, but without any relation to marriage or family.

Two Norms of Sexual Morality:

1. Laws of social attitudes that hinder human freedom to achieve these values in ways the individual desires are
unjust and oppressive.

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

REFERENCES

Agnelli, R. (2019). The Principle of Totality. Retrieved from http://www.twowingstogod.com/

the-principle-of-totality/. November 18, 2020

Ashley, B. & O’Rourke, K. (n.d). Ethics of Health Care: An Introductory Textbook. Retrieved

from http://docshare02.docshare.tips/files/3859/38592041.pdf. November 21, 2020

Curran, C. (1973). Sterilization: Roman Catholic Theory and Practice. Retrieved from

https://core.ac.uk/download/pdf/213068195.pdf. November 21, 2020

Earp, B. (2019). The Child’s Right to Bodily Integrity. Retrieved from https://www.

researchgate.net/publication/326671234. November 20, 2020

Fineschi, V. & Turillazzi, E. (2007). Female genital mutilation. Retrieved from https://www.

ncbi.nlm.nih.gov/pmc/articles/PMC2598237/. November 21, 2020

Harivandi, Z. (2010). Invisible and Involuntary: Female Genital Mutilation as a Basis for

Asylum. Retrieved from https://scholarship.law.cornelli.edu/cgi/viewcontent.cgi?

article=1089&context=clr. November 21, 2020

Hospice Friendly Hospitals (2013). The Ethics of Life Prolonging Treatments. Retrieved from

http://hospicefoundation.ie/wp-content/uploads/2013/10/Module-6-The-Ethics-of-

Life-Prolonging-Treatments.pdf. November 18, 2020

Iscara, J. (2013). To Live and Let Die. Retrieved from http://archives.sspx.org/against_sound

bites/to live_and_let_die.htm. November 18, 2020

Jonsen, A. (2012). The Ethics of Organ Transplantation: A Brief History. Retrieved from

https://journalofethics.ama-assn.org/article/ethics-organ-transplantation-brief-

history/2012-03. November 19, 2020

Juhari, N. (2017). Organ Donation. Retrieved from https://www.scribd.com/document/

352199676/Organ-Donation. November 19, 2020

Kelly, C. (2019). Ethics in Perioperative Practice- Principles and Applications. Retrieved from

https://epublications.marquette.edu/cgi/viewcontent.cgi?article=1745&context=theo fac.

November 19, 2020

Lederer, M. (1995). Healthcare Ethics—Theological and Papal Perspectives. Retrieved from

http://www.arthurstreet.com/MEDICAL_ETHICS1995.htm. November 20, 2020

Maedica (2019). Ethical, Socio-Cultural and Religious Issues in Organ Donation. Retrieved

from https://www.ncbi.nlm.nih.gob/pmc/articles/PMC6511665/#:~:text=Brain%20death

%20and%20cadaveric%20organ, the%20act%20of%20organ%2odonation. November

19, 2020

Matwijec, G. (2012). Catholic Health Care Select Moral Principles. Retrieved from

https://www.slideshare.net/gmat2000/catholic-health-care-ethics-select-moral-principles.

November 20, 2020

May, W. (1977). Sterilization: Catholic Teaching and Catholic Practice. Retrieved from

https://www.catholicculture.org/culture/library/view.cfm?recnum=5234. November 21,

 2020

Mirkes, R. (2009). Needed, an Ethics Audit of Catholic Sterilization Policies. Retrieved from

https://www.popepaulvi.com/PDF/SrReneeArticles/200905_Needed_an_Ethics_Audit_

of_Catholic_Sterilization_Policies.pdf. November 21, 2020

Nichols, A. (2014). Sterilization for the Life of the Mother. Retrieved from https://www.crisisma

gazine.com/2014/sterilization-life-mother. November 21, 2020.

Saunders, W. (2004). Sterilization: Why It Is Wrong. Retrieved from https://www.catholiceducat

ion.org/ en/culture/catholic-contributions/sterilization-why-it-is-wrong.html.

November 21 2020

Schroeter, K. (2020). Ethics in Perioperative Practice- Principles and Applications. Retrieved

from https://epublications.marquette.edu/cgi/viewcontent.cgi?article=1695&context=

nursing_fac&fbclid=lwAR18x9wKAo8-zwuCT56HDSNACPNFg3G8vh-

pfnfGkv07dF60MZT-uZgFLck. November 19, 2020

Slosar, J. (2007). Fr. O'Rourke and Beginning-of-Life Issues. Retrieved from https://www.chaus

org/publications/health-progress/article/march-april-2007/fr.-o'rourke-and-beginning-of

-issues. November 21, 2020

Sulmasy, D. (2006). End-of-life Care Revisited. Retrieved from https://www.chausa.org/publicati

ons/health-progress/article/july-august-2006/end-of-life- care-revisited. November

18, 2020

Uy, N. (2014). Principle of Personalized Sexuality. Retrieved from https://prezi.com/z6zowcry2g

k2/principle-of-personalized-sexuality/. November 21, 2020

Vavonese, C. (2016). A Resource of Catholic Moral Teaching on End-of-Life Issues. Retrieved

from https://www.stmichael-stpeter.org/End-of-Life-Resources.pdf. November 18,

2020

Veins, A. (2017). Bodily Integrity as a Barrier to Organ Donation. Retrieved from

https://plasticsurgerykey.com/bodily-integrity-as-a-barrier-to-organ-donation/.

November 20, 2020

World Contraception Day (2019). Sterilization: A Permanent Method. Retrieved from https://ww

w. your-life.com/en/contraception-methods/other-methods/sterilization/. November

21, 2020
 DIGNITY IN DEATH AND DYING
The word “dignity” is derived from the Latin, dignitas, meaning worthiness and nobility. It may be attributed to a
broad range of things. In the first place, it may be attributed to humans, animals and, even, objects; hence one might
speak of the dignity of a ballet dancer, or an old soldier, of a swan, and of a work of art. The term may also be
attributed to actions; hence one might speak of someone conducting herself in a dignified way . Kass suggests that
the discussion of death with dignity conceals four senses of the term “death”:

Non-being—the rather mysterious state of being dead;

Transition—the point at which one moves from being to non-being;

Process—the period leading to death. This is not entirely straightforward as we are in this process from the moment
of conception. In practice it usually means a period in which there is an awareness of what will end a particular
person’s life and, roughly, when.

The fact of mortality—death as a universal truth that attaches to us all.

When one hears the words ‘patient dignity’, one tends to think of showing the patient that they are, in a sense,
worthy of honor and respect. Maintaining patient dignity is something we often hear mentioned when discussing the
principles of palliative care; however, it is possible that this almost becomes a phrase of vain repetition with little
relevance to the quality of care the patient actually receives. The application of the phrase “death with dignity” in
health care has been attacked. Ramsey suggested that death is an indignity, an affront to life, and that the phrase is,
therefore, an oxymoron. His argument, however, makes two errors. The first is that it confuses the different senses
of “death”. Ramsey moves from the quasi-existentialist belief that death is an indignity for all people, to the view
that every person’s process of dying is undignified. This is not a justified move. The second error is that it
mistakenly assumes that being subject to an indignity undermines one’s dignity. On the other hand, Coope has a far
more robust critique. He suggested that it is not clear that the notion makes any sense at all. One can die in
undignified circumstances, but he questions whether one can die with dignity any more than one can be born or
breathe with dignity. He considers a common reply to this question: that dying with dignity is whatever the dying
person thinks it is. Hence, for example, if someone thinks it is undignified to die in a confused state, or incontinent,
or heavily dependent on others, then it is undignified for him.

Death without Indignity

According to Aristotelian idea, the unique and essential feature distinguishing humans from other animals is
rationality, the ability to reason and to act upon reasons. Human dignity would, therefore, arise from this feature. We
would affront such dignity by failing to acknowledge this in an individual; instead treating them as an object or an
animal. For example, if one were to engage in euthanasia without consent (“involuntary euthanasia”) then this would
look like an affront to someone’s dignity (even if he would have chosen that option had it been offered); it looks as
though one has “put someone down” like a dog. Another example of an affront to human dignity would be failing to
tell someone of his terminal diagnosis to avoid upsetting him. This is an affront because it removes the ability for
him to make choices about his own life. In more Kantian terms, we would be failing to recognize this person as an
end in his or her own right. Not all affronts to human dignity will be imposed by human agents, however; disease
processes that take away an individual’s ability to reason might also be seen in this way. A death without indignity
will be one in which these types of affront do not occur.

Death with Dignity

The concept of “dying with dignity” may be a theoretical ideal that detracts from our understanding of the process of
dying as unique for everyone. It follows that a dignified death will be something earned. Someone who lives a good
life, lives virtuously, will die in that way. For the rest of us, death with dignity will be, like life with dignity,
something to aim for but only partially to achieve. The potential for dying with dignity may also be lost in those who
lose their reasoning capacities—for example, through dementia-inducing illnesses. Similarly, unbearable (and
uncontrollable) pain or other suffering may undermine someone’s ability to reason and to choose and, hence, to die
with dignity.

Support and Opposition to the Right to Die with Dignity

For centuries, politicians and citizens alike have debated the issues surrounding a person’s right to die. Advocates of
physician-assisted suicide contend that although a person’s life is always valuable, “a patient's desire to control his
or her manner of death and to die a more painless and/or dignified death should be given precedence over the value
of his or her life.” Opponents, however, sort their argument into two main categories: protecting the interests of the
individual and protecting the interests of society. Regardless the issues surrounding the right to die are classified into
ethical, philosophical, religious, and legal considerations.

A History of the Physician-Aid in Dying Movement

Gaining momentum in the 1980s with the medicalization of death, a movement emerged among the public with
advocates holding both affirmative and negative views on whether we have a right to die. After helping his wife
commit suicide in the face of breast cancer and a terminal prognosis, a Californian named Derek Humphry founded
the Hemlock Society. Although this foundation dissolved in 2003, it was the first of its kind and grew to 80 national
chapters by 1992. Mr. Humphry advocated for terminally ill patients' right to die peacefully. Many groups followed
his lead, including the Compassion in Dying organization, founded in Washington State in 1993. To minimize
violent suicides, the Compassion in Dying organization focused on informing terminally ill patients of their many
options for dying peacefully. Into the 1990s, the movement continued to gain traction but also continued to face
opposition. In Oregon in 1990, Dr. Jack Kevorkian, known infamously as "Dr. Death," began an eight-year path of
assisting approximately 130 people in taking their own lives before he was convicted of second-degree murder in
1999. Some advocates claim that his shocking methods of gaining awareness for physician-assisted deaths, the most
well-known of which involved broadcasting a video of himself lethally injecting a patient with amyotrophic lateral
sclerosis (ALS) disease, hindered the movement's progress. The next year, Dr. Timothy Quill, while working in
palliative care, prescribed a lethal dose of medication to a terminally ill patient with leukemia who wished to die.
Despite the Kevorkian outrage around this time, Quill was not indicted by a grand jury for this act. Advocates in
Oregon and California proposed legislation in 1991 and 1992, both of which failed. In 1993, Michigan affirmatively
banned assisted suicides with legislation that was upheld by Michigan's Supreme Court in 1994.

Significantly, just three years after its initial failure at the committee level, Oregon voters passed the Death with
Dignity Act, the first of its kind. Despite opposition and a three-year delay in becoming law, the act has
continuously been upheld and remains in effect today. In 1997, a ballot measure attempted to repeal the act, but was
rejected by 60 percent of voters. In Gonzalez V. Oregon the act was addressed by the Supreme Court in a 6-3
decision holding that it did not violate the federal Controlled Substance Act and reserved medical practice
authorization to the states. Conversely, the Court, in a 1997 case, held that state laws which banned physician
assisted suicides did not violate the Constitution. The holdings in Glucksberg and Gonzalez deemed physician aid-
in-dying a state issue.

Oregon Death with Dignity Act

The Oregon Death with Dignity Act can be viewed from two dichotomous perspectives. On one hand, it opens the
choice to dying patients who might preserve their dignity by arranging the timing of death before they become
totally incapacitated. On the other hand, it risks capitulation to societal pressures to create “good patients,” who seek
not to burden others nor to drain economic and medical resources that could be put to better use in the service of
individuals who are economically productive . This law provides dying patients with full autonomy to choose to die
while still in full control of cognitive and bodily functions and before they become a burden to others, thus
preventing possibly unbearable pain and financial hardship. To some, death is a natural part of existence, and the
proper time to die with dignity is when one’s quality of life shifts from positive to negative. Loss of dignity may be
one aspect of a common pathway leading some dying patients to lose their will to live. One of the primary reasons
given by dying patients seeking hastened death was hopelessness and a belief in the pointlessness of living longer.

Whatever the case, health care professionals cannot ensure that people die with dignity. They can, on the other hand,
try to ensure people die without indignity, in two ways. The first is by not imposing indignities—for example, taking
choices away from people at the end of their lives. The second is by acting to minimize indignities, such as pain. But
there would never be caused to criticize people who suffer such indignities, nor hold them in contempt, because they
are not in control of whether they suffer them.

Euthanasia and Prolonging of Life

Much ambiguity still surrounds the issue of euthanasia and physician-assisted suicide, with its ethical, legal, and
social ramifications. This is compounded by a shift in the attitudes of physicians towards this practice over the years.
For example, according to Louhiala et al. in Finland, physicians’ support of euthanasia increased from 29% in 2003
to 46% in 2013. Attitudes among physicians in Kuwait are equally varied due to the diversity among physicians.
Kuwait hosts doctors from countries such as Egypt, Syria, Lebanon, India, and Pakistan, as well as Kuwaiti
nationals. This diversity is amplified by the myriad of religious beliefs among doctors in Kuwait, the majority being
Muslim, followed by Christians and Hindus, as well as atheists.

There are 4 main types of euthanasia, i.e., active, passive, indirect, and physician-assisted suicide. Active euthanasia
involves “the direct administration of a lethal substance to the patient by another party with merciful intent”. Passive
euthanasia is “withholding or withdrawing of life-sustaining treatment either at the request of the patient or when
prolonging life is considered futile.” Indirect euthanasia refers to the prescription of painkillers that may be fatal in
an attempt to relieve suffering. Physician-assisted suicide refers to a medical professional aiding a patient in
terminating their life upon the patient's request.

Although euthanasia is illegal in most countries, a few like The Netherlands, Belgium, and Luxembourg have
legalized it under certain conditions. A few states in the USA, including Oregon, Washington, Vermont, and
Montana, have also permitted it. In Kuwait, no specific law exists pertaining to euthanasia; however, the legal view
may be inferred from article 149/4 of Kuwaiti criminal law that forbids murder, or ending a person's life. Moreover,
euthanasia is forbidden under Islamic teachings.
Physician's views on euthanasia are an important element in the implementation of this practice. Their views may be
influenced by many factors, including religion, the country where the physician is practicing medicine, or the
physician's subspecialties within the medical field. Disapproval of euthanasia has been reported to be higher among
those with strong religious beliefs. For example, in Catholicism, conservative Protestantism, and Islam, physician-
assisted suicide and euthanasia are strictly prohibited, for the individual is believed to be “neither the author of his or
her own life nor the arbiter of his or her own death.” On the other hand, secular cultures support an individual's right
to make his or her own decisions regarding life and death.

A new BBC report has been published on Belgian Paralympian Marieke Vervoort who has obtained papers
authorizing her euthanasia. She has suffered from a progressive, incurable spinal condition, for 16 years. The report
describes her severe pain which is not fully controllable by medication. A video clip shows her suffering. The story
follows an earlier report last September.

Her case demonstrates how a supportive, professional approach to palliative care can include the possibility of
euthanasia, in a country where it is a legal option. When Marieke felt suicidal, due to her incurable condition, she
was referred to a palliative care expert who discussed the option of euthanasia with her. The knowledge that she
could end her life in a peaceful manner at a time she chose, gave her the ability to carry on – perhaps prolonging her
life by avoiding a suicide, and certainly improving its quality.

“If I didn’t have those papers [permitting euthanasia], I wouldn’t have been able to go into the Paralympics. I was a
very depressed person – I was thinking about how I was going to kill myself … It’s thanks to those papers that I’m
still living. With euthanasia you’re sure that you will have a soft, beautiful death.”

In contrast, in the UK there is no legal option of medically assisted suicide or voluntary euthanasia. As a result,
doctors cannot discuss it meaningfully, so people like Marieke cannot get the consultation they need. This aspect of
the doctor patient relationship is broken. Instead, people are driven to consider other ways of ending their lives,
possibly earlier than they would wish, while they are still able. Options include going to one of the Swiss
organizations that can offer assisted suicide to foreigners, or unassisted suicide. Both these options have many
disadvantages. We need a more compassionate approach in this country.

It is important to point out that this case is another example of someone who is not terminally ill, in the sense of
having a life expectancy of six months or less. Because of this, the approach taken by Dignity in Dying would not
help people like Marieke as that proposal restricts assisted dying to people with a six-month life expectancy or less –
an approach that was rejected by the House of Commons in September 2015. Marieke’s story is another example of
why MDMD do not support the six-month criterion.

It is only when assisted suicide or euthanasia is a legal option that palliative care can offer the full range of options a
person may want, together with meaningful independent professional consultation to help the patient reach the best
decision for them. The irony, demonstrated so clearly by Marieke Vervoort, is that the possibility of a medically
assisted death can actually prolong life. And not only that – it can improve the quality of life during the remaining
time, helping to reduce understandable depression and anxiety, and eventually bring about a “soft, beautiful death” –
the sort of good death some people want.

“Sanctity-of-Life “—A Bioethical Principle for a Right to Life?

For about five decades the phrase “sanctity of life” has been part of the Anglo-American biomedical ethical
discussion related to abortion and end-of-life questions. Nevertheless, the concept’s origin and meaning are unclear.
Much controversy is based on the mistaken assumption that the concept denotes the absolute value of human life
and thus dictates a strict prohibition on euthanasia and physician-assisted suicide.

The phrase “sanctity-of-life” has played an important ideological role in public controversy about abortion and
euthanasia in the United States of America. In 1984, President Ronald Reagan proclaimed January 22—the
anniversary of the U.S. Supreme Court’s “Roe v. Wade” (1973) decision —as the first “National Sanctity of Human
Life Day.” Following Reagan, the proclamation was made annually by Republican Presidents George H.W. Bush
and George W. Bush. It was not issued by Democratic President Bill Clinton and has not been issued by President
Barack Obama. Since 1995, conservative members of Congress, including 2012 presidential candidate Ron Paul,
have made several attempts to introduce a “Sanctity of Life Act” (2011) in order to establish rights of personhood
for all human life beginning from conception.
As on the political battlefield, the phrase has also emerged as a key principle in contemporary Anglo-American
bioethics, especially in the debates about end-of-life issues and abortion (Kohl 1974). According to George Khushf’s
literature search (1996) it seems that Presbyterian preacher John Sutherland Bonnell was one of the first who started
the phrase’s bioethical usage. In his plea against euthanasia, entitled “The Sanctity of Human Life” (1951 p 201) he
contributed only a single sentence with the phrase: “Christianity has never ceased to emphasize the sanctity of
human life and the value of the individual, even the humblest and lowliest, including the afflicted in mind and
body.” Without explicating the phrase’s origin and its logic of argumentation Bonnell used it as a self-evident
prohibition against killing innocent humans. Whether it may serve as a principle fundamental to the human right to
life—like human dignity (Bayertz 1996)—has been doubted, not only because of its religious origin (Clouser 1973,
Engelhardt 1996 p 203 ff.), but also because of the question of whether an absolute prohibition against killing can be
regarded as adequate in the biomedical field of end-of-life questions (e.g., Fletcher 1951). Some decades later,
philosopher and bioethicist Peter Singer (1994, 1999), and his colleague Helga Kuhse (1987) led the opposition
against so-called “sanctity-of-life ethics” and predicted the rise of the new quality-of-life ethic with regard to
questions of abortion and end-of-life decision-making. In response, the Roman Catholic theologian Donald Demarco
has called Singer an “Architect of the Culture of Death” (2003).

“Sanctity-of-life”—A Mysterious Concept in the Bioethical Debate In his literature review, Khushf wondered why,
although “both advocates and detractors designate ‘sanctity of life’ as an ancient principle of the Judeo-Christian
and Hippocratic traditions”, they failed to cite any literature earlier than the twentieth century (Khushf 1996 p 294).
He noticed that current writers use the term in ways that do not easily and directly map to earlier traditions he found
in his literature search. At the same time the new “old” principle has been defined in the “New Dictionary of
Medical Ethics” (1997 p 228) as follows: “This essentially religious concept has its basis in the notion that life is a
gift from God. An additional factor within Christianity is the belief that humans are created in the image of God. In
non-religious circles the term is used to indicate the utmost respect with which human life should be treated.” At a
conference on “Sanctity of Life and Human Dignity,” in Bielefeld, Germany in October 1992, Catholic theologian
and ethicist James Keenan, SJ sought to provide insight into the history and semantics of the sanctity-of-life
principle, but had to admit “that the concept’s origin has not been recorded nor its development narrated. More
surprising is the fact that we do not seem to know where the term came from, what its roots are, and why it has been
appropriated elsewhere. Worse, this lack of knowledge becomes a particular asset for those who oppose the values
that the concept purports to protect.” (Keenan 1996 pp 1–2).

Keenan assumed that the critics of the sanctity-of-life principle “create their own straw man”. With this in mind,
Keenan has tried to counter those critical positions with a reconstruction of “sanctity as absolute inviolability” of
physical human life based on the Catholic natural law tradition (Keenan 1997). As Keenan has observed, the
meaning of sanctity as inviolability of physical human life is used especially in the writings of Pope John Paul II.
(Keenan 1996 pp 3–4), and is also generally accepted by most of its theological (e.g., Ramsey 1968, Thomasma
1999) and philosophical (e.g., Frankena 1975, Dworkin 1993) defenders. Keenan has offered his interpretation
despite the fact, as he has noted, that the term sanctity-of-life does not appear even “in the four most important
modern documents from the Roman Catholic Church’s teachings on matters dealing with killing.” (Keenan 1996 p
4) Like Keenan, many Christian (e.g., Fletcher 1951, Thomasma 1999 p 59f, Kopfensteiner 1999 p 202, Götz 2000 p
280) as well as Jewish (Green 1999 p 28, Kass 2002, Weingarten 2004, 2007) ethicists feel uneasy with the so-
called “vitalistic” 2 smell of sanctity-of-life when used as a bioethical principle. “Vitalism” is the term they use to
criticize ethically “naturalistic philosophy” that “assumes that physiological life is sacrosanct” (Fletcher 1951 p 206)
or endows it with value in and from itself. Theologically speaking, they maintain: “Although life is indeed the gift of
God, it is not merely a biological gift, and morally neutral.” (Weingarten 2007 p 333).

The Naturalistic “Straw Man” in the Bioethical Debate

One of the most influential philosophical critiques is delivered by Helga Kuhse in her book “The Sanctity-of-Life
Doctrine in Medicine” (1987). She largely adopts the position of William Frankena (1975). In contrast to Fletcher
(1951 p 206), Frankena claimed that wherever the sanctity-of-life principle is rooted, either in the Pythagorean
background of the Hippocratic oath or in the Judeo-Christian tradition or elsewhere,3 that it was Christian theology
that made it especially influential. Kuhse follows Frankena’s conviction that the sanctity-of-life principle primarily
aims at the protection of the bodily life of a human individual, but both struggle with the problem of so-called
“vitalism” (Frankena 1975 p 44) and with “speciesism” (Kuhse 1987 pp 13–14, 210–212). Frankena carefully
examined a variety of positions about respect for life: “absolute” (all life-shortening acts are morally wrong) and
“qualified” forms (some life-shortening acts might be permissible, 1975 p 32), “direct” and “indirect” forms of
respect for life for its own sake or for life as a condition for other good (1975 p 34), religious and moral foundations
of the doctrine (p 31), “intrinsic” (valuable in and from itself) and “related” (valued by another, e.g. God) (p 40),
“comprehensive” (all forms of life) and “non-comprehensive” (only human life) forms with regard to the extension,
and so on. While Frankena recognized that all these forms can be held also by religiously-bound scholars, Kuhse
determines that the theory of “the absolute prohibition of the intentional termination of life has its source in
theology” (Kuhse 1987 p 15), but admits not being interested in the “specifically religious sense” (p 2) of the term.
She defines the doctrine’s “absolute” formula as follows: “It is absolutely prohibited either intentionally to kill a
patient or intentionally to let a patient die, and to base decisions relating to the prolongation or shortening of human
life on considerations of its quality or kind.” (p 11) Then she argues that medical practitioners and also the Vatican’s
Declaration of Euthanasia make implicit use of quality-of-life considerations and deny any difference between
killing and letting die when proposing “to refrain from preventing death”. In consequence, says Kuhse, they do not
assert the “absolute,” but only a “modified” type of the “sanctity-of-life doctrine” which leads, however, to its
complete theoretical inconsistency. Thus, the focus of her book questions the distinction between killing and letting
die, and tries to show that the latter is an intentional act, which implicitly relies on quality-of-life judgments. Since
her study on the “sanctity-of-life doctrine,” she has, with other bioethicists such as Peter Singer, promoted the
program of “unsanctifying human life” (Kuhse 2001) in order to drop “the ‘sanctity-of-life’ doctrine and work out a
quality-of-life ethic instead” (Kuhse 1987 p 220, see also Singer 1994, 1999)—a contradistinction which Warren
Reich (1978 p 831) early criticized as “a misleading dichotomy”.
The Non-naturalistic Theological Alternative
Frankena’s and Kuhse’s examinations share with most sanctity-of-life interpretations the focus on the element “life”.
Here, we find many suggestions and speculations about what kind of life could be meant: merely biological, a body-
mind unit, a more Cartesian-like life of pure mind or a biographical life (see the overview in Zimmermann-Acklin
2002 pp 165– 173). Even authors who are dealing with the whole phrase (e.g., Clouser 1973; Engelhardt 1996), are
not interested in a theological reconstruction of its meaning, since they find it inappropriate for pluralistic societies.
But reconstructing the history of a religious idea in 298 H. Baranzke order to understand its original meaning is one
thing; defending religious fundamental arguments is quite another one. Thus, I shall firstly take seriously the
religious element “sanctity” in order to find out what sort of life could be meant in the expression sanctity-of life. If
this approach delivers a plausible reconstruction of the original meaning of the concept, we can, in a second step,
look for reasonable possibilities to secularize the concept ‘within the limits of reason alone’ (Kant 1960).

Two Ways of Translating Sanctity of Life

Secularization as Self-moralization: Immanuel Kant’s Model of Internalization What results can be drawn from
Kant’s engagement with the sanctity-of-life tradition? Kant’s conceiving bodily human life as a sanctuary contains
three interesting aspects: first, that Kant does not defend a biologically based ethical naturalism, since physical life is
not characterized as intrinsically holy, but projected only as the fundamental natural condition for conducting a
moral life. As such, physical life participates in the inviolability of the moral integrity of the agent who is dedicated
to fulfill the “intrinsic” “holy” moral law. Therefore, Kant can even deliver casuistic reflections upon the ultimate
possibility of morally justified self-killing acts if morally higher values could be realized. But dealing with self-
sacrifice as a kind of “moral martyrdom” only in the context of duties to oneself underlines that this can never be a
duty demanded by others. That leads to a second, often neglected aspect: Duties to oneself are not addressed in the
Doctrine of Right, only in the Doctrine of Virtue. That is meaningful because the Doctrine of Right refers only to
interpersonal duties, not to intrapersonal duties. In 6 Doctrine of Virtue, Kant explicitly refrains from dealing with
suicide “as a violation of one’s duty to other people” (1996 6:422) like spouses, children or fellow citizens, which
may be possible reasons in a normative ethical or in a juridical debate. But looking at one’s physical life as a
“sanctuary” is restricted to the subject’s moral self-relationship, that is, to the moral first-person perspective.
Although duties to oneself have objective moral validity for Kant, it is their nature that they cannot be prescribed by
another person or judged from an external position. Only the moral agent oneself can and shall take these duties into
account by recognizing and constituting oneself as a moral subject. Realizing this inner act of recognition of one’s
own responsibility makes the moral subject irreplaceable. With that, Kant confidently transfers the biblical sanctity-
of life concept into a secular virtue-ethical self-relationship between the empirical person (homo phenomenon) and
the ideal moral personality (homo noumenon). Finally, the understanding of human bodily life as an instrument for
leading a moral life is not only significant with regard to physical self-preservation and therefore to end-of-life
situations. In addition, the duty to self-preservation considers life as the basic good that enables leading a moral life
in general in the full range of the basic motif: praising God through living a holy life (Kiddush haShem through
Kiddush haChayim). The question of suicide is therefore only the extreme point, where the moral question of how to
live a life emerges. Thus, reducing the sanctity of human life to mortal questions fundamentally impoverishes its
meaning.

Hence, the theological history of the idea of sanctity-of-life already offers a model of its secularization through
internalization by Kant. Kant adopts the commandment from Lev 19:2 as a call for moral self-perfection, but drops
the theological foundation. With that, he replaces the God-human relationship with the relation the moral agent as a
homo phenomenon has to her own consciousness as the homo noumenon, in which the moral law’s claim is present
as a fact of reason. That is how the external interpersonal relation between God and the human being is turned into
the internal or intrapersonal relation of the human moral “Sanctity-of-Life “—A Bioethical Principle for a Right to
Life? 303 agent herself—a process described as the secularization of human moral consciousness by Kant
(Kittsteiner 1995). “Be holy!” can only work as a call for moral self-perfection under the precondition of an
intrapersonal relationship of the moral self whose theoretical structure Kant develops in the Doctrine of Virtue
§3(1996 6:418) when scrutinizing how duties to oneself could be possible. Since it is not logically impossible to
think of ourselves this way, the human being can be thought of as having the unique ability to put oneself under
obligation. Therefore, being human means not only being alive, but being able to conduct a moral life and take
responsibility. According to Kant (1996 6:417–418), the internal possibility of self-obligation is the necessary
precondition for the possibility of any external obligation towards others. Obligations to others presuppose self-
obligation.

A (Bio-)Ethical Outlook: What is Sanctity-of-life Useful for?

Finally, what is the outcome of the examination of the history of the idea of sanctity-of-life— bioethically and
ethically? What purpose does it serve and what purpose should it not be asked to serve? First, we see that for a
variety of bioethicists, secular or religiously bound, liberals or conservatives, the sanctity-of-life concept disappoints
with regard to end-of-life decisions. It “Sanctity-of-Life “—A Bioethical Principle for a Right to Life? 305 delivers
no criterion and no norm with which to decide upon euthanasia issues. One reason for this, I have argued, is that it
does not relate to the physical conditions of human life, but rather to the agent’s own moral attitudes and the virtue-
ethical quality of acting. The fact that the concept is met with wrong expectations makes it understandable that many
bioethicists find the term ‘sanctity of life’ more confusing than clarifying and seek to replace it by ‘value of life’.
Second, although it touches peripherally the problem of the moral justification of suicide, the sanctity-of-life idea
should not be reduced to functioning as a bioethical principle. Arguments might perhaps indirectly be drawn from
the sanctity-of-life motif for reflections on the moral justification of (assisted) suicide in biomedical contexts, but
these ethical deliberations do not derive solely from a so-called sanctity-of-life principle.

Normative bioethical argumentation about (assisted) suicide has to consider more than the isolated and perhaps
academic question of whether there might be ethically justified cases of really free suicidal acts. With regard to end-
of-life care, research in hospice ethics and palliative care ethics has shown that it is absolutely necessary to establish
excellent supportive and patient-centered care for terminally ill and dying people to help ensure that the quality of
care they are missing does not lead to a patient’s desire for (assisted) suicide. Third, the sanctity-of-life is not a
doctrine of the basic human right to life, since it is a virtue-ethical concept and not a rights concept. Sanctity-of-life
does not simply refer to a value of biological existence, but to a spiritual and virtue-ethical way of how to use one’s
own physical existence. Hence, it is not a claim about other persons, but only a claim about one’s self. The rights-
perspective is an interpersonal issue, sanctity-of-life in its secular form, however, denotes a virtue-ethical
intrapersonal relationship. This insight, drawn from the concept’s history, opens a more fruitful avenue for ethical
reflections on questions of self-responsibility, moral autonomy, self-reliance, truthfulness as well as further
considerations on moral agency, moral attitudes and virtue-ethical issues which are often overlooked in bioethics.
The old biblical, Jewish and Christian concept of sanctity-of-life, which we recovered in Kant’s virtue-ethical
imperative “Be holy!”—that is: Strive for increasing truthfulness in your acts and decisions and bear the
responsibility for what you are doing and willing! —cannot and must not replace normative ethical deliberations or a
rights-based ethic. But it may be a keystone in the process “Toward a Virtue-Based Normative Ethics for the Health
Profession” (Pellegrino 2001 p 113) and a necessary element in an ethic of “responsibility” that completes a “rights-
based morality” (Tauber 2011). From this perspective, the idea of sanctity-of-life is an ethically useful concept.
Euthanasia and Suicide
Euthanasia and physician-assisted suicide refer to deliberate action taken with the intention of ending a life, in order
to relieve persistent suffering. In most countries, euthanasia is against the law and it may carry a jail sentence. In the
United States, the law varies between states. Euthanasia has long been a controversial and emotive topic. Euthanasia
and assisted suicide: The definitions of euthanasia and assisted suicide vary.
Euthanasia: A doctor is allowed by law to end a person’s life by a painless means, as long as the patient and their
family agree.
Assisted suicide: A doctor assists a patient to commit suicide if they request it.

Voluntary and Involuntary euthanasia

Euthanasia can also be classed as voluntary or involuntary.
Voluntary: When euthanasia is conducted with consent. Voluntary euthanasia is currently legal in Belgium,
Luxembourg, The Netherlands, Switzerland, and the states of Oregon and Washington in the U.S.
Non-voluntary: When euthanasia is conducted on a person who is unable to consent due to their current health
condition. In this scenario the decision is made by another appropriate person, on behalf of the patient, based on
their quality of life and suffering.
Involuntary: When euthanasia is performed on a person who would be able to provide informed consent, but does
not, either because they do not want to die, or because they were not asked. This is called murder, as it’s often
against the patients will.

Passive and Active Euthanasia

There are two procedural classifications of euthanasia:
Passive euthanasia is when life-sustaining treatments are withheld. The definitions are not precise. If a doctor
prescribes increasing doses of strong painkilling medications, such as opioids, this may eventually be toxic for the
patient. Some may argue that this is passive euthanasia. Others, however, would say this is not euthanasia, because
there is no intention to take life.
Active euthanasia is when someone uses lethal substances or forces to end a patient’s life, whether by the patient or
somebody else. Active euthanasia is more controversial, and it is more likely to involve religious, moral, ethical, and
compassionate arguments.

What is Assisted Suicide?

Assisted suicide has several different interpretations and definitions.
One is: “Intentionally helping a person commit suicide by providing drugs for self-administration, at that
person’s voluntary and competent request. Some definitions include the words, “in order to relieve
intractable (persistent, unstoppable) suffering.”

The Role of Palliative Care

Since pain is the most visible sign of distress of persistent suffering, people with cancer and other life-threatening,
chronic conditions will often receive palliative care. Opioids are commonly used to manage pain and other
symptoms. The adverse effects of opioids include drowsiness, nausea, vomiting, and constipation. They can also be
addictive. An overdose can be life-threatening.

Refusing Treatment
In many countries, including the U.S., a patient can refuse treatment that is recommended by a health professional,
as long as they have been properly informed and are “of sound mind.”

History
One argument against euthanasia or physician-assisted suicide is the Hippocratic Oath, dating back some 2,500
years. All doctors take this oath.

The Hippocratic Oath

The original oath included, among other things, the following words: “I will neither give a deadly drug to
anybody who asked for it, nor will I make a suggestion to this effect.” There are variations of the modern oath.
One states: “If it is given me to save a life, all thanks. But it may also be within my power to take a life; this
awesome responsibility must be faced with great humbleness and awareness of my own frailty.” As the world
has changed since the time of Hippocrates, some feel that the original oath is outdated. In some countries, an
updated version is used, while in others, for example, Pakistan, doctors still adhere to the original. As more
treatments become available, for example, the possibility of extending life, whatever its quality, is an increasingly
complex issue.

Controversy
Various arguments are commonly cited for and against euthanasia and physician-assisted suicide.
Arguments for Freedom of Choice: Advocates argue that the patient should be able to make their own choice.
Quality of Life: Only the patient really knows how they feel, and how the physical and emotional pain of illness
and prolonged death impacts their quality of life.
Dignity: Every individual should be able to die with dignity.
Witnesses: Many who witness the slow death of others believe that assisted death should be allowed.
Resources: It makes more sense to channel the resources of highly-skilled staff, equipment, hospital beds, and
medications towards life-saving treatments for those who wish to live, rather than those who do not.
Humane: It is more humane to allow a person with intractable suffering to be allowed to choose to end that
suffering.
Loved ones: It can help to shorten the grief and suffering of loved ones.
We already do it: If a beloved pet has intractable suffering, it is seen as an act of kindness to put it to sleep. Why
should this kindness be denied to humans?

Arguments Against
The Doctor’s Role: Health care professionals may be unwilling to compromise their professional roles, especially
in the light of the Hippocratic Oath.
Moral and Religious Arguments: Several faiths see euthanasia as a form of murder and morally unacceptable.
Suicide, too, is “illegal” in some religions. Morally, there is an argument that euthanasia will weaken society’s
respect for the sanctity of life.
Patient Competence: Euthanasia is only voluntary if the patient is mentally competent, with a lucid understanding
of available options and consequences and the ability to express that understanding and their wish to terminate their
own life. Determining or defining competence is not straightforward.
Guilt: Patients may feel they are a burden on resources and are psychologically pressured into consenting. They
may feel that the financial, emotional, and mental burden on their family is too great. Even if the costs of treatment
are provided by the state, there is a risk that hospital personnel may have an economic incentive to encourage
euthanasia consent.
Mental illness: A person with depression is more likely to ask for assisted suicide, and this can complicate the
decision.
Slippery slope: There is a risk that physician-assisted suicide will start with those who are terminally ill and wish to
die because of intractable suffering, but then begin to include other individuals.
Possible recovery: Very occasionally, a patient recovers against all the odds. The diagnosis might be wrong.
Palliative care: Good palliative care makes euthanasia unnecessary.
Regulation: Euthanasia cannot be properly regulated.

How many people die each year?

In countries where euthanasia or assisted suicide are legal, they are responsible for a total of between 0.3 and 4.6
percent of deaths, over 70 percent of which relate to cancer. In Oregon and Washington states, fewer than 1 percent
of physicians write prescriptions that will assist suicide each year.
Dysthanasia
Dysthanasia means slow and painful death without quality of life. The concept of "dysthanasia" is still partially
known in the world academic community. The concept is opposite to the concept of "euthanasia", incomparably
more often mentioned, but without doubt much less often practiced in health-care institutions, especially in intensive
care units.

The Position of Dysthanasia Within Objectives of Modern Medicine

Medicine that simultaneously strives to be honorable, balanced, accessible, supportive, and unbiased continually
needs to contemplate its objectives. Health is something that each individual possesses to a greater or lesser degree.
Achieving the highest degree of health is one of the basic rights of a human being. It is understandable that man has
been striving for thousands of years to attain this state of health, and if possible, to maintain it. Oppositely, the
concept of infirmity could be defined by four notions present in the English language: malady, disease, illness, and
sickness. "Malady" presumes various conditions – besides illness – that threaten health. It includes deficiency,
injuries, and defectiveness. Thus, it is possible to define "malady" as a condition in which a person suffers, or there
exists a danger that he or she will suffer from any kind of harm. "Disease" is poor physiological or mental
functioning, according to statistically standardized norms, that causes illness, deficiency, or increases the possibility
of premature death. "Illness" is a subjective feeling of a person whose mental or physical well-being is absent or
weakened, in other words, his usual functions are weakened. "Sickness" is the perception society has on health
conditions of an individual. In general, it is the external perception that a person is not well mentally or physically.
Taking into account the quoted concepts, it is possible to analyze two basic objectives of medicine:

The first is to save and prolong life. However, what does that goal signify today, within the modern medical
technology, when there is equipment available that can maintain a body alive "until further notice?" Where are the
limits to which medicine can and may prolong life, and who is the person who will be able to, have a right to, and
know how to say: enough! One of Potter’s definitions of bioethics is that bioethics should be the controller of
science and warn us if science nowadays has the permission to do all it can do. Does this definition gain in
significance and concrete, practical use within the context of discussions on dysthanasia?

The second objective of medicine is to improve and maintain health. But, what does this mean in an era in which a
prematurely born child that weighs less than 1,000 grams or a geriatric patient that has lived to be 100 years old can
attain health? Do we truly do not wish to (or cannot) accept the concept of illness and death as the integral part of
life? The third traditional objective of medicine is to palliate pain and suffering. Does this mean that euthanasia,
dysthanasia, and medically assisted suicide should be accepted as integral parts of medicine? The question that
simply needs to be asked in this context is: what is the legitimate area of medicine and where to set the limit that
legitimates any sort of medication?

Orthothanasia
The word orthothanasia was used for the first time in the 1950s. It means correct dying, or allowing to die or letting
die. It is vital to note the difference between allowing death to occur and intending death to happen. While in
euthanasia the death of the patient is directly intended and caused, in allowing to die his death is directly caused by a
grave pathology: the morphine administered to the patient in pain directly causes the relief of his pain and indirectly
and unintendedly may perhaps advance his death, which is merely foreseen and tolerated.

Let us underline that in the case of letting die, what is directly intended is the relief of the acute pain of the patient.
In allowing to or letting die, therefore, death is neither directly caused nor intended or postponed. It merely happens.
It is an event, part of the temporal life of every human being. Hence, allowing to die is anti-euthanasia, which
unethically anticipates death, and anti-dysthanasia, which unduly postpones it.

Allowing to Die: Possibilities

Allowing to die includes, in particular, three possibilities:

First possibility: when the treatment to prolong life is useless or futile for the patient, and therefore ought not to be
given. We remember the world of the poet: For man to want to live when God wants him to die is madness.
Second possibility for letting die: when the prolongation of life or the postponement of death is unduly
burdensome in the first place for the patient – also for the family. On this point, the Catechism of the Catholic
Church summarizes the traditional teaching of the magisterium: “Discontinuing medical procedures that are
burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the
refusal of ‘over-zealous’ treatment. Here one does not will to cause death; one’s inability to impede it is merely
accepted” (CCC, 2278).
Third possibility for allowing to die: when the patient needs painkillers or medical sedation, which does not intend
the death of the patient. These painkillers directly mitigate suffering and indirectly may shorten life. Physicians and
significant others are committed to relieve pain and suffering, which is their professional commitment, or moral duty
limited only by the prohibition against direct killing. Summing up the traditional teaching of the Church, the
Catechism states: “The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their
days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only
foreseen and tolerated as inevitable” (CCC, 2279).

As a rule, the terminally ill patient has the right to opt for dysthanasia - exceptional treatments that will potentially
prolong the lifetime - or orthothanasia. Therefore, as opposed to dysthanasia, orthothanasia would advance death,
but if the patient chooses to discard the option of extraordinary treatments and select orthothanasia, death would still
occur due to the progression of the disease, at its own pace, not advancing the time of death. However, the ethics and
legality of orthothanasia practice is not limited to advancing or not the terminally ill patient’s death, but it is
extended to the preservation of the human dignity and the respect for the patient’s autonomy and declaration of
intent. Orthothanasia is the humanization of the patient’s death process, caring for the individual at the end of life, so
that he can find death with comfort and minimum possible suffering, ensuring his dignity12. Consequently,
orthothanasia and passive euthanasia have little in common, since the death of the terminally ill patient is not
induced. In orthothanasia death is inevitable and imminent; the treatments innocuous to the reversal of the patient’s
condition are suspended.
Administration of Drugs to the Dying
In medicine, specifically in end-of-life care, palliative sedation is the practice of relieving distress in a terminally ill
person in the last hours or days of a dying patient’s life, usually by means of a continuous intravenous or
subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and
discreet administration of ongoing medications via the rectal route.

1. Palliative sedation is an option of last resort for patients whose symptoms cannot be controlled by another
means.
2. It is not a form of euthanasia, as the goal of palliative sedation is to control symptoms, rather than to
shorten the patient’s life.

Advance Directives: The Nurse’s Role

Persons receiving health care often worry that if they become incompetent and unable to express their wishes, they
will be subjected to treatments and interventions they do not want. Advance directives have been suggested as one
way to address this problem, and in 1994 the Canadian Nurses Association (CNA), along with several co-sponsors
concerned with ethical issues in health care, produced a Joint Statement on Advance Directives to facilitate their use
in practice. While the use of advance directives is becoming more common, the ethical and legal responsibilities of
the registered nurse* caring for clients making end-of-life decisions are not always clear.

Advance Directives refer to the means used to document and communicate a person’s preferences regarding life-
sustaining treatment in the event that they become incapable of expressing those wishes for themselves. Advance
directives may take two forms: an instructive directive commonly referred to as a living will, which details what
life-sustaining treatments a person would want or not want in given situations; or a proxy directive, which explains
who is to make health care decisions if the person becomes incompetent. A proxy directive is frequently referred to
as a power of attorney for personal care.

Assessing the Client and/or Staff Members' Knowledge of Advance Directives

When a learning needs in respect to advance directives is assessed by the registered nurse, education should be
planned to correct any identified knowledge deficits in reference to all aspects of advance directives including living
wills, health care proxies, and durable power of attorney for health care [DPAHC].

For example, when a client asks the registered nurse if they can change their advance directives, the registered nurse
should know that the client has a knowledge deficit relating to the fact that advance directives can be changed at any
time and when the supervising registered nurse manager audits client medical records and documentation and learns
that the staff are not including complete information about whether or not the clients have or do not have advance
directives, the supervising registered nurse manager should know that the staff have a knowledge deficit relating to
the fact that the presence or absence of advance directives must be assessed and documented.

The ultimate purpose of advance directives is to guide professional decision making and direct the client's care and
treatments at the end of life. Advance directives also provide the legal basis for all clients to accept or reject care as
they wish because they have the innate right to autonomous decision making without coercion and self-
determination even when they are no longer competent to do so. Nurses must review and verify the patient's advance
directive status with their first patient contact because an emergency life threatening situation like a cardiac or
respiratory arrest can occur at any time with little or no time to review these documents at that time. If, for example,
the patient has an advance directive to NOT have CPR, the nurse may administer CPR because they have failed to
review the client's advance directive. This CPR, then, is contrary to the patient's wishes.

Living Will
A Living Will is the oldest type of health care advance directive. It is a signed, witnessed (or notarized) document
called a “declaration” or “directive.” Most declarations instruct an attending physician to withhold or withdraw
medical interventions from its signer if he/she is in a terminal condition and is unable to make decisions about
medical treatment. Since an attending physician who may be unfamiliar with the signer’s wishes and values has the
power and authority to carry out the signer’s directive, certain terms contained in the document may be interpreted
by the physician in a manner that was not intended by the signer. Family members and others who are familiar with
the signer’s values and wishes have no legal standing to interpret the meaning of the directive.

Durable Power of Attorney in Health Care

A Durable Power of Attorney for Health Care is a signed, witnessed (or notarized) document in which the signer
designates an agent to make health care decisions if the signer is temporarily or permanently unable to make such
decisions. Unlike most Living Wills, the Durable Power of Attorney for Health Care does not require that the signer
have a terminal condition. An agent must be chosen with great care since the agent will have great power and
authority to make decisions about whether health care will be provided, withheld or withdrawn from the signer It is
extremely important that the signer carefully discuss his/her values, wishes and instructions with the agent before
and at the time the document is signed. Such discussions may also continue after the document is signed. It is also
important that the agent be willing to exercise his/her power and authority to make certain that the signer’s values,
wishes and instructions are respected.

Combination Advance Directive

A combination advance directive is a signed, witnessed (or notarized) document which contains specific written
directions that are to be followed by a named agent. Since it is not possible to predict all circumstances that may be
faced in the future or to cover all possible interventions, specific directions may severely limit the discretion and
flexibility that the agent needs and may restrict the agent’s authority in a way the signer did not intend. In addition,
the specific written directions may not be altered through discussions between the signer and the agent. Any changes
necessitate a new document to reflect nuances or changed directions. It is important that all adults consider who will
make medical decisions for them if they are temporarily or permanently unable to make them for themselves. Unless
a person has an advance directive, many health care providers and institutions will make critical decisions for
him/her or a court may appoint a guardian who is unfamiliar with the person’s values and wishes.

Protective Medical Decisions Document (PMDD)

The PMDD is a protective Durable Power of Attorney for Health Care which is available from the Patient’s Rights
Council. In the PMDD the signer names a trusted person to make health care decisions in the event that the signer is
temporarily or permanently unable to make such decisions.
The PMDD, which specifically prohibits assisted suicide and euthanasia, is available in a Multi-State version for use
in most states. It is also available in state-specific versions for states where particular requirements make a state-
specific version necessary.

Providing the Client with Information About Advance Directives

Clients should be provided with complete information about advance directives and they should also have the
opportunity to discuss all of their alternatives and options. This education should also include the benefits and risks
associated with their choices in the same manner that is done with all informed consent.
Some of the specific information that should be provided to the client, in writing and/or orally include
understandable information about:

• The Patient Self Determination Act

• The Uniform Determination of Death Act
• The Uniform Anatomical Gift Act
• Living wills
• Health care proxies and surrogates
• Durable powers of attorney for health care (DPAHC)

Another piece of useful information for both the client/family members and healthcare providers in terms of advance
directives is the Five Wishes which was developed with a Robert Wood Johnson Foundation grant. The Five
Wishes, which can and should be considered and addressed in the client's advance directive, include the client's
choices in respect to:

1. Who they desire to make healthcare related decisions for them about their care when they are no longer able to
make these important decisions
2. All medical care and treatments that the patient ELECTS TO HAVE and all of those that the client does NOT
want
3. How the client wants to be treated and cared for by others at the end of life
4. Decisions relating to the promotion of comfort and the relief of pain
5. Things that they want their loved ones to know

Another decision and document that may be highly useful to clients and their healthcare decisions makers is a values
history. Although not mandated by law, value histories are recommended and highly beneficial when it comes to end
of life care and decision making, particularly when a person is appointed as a health care proxy or durable power of
attorney for healthcare. Values histories contain and consist of the client's general basic beliefs, values, opinions and
principles relating to these principles and beliefs in addition to others:

• The quality of life versus the quantity of life

• The management of pain even if it may shorten the duration of life
• Surgical procedures and associated alterations of the body image
• "Being a guinea pig"
• Dignity and maintaining dignity at the end of life

DNR or End of Life Care Plan

DNR means no resuscitation in the setting of a full cardiopulmonary arrest. This is often misinterpreted, and
sometimes associated with lower quality or less care. Patients can and should still receive full and aggressive
medical management even if they are rendered DNR.

Based on the study by Bacchetta, Eachempati, Finns, Hydo, and Barie (2006), patients with a
diagnosis of malignant disease (with or without metastasis), cardiovascular disease, or
endocrinopathy, and patients receiving chronic glucocorticoid therapy, had higher incidences of DNR orders.
Patients who experienced chronic illnesses were more likely to have a DNR order,
possibly because they understood the burdens of life-threatening diseases.

Berger (2003) advocates the avoidance of partial DNR orders and instead suggests care plans
contain the following five elements for life-threatening conditions in patients with DNR orders.
These elements may also assist with discussions regarding goals of care and DNR orders:

1) Identification of the patient’s treatment goals

2) Identification of specific medical interventions declined because of burden or discomfort
3) Physician discretion in determining the utility of specific treatments within the context of
the patient’s care objectives
4) Correlate goals of care only with medically appropriate interventions
5) Care Plans that can be easily translated by any physician or first responder to a medical
Emergency

Discussion of these five elements and the subsequent documentation would provide nurses and
other members of the interdisciplinary health care team with a clear view of a patient’s desired
end-of-life care.

There is evidence that nurses often feel that it is not their place to actually recommend a DNR
order, although they feel confident about their ability to discuss DNR orders (Sulmasy, He,
McAuley, & Ury, 2008). Nurses do, however, have a duty to:

1) Educate patients and their families about the use of biotechnologies at the end of life,
termination of treatment decisions and advance directives;
2) Encourage patients to think about end-of-life preferences in illness or a health crisis;
3) Support patients, their families, and their surrogates to have end-of-life discussions with
their physicians;
4) Ensure advance directives are implemented;
5) Communicate known information that is relevant to end-of-life decisions to appropriate
health care personnel;
6) Advocate for a patient's end-of-life preferences regardless of surrogate decision maker’s
or physician’s desire to not honor them if indeed the preferences reflect beneficent care.

Discussing Prognosis in End-of-Life Care in Emergency Medicine

There are multiple barriers to communicating prognosis which include:
• Physicians in general are poor prognosticators: ED physicians in particular do not have experience taking care of
patients over time in their trajectory towards death
• There is uncertainty in medicine: uncertainty should be communicated with patients; this also leads to the patient’s
increase in sense of trust with the health care team.
• ED physicians often feel a lack of ownership/responsibility regarding end-of-life discussions, as it is thought to be
the responsibility of the primary care physician
• Lack of skill in communication of prognosis
• Physicians assume patients that they do not want to know their prognosis; however, it has been shown that the
majority of patients do want to know their prognosis.

Models for Prognostication in End-of-Life Care

There are two models of death, which can help ED physicians prognosticate for patients. The first one describes the
final hours/days and the second one describes the final months-years.

The 'Two Roads to Death' Model

Usual Road: In this pathway, patients are sleepy, lethargic, obtunded and then progress towards death.
Death typically occurs quickly.
Difficult Road: In this pathway, patients are restless, confused, develop hallucinations, delirium, may
develop seizures, and ultimately progress towards death. In this pathway, death is typically prolonged
and more difficult.
Trajectory of Illness Model
1. Sudden Death: In this trajectory, patients have not been ill, and there is nothing to predict anything bad will
happen. Patients suddenly become critically ill or injured and die. (i.e., sudden massive MI, traumatic injury, etc.)
2. Frailty: In this trajectory, patients die of ‘old age’, and have a slow and gradual decline. These patients may or
may not develop a severe illness, but slowly decline in mobility, function and/or cognition, and ultimately die from a
complication of their progressive disability.
3. Terminal Illness: In this trajectory, it is expected that patients will have a prolonged illness where they can
generally maintain their function, until the end of life, when function sharply drops off. (i.e., cancer).
4. Organ Failure: In this trajectory, there is a relatively steep decline in function with intermittent exacerbations.
Patients ultimately die during one of these exacerbations, and if they survive, they never reach their prior level of
function. (i.e., heart failure, COPD).

Terminally Ill Patients

With the advent of palliative care, severely ill patients with terminal illnesses are often treated in accordance with
their autonomy and with dignity, compassion, and comfort. However, this most often happens if the patient is dying
from the said terminal illness such as renal or heart failure or cancer. Such patients may choose to die at home or
even in palliative care wards. It is a comforting feeling for physicians and families that nonbeneficial life-sustaining
and often agonizing care is not being delivered against a patient's wishes. There are pathways, protocols, and
advance care plans for identifying and allowing such patients to complete their journey at the end of life. However,
an alarming number of patients with terminal illnesses fall through the cracks of this optimal situation. Patients may
receive care that is not in keeping with their natural trajectory of illness or wishes if they are admitted with an acute
potentially “reversible” pathology while having a background terminal illness such as developing pneumonia,
suffering myocardial infarctions, or be involved in trauma. The rising costs of admitting and treating terminally ill
patients with acute illness with modern day technology is unsustainable.

In an aging world with limited critical care resources, there are many demands on acute care settings such as
Intensive Care Units. Patients who may not benefit from aggressive life-sustaining care perhaps should not be
offered such treatment options such as life-saving surgery, if in fact it is merely prolonging their ultimate fate, unless
it can add to alleviating suffering. Instead, effort and resources should be used in trying to match their goals and
values, including palliation, and providing mindful dignity and comfort. Often symptom control to provide relief is
the driving force behind acute admissions in terminally ill patients; however, it seems that frank and consistent
communication with patients and families may allay the ethical conflicts that usually arise when a patient presents in
extremis while already dying from a separate illness including old age.

This issue of Virtual Mentor discusses end-of-life ethical issues that all physicians should have an awareness and
understanding of. One theme of the issue is the distinction between palliative care and end-of-life care. The Center
to Advance Palliative Care defines palliative care as “specialized medical care that is focused on providing patients
with relief from the symptoms, pain, and stress of a serious illness, whatever the diagnosis. The goal is to improve
quality of life for both the patient and the family”. Palliative care can and should be offered to terminally ill as well
as non-terminally ill patients, and, contrary to popular belief, palliative care can be given in conjunction with
curative medical interventions. 

Physician-Assisted Suicide (PAS)

Physician-assisted suicide (PAS) has become a polarizing healthcare topic. Support for PAS has largely originated
from individuals with a terminal illness and the loved ones around them. Palliative care, hospice care, and pain relief
treatment are not always successful at mitigating the tremendous suffering caused by end-stage terminal illness.
Quality of life can decline to a level where pain abatement, whether physically or mentally, is simply not possible.
In addition to pain abatement, advocates stress the immeasurable value of peace of mind and sense of control
provided by end-of-life medication. The diagnosis of a terminal illness and a prognosis of six months or less to live
can strip any sense of control from such an individual. The ability to say goodbye on one’s own terms and in a
dignified manner allows the individual autonomous influence and control. This freedom can be one of the scant
silver linings amid a tragedy. Proponents of legal access to end-of-life medication often point out that in states where
this treatment is prohibited, terminally ill individuals may resort to suicide attempts, often unsuccessfully and in an
inhumane way.
A principal source of opposition to assisted suicide derives from religious arguments in favor of the right to life. In
addition, common objections are found in the conceptual role of a physician assisting a patient in suicide, given the
potential for abuse towards vulnerable populations, and the frequency of incorrect prognosis and medical error.
Assisted suicide is often interpreted as a contradiction to the core responsibility of doctors: to preserve life through
healing. To large segments of medical professionals, incorporating physician-assisted suicide would fundamentally
alter the physician-patient relationship and potentially undermines public trust in the medical profession.
Beneficence is a core principle of medical practice; and, to many, physician-assisted suicide would erode this core
tenet of physician practice. Opponents in Colorado fear that legalizing physician-assisted suicide would
disproportionately affect the elderly, physically disabled, and populations of low socioeconomic status. The
expensive, life-prolonging treatment usually prescribed to a terminally ill patient can place a disproportionately
heavy burden on the uninsured and low-income population which might influence their decision making to favor the
assisted suicide route.

WHAT ARE THE ARGUMENTS IN FAVOR?

 Respect for autonomy: Decisions about time and circumstances around death are very personal. Every
competent person should have right to choose death.

 Justice: Justice requires that we “treat like cases alike.” Competent, terminally ill patients have the right to
hasten death by treatment refusal. For some patients, treatment refusal will lead to more suffering. Justice
requires that we should allow assisted death for these patients.

 Compassion: Suffering means more than pain; there are other physical and psychological burdens. It is not
always possible to relieve suffering. Allowing terminally ill people to determine the timing and manner of
their deaths is a compassionate response to unbearable suffering.

 Individual liberty vs. state interest: Though society has strong interest in preserving life, that interest
lessens when person is terminally ill and has strong desire to end life. A complete prohibition on assisted
death excessively limits personal liberty.

 Openness of discussion: Assisted death already occurs, albeit in secret. For example, morphine drips
ostensibly used for pain relief may be a covert form of assisted death or euthanasia. In states without Death
with Dignity laws, open discussions between patients and physicians are avoided and prohibited.
Legalization would promote open discussion.

Opinion on Caring for Patients at the End of Life

Advance Care Planning

The process of advance care planning is widely recognized to support patient self-determination, facilitate decision
making, and promote better care at the end of life. Although often thought of primarily for terminally ill patients or
those with chronic medical conditions, advance care planning is valuable for everyone, regardless of age or current
health status. Planning in advance for decisions about care in the event of a life-threatening illness or injury gives
individuals the opportunity to reflect on and express the values they want to have govern their care, to articulate the
factors that are important to them for quality of life, and to make clear any preferences they have with respect to
specific interventions. Importantly, these discussions also give individuals the opportunity to identify who they
would want to make decisions for them should they not have decision-making capacity.

Advance Directives

Advance directives, whether oral or written, advisory or a formal statutory document, are tools that give patients of
all ages and health status the opportunity to express their values, goals for care, and treatment preferences to guide
future decisions about health care. Advance directives also allow patients to identify whom they want to make
decisions on their behalf when they cannot do so themselves. They enable physicians and surrogates to make good-
faith efforts to respect the patient’s goals and implement the patient’s preferences when the patient does not have
decision-making capacity.

Withholding or Withdrawing Life-Sustaining Treatment

Decisions to withhold or withdraw life-sustaining interventions can be ethically and emotionally challenging to all
involved. However, a patient who has decision-making capacity appropriate to the decision at hand has the right to
decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead
to his or her death and regardless of whether or not the individual is terminally ill. When a patient lacks appropriate
capacity, the patient’s surrogate may decline an intervention or ask that an intervention be stopped in keeping with
ethics guidance for surrogate decision making.

Orders Not to Attempt Resuscitation (DNAR)

The ethical obligation to respect patient autonomy and self-determination requires that the physician respect
decisions to refuse care, even when such decisions will result in the patient’s death. Whether a patient decline or
accepts medically appropriate resuscitative interventions, physicians should not permit their personal value
judgments to obstruct implementation of the patient’s decision. Orders not to attempt resuscitation (DNAR orders)
direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. DNAR orders can
be appropriate for any patient medically at risk of cardiopulmonary arrest, regardless of the patient’s age or whether
the patient is terminally ill.

Medically Ineffective Interventions

At times patients (or their surrogates) request interventions that the physician judges not to be medically appropriate.
Such requests are particularly challenging when the patient is terminally ill or suffers from an acute condition with
an uncertain prognosis and therapeutic options range from aggressive, potentially burdensome life-extending
intervention to comfort measures only. Requests for interventions that are not medically appropriate challenge the
physician to balance obligations to respect patient autonomy and not to abandon the patient with obligations to be
compassionate, yet candid, and to preserve the integrity of medical judgment.

Sedation to Unconsciousness in End-of-Life Care

The duty to relieve pain and suffering is central to the physician’s role as healer and is an obligation that physicians
have to their patients. When a terminally ill patient experiences severe pain or other distressing clinical symptoms
that do not respond to aggressive, symptom-specific palliation it can be appropriate to offer sedation to
unconsciousness as an intervention of last resort.

Nursing Roles and Responsibilities

1. Treat people compassionately

2. Listen to people

3. Communicate clearly and sensitively

4. Identify and meet the communication needs of each individual

5. Acknowledge pain and distress and take action

6. Recognize when someone may be entering the last few days and hours of life.

7. Involve people in decisions about their care and respect their wishes

8. Keep the person who is reaching the end of their life and those important to them up to date with any changes in
condition.

9. Document a summary of conversation and decisions

10. Seek further advice if needed

11. Look after yourself and your colleagues and seek support if you need it

12. Learning from complaints

13. Care of the person

Making Decisions

Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced method for exploring
the ethical aspects of a decision and weighing the considerations that should impact our choice of a course of action.
Having a method for ethical decision making is absolutely essential. When practiced regularly, the method becomes
so familiar that we work through it automatically without consulting the specific steps.

The more novel and difficult the ethical choice we face, the more we need to rely on discussion and dialogue with
others about the dilemma. Only by careful exploration of the problem, aided by the insights and different
perspectives of others, can we make good ethical choices in such situations.

A Framework for Ethical Decision Making Recognize an Ethical Issue

Could this decision or situation be damaging to someone or to some group? Does this decision involve a choice
between a good and bad alternative, or perhaps between two "good" or between two "bad"? Is this issue about more
than what is legal or what is most efficient? If so, how?

Get the Facts

What are the relevant facts of the case? What facts are not known? Can I learn more about the situation? Do I know
enough to make a decision?

What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?

What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative
options?

Evaluate Alternative Actions

Evaluate the options by asking the following questions:

Which option will produce the best and do the least harm? (The Utilitarian Approach)

Which option best respects the rights of all who have a stake? (The Rights Approach)

Which option treats people equally or proportionately? (The Justice Approach)

Which option best serves the community as a whole, not just some members? (The Common Good Approach)

Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

Considering all these approaches, which option best addresses the situation?

If I told someone I respect -- or told a television audience -- which option I have chosen, what would they say?

Act and Reflect on the Outcome

How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?

How did my decision turn out and what have I learned from this specific situation?

The Importance of Ethical Standards

Leaders have to develop ethical standards that employees in their company will be required to adhere to. This can
help move the conversation toward using a model to decide when someone is in violation of ethics.

There are five sources of ethical standards:

Utilitarian

This one is all about balance, and this approach tries to produce the greatest good with the least amount of harm to
those involved. It deals with consequences and practitioners who use this method are trying to find the best ethical
approach for the most people.

Rights

Leaders who decide to go with a “rights approach” are looking to protect and respect the rights and morals of
anyone who could be impacted by ethical decisions. The intent is for people to be treated fairly and with dignity and
not as a means to an end.

Fairness

This one touches on the fact that everyone should be treated equally regardless of their position or influence in a
company.

Common Good

Leaders should strive to protect the well-being of those around them. This ethical standard puts a lot of emphasis on
relationships, and how compassion for the fellow man should drive people to do good by others.

Virtue

A virtue approach requires leaders to base ethical standards on universal virtues such as honesty, courage,
compassion, tolerance, and many others. Principles that are chosen should cause people to strive to be their better
selves and wonder if an inappropriate action will negatively impact their inherent desire to be kind to others.
 The Ethical Decision-Making Process

Take Time to Define the Problem

Some initial analysis has to happen for leaders to truly understand where they need to bring in ethical principles.
Leaders need to decide why an ethical decision needs to be made and the outcomes that are desired for the decision.

Consult Resources and Seek Assistance

Leaders then need to work on developing a strategy using the resources and people around them. Whether it be
qualified co-workers, HR professionals, or policies and handbooks set long ago, leaders need to gain clarity from
other sources when creating a strategy to tackle the issue.

Think About the Lasting Effects

While identifying the problem and seeking viable resources to help is the way to go, any advice for how to handle an
issue should be filtered through the lens of how it will affect others. For instance, if there is an issue with employees
getting to work on time, managers could install policies that change the time workers report, but if they are not
careful, it may have a detrimental impact on other workers, and even clients.

Consider Regulations in Other Industries

Regulations and standards that other companies have established can be a good starting point for developing ethical
strategies. Leaders should take a look at how they handle specific issues that have come their way. It might also be
helpful to take a look at the mistakes the leader’s company and other organizations have made and learn from them.
Everyone does not always get it right 100 percent of the time. Therefore, it is essential to see the good and bad side
to become even more informed about a decision that should be made.

Decide on a Decision

After consulting others and doing a bit of extra research, it is time for a final decision. Since the choice will likely
impact many it is a good idea to create a proposal of what the issue is and how leaders plan to work with the team to
solve it. If the problem is more personal and involves harassment of some kind, it is more appropriate to only deal
with those involved and establish a plan of action to handle that particular situation. However, for widespread ethical
issues that have become a problem in the workplace, it is a good practice to bring decisions to the team at large.

Implement and Evaluate

This is where talk meets action. It is easy for people to research and create solutions to a problem, but when dealing
with morality and ethics, it can be challenging to put it into action finally. No one benefits from a plan that is not put
into practice, so at some point, leaders need to facilitate the implementation of the ethical decision. Also, the
application is not enough. Evaluation allows everyone to see how the approach is working out, and if there were
some unintended consequences leaders did not foresee. Is the problem finally fixed? Did things get better or worse?
Analysis of this issue can help those involved figure out if the implementation was the appropriate response.

PLUS Ethical Decision-Making Model

PLUS Ethical Decision-Making Model is one of the most used and widely cited ethical models. To create a clear
and cohesive approach to implementing a solution to an ethical problem; the model is set in a way that it gives the
leader “ethical filters” to make decisions. The letters in PLUS each stand for a filter that leaders can use for
decision-making:

P – Policies and Procedures:

Is the decision in line with the policies laid out by the company?

L – Legal:

Will this violate any legal parameters or regulations?

U – Universal:

How does this relate to the values and principles established for the organization to operate? Is it in tune with core
values and the company culture?

S – Self:

Does it meet my standards of fairness and justice? This particular lens fits well with the virtue approach that is a part
of the five common standards mentioned above.
These filters can even be applied to the process, so leaders have a clear ethical framework all along the way.
Defining the problem automatically requires leaders to see if it is violating any of the PLUS ethical filters. It should
also be used to assess the viability of any decisions that are being considered for implementation, and make a
decision about whether the one that was chosen resolved the PLUS considerations questioned in the first step. No
model is perfect, but this is a standard way to consider four vital components that have a substantial ethical impact.

REFERENCES
Abohaimed et al. (2019). Attitudes of Physicians towards Different Types of Euthanasia in
Kuwait.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598031/. November
29, 2020
Allmark, P. (2002). Death with Dignity. Retrieved from https://jme.bmj.com/content/28/4/255.
full. November 27, 2020
AMA Principles of Medical Ethics (2019). Opinions on Caring for Patients at the End of Life.
Retrieved from https://www.ama-assn.org/system/files/2019-06/code-of-medical-
ethics-chapter-5.pdf. November 27, 2020
Baranzke, H. (2012). “Sanctity-of-Life “—A Bioethical Principle for a Right to Life? Retrieved
from https://www.researchgate.net/publication/257560710_Sanctity-of-Life-
A_Bioethical_Principle_for_a_Right_to_Life. November 29, 2020
Braddock III, C. (1998). Patient-Assisted Death: For Healthcare Providers. Retrieved from
https://www.deathwithdignity.org/learn/death-with-dignity-acts/. November 27, 2020
Brazier, Y. (2018). Euthanasia and Assisted Suicide. Retrieved from https://www.medicalnews
today.com/articles/182951#history. November 29, 2020
Bilajac et al. (2005). Dysthanasia: The (il)legitimacy of Artificially Postponed Death. Retrieved
from https://pubmed.ncbi.nlm.nih.gov/15997684/. November 29, 2020
Cedola, S. (2013). Dying in the Twenty-First Century. Retrieved from https://journalofethics.
ama- assn.org/article/dying-twenty-first-century/2013-12. November 27, 2020
Cosmer, T. (2017). Assisted Suicide Heads to Colorado. Retrieved from https://www/journals.
library.columbia.edu. November 27, 2020
Cruz, M. & Oliveira, R. (2013). The Civil Legality of the Practice of Orthothanasia by
Physicians regarding the Patient’s Free Will. Retrieved from https://www.revistas.
ucm.es › index.php › PSIC › article › download. November 29, 2020
De Menezes et al. (2009). Dysthanasia: Nursing Professionals' Perception. Retrieve from
https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692009000400002.
November 29, 2020
Department of Social Sciences et.al (2005). Dysthanasia: The (il)legitimacy of Artificially
Postponed Death. Retrieve from https://bib.irb.hr/datoteka/200645.19_Dysthanasia_-_
The_Illegitimacy_of_Artificially_Postponed_Death.pdf. November 29, 2020
Frank, M. (2020). Dignity in Death: Why the Fundamental Right of the Individual to Choose
Their Final Moments Outweighs the Government’s Societal Inter Societal Interests to
Preserve Life. Retrieved from https://scholarworks.law.ubalt.edu/cgi/viewcontent.cgi?
article=2066&context=ublr. November 27, 2020
Gomez, F. (2017). Life Matters: Orthothanasia or Allowing to Die. Retrieved from https://www.
oclarim.com.mo/en/2017/06/09/life-matters-4-orthothanasia-or-allowing-to-die/.
November 29, 2020
Grewal, K. & Helman, A. (2015). Discussing End of Life Care in Emergency Medicine.
Retrieved from https://emergencymedicinecases.com/wpcontent/uploads/filebase/pdf/
Episode%20070%20Oct2015%20End%20of%20Life%20Care.pdf. November 29, 2020
Jacelon, C. & Proulx, K. (2004). Dying with Dignity: The Good Patient versus The Good Death.
Retrieved from https://citeseerx.ist.psu.edu/viewedoc/download?doi=10.1.1.913.2104&
rep=rep1&type=pdf. November 27, 2020
Kennedy, G. (2016). The Importance of Patient Dignity in Care at the End of Life. Retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847835/. November 27, 2020
Knox, E. (2019). Death with Dignity: A Right to Death? Retrieved from https://lawecommons.
luc.edu/cgi/viewcontent.cgi?article=1568&context=pilr. November 27, 2020
Markkula Center (2015). A Framework for Ethical Decision Making. Retrieved from
https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/a-framework-for-
ethical-decision-making/. November 29, 2020
My Death, My Decision (2016). Ironically, the Option of Euthanasia can Prolong Life and its
Quality. Retrieved from https://www.mydeath-mydecision.org.uk/ironically-option-
euthanasia-can-prolong-life-quality/. November 29, 2020
Nursing World (2012). Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death
(AND) Decisions. Retrieved from https://www/nursingworld.org/~4ad4a8/globalassets/
docs/ana/nursing-care-and-do-not-resuscitate-dnr-and-allow-natural-death-decisions.pdf.
November 29, 2020
Siddiqui, S. (2016). Dying within Dying: Ethical Dilemmas of Treating Terminally Ill Patients
with Acute Life-Threatening Illnesses. Retrieved from https://www/ncbi.nlm.gov/pmc/
articles/PMC4876656/. November 27, 2020

Ethical Consideration in Leadership and Management

The leadership, ethics, and decision-making nexus is complex; yet many scholars posit a direct relationship between
ethical behaviors influenced by leaders and enhanced organizational performance (Brown and Treviño 2006; Detert
et al. 2007; Ehrhart 2004; LePine et al. 2008). Furthermore, given the aggregate number of issues encompassed
within the term “ethics,” there are few management decisions free of any ethical component. Decision-making is
embedded in the concept of leadership, as those who have the authority and the ability to make informed, well-
reasoned, and timely decisions are often viewed as leaders. Early research in the field of organizational behavior
established an understanding of decision-making processes as essential to an understanding of the behavior of
organizations (Cyert and March 1963; March and Simon 1958). Despite such a clear overlap, leadership, ethics, and
decision-making are often discussed in isolation from one another or through paradigms that propose relatively new
concepts rather than integrate existing ones. However, through an analysis of well-established paradigms in each of
these areas, as well as the leading thought on ethical leadership and ethical decision-making, a clear depiction of the
interdependency among leadership, ethics, and decision-making begins to emerge.

More specifically, decision-making is a dynamic mechanism through which ethical leaders influence ethical
behavioral outcomes of group members. To understand how this relationship functions, it is important to distinguish
between the two widely established components of ethical leadership: moral person and moral manager. A leader
who is moral person and self identifies as a moral person or possesses a moral identity is more likely to integrate
ethics into their decision-making processes and, thus, produce ethical outcomes. A moral person is someone seen as
possessing trustworthiness, integrity, and honesty. As a moral manager, a leader will inform the decision-making of
group members by role modeling behavior as a moral person, communicating relevant information, as well as
strategically using rewards and punishments to develop group members’ capacity for ethical decision-making on
their own (Treviño et al. 2006).

Moral Decision-Making

Moral Versus Amoral and Immoral Management

Immoral managers make decisions that are discordant with the ethical standards of an organization or society, in
general. They actively choose options or adopt behaviors they know to be unethical in order to pursue some other
aim. An immoral manager’s motives are often selfish and unsupported by any moral philosophy. At the extreme,
they do not consider stakeholder interests, unless these interests benefit the manager, when making decisions, and
show little regard for those who stand between them and their interests. It is important to note that moral
management stands in contrast to not only immoral management, but amoral management. Amoral managers that
simply fail to recognize the moral components of decision-making in organizations can do so intentionally or
unintentionally. Perhaps not as nefarious as immoral managers, amoral management can be just as damning ethically
to an organization. Intentionally amoral managers believe that business decisions can be isolated from ethics and
intentionally exclude any ethical considerations from factoring into their judgments. Unintentionally amoral
managers lack the moral awareness and ethical perception needed to realize the ethical components of decisions.
Regardless of intentionality, amoral managers fail to provide the ethical guidance their organizations need.

Moral Person and Awareness

There are several mechanisms through which a leader’s moral person influences the decision-making process. In the
initial stage, a person that self-identifies as ethical will have greater moral awareness, or the ability to recognize the
ethical component of an issue or decision. According to Lapsley and Lasky, a person who has a moral identity is
“one for whom moral schemas are chronically available, readily primed, and easily activated for information
processing” (2001, p. 347). Thus, leaders who are moral persons will naturally consider relevant ethical issues when
making a decision or at a minimum recognize where a moral dimension might need further consideration. Moral
awareness assumes an above-average familiarity with a broad range of ethical issues. However, there are leaders
considered to be moral persons that simply have never been exposed to certain issues or had cause to consider them.
Moral persons aiming to be ethical leaders can employ certain strategies, such as stakeholder engagement or
participative decision-making to counteract deficiencies in moral awareness.

Moral Person and Judgment

The judgment stage of the decision-making process is influenced by the cognitive thought processes of a moral
person, or moral judgment. Kohlberg’s (1969) theory of cognitive moral development proposes three levels of
development to differentiate the reasoning processes used when making moral judgments. A moral person can be
said to have advanced to the final or postconventional, autonomous, principled level within Kohlberg’s moral
development schema. Within each level, two stages exist to further differentiate development. Once reaching the
final level, a moral person can reside at stage 5 – social-contract orientation – or stage 6, universal ethical principle
orientation. Both stages are characterized by an emphasis on the universality of individual rights and ethical
principles. Thus, a moral person would likely seek and weight criteria based on the moral philosophy to which he or
she prescribes.

An ethical consequentialist – someone who evaluates the ethics of a decision based on the outcomes of that decision
rather than the actions employed to produce said outcomes – would include effects of a decision within the list of
criteria analyzed. On the other hand, an ethical formalist – someone who determines the ethics of a situation based
on the actions taken or means rather than effects or ends – would only identify criteria related to a specific behavior
rather than the outcomes of such behavior. Werhane (1999) suggests that moral imagination is needed to generate
decision alternatives that recognize and address the norms, relationships, and social roles interfused within the
situation. Once alternatives are developed, a moral person may evaluate them based on which best promotes the fair
treatment of people (principle of justice), best protects an individual’s moral and legal rights (principle of rights), or
produces the greatest good for the greatest number of people (has the greatest utility principle of utilitarianism).

Moral Person and Intention

The personal morality of a leader influences the way in which alternatives are selected at the intention stage of the
decision-making process. Theoretically, a person with greater moral awareness would be less likely to use
subconscious decision-making biases that lead to unintended, unethical outcomes. Because they prioritize moral
values over others (Rest 1986), their selections are less likely to be based on mental schemas responsible for biased
decision-making. Mental schemas are often unintended yet still self-serving. However, even individuals with high
morality have unconscious biases or use decision-making heuristics, or shortcuts. Specifically, four sources of
unconscious influence have been suggested as particularly common, including implicit forms of prejudice, self-
serving biases, conflicts of interest, and fundamental attribution errors. The fundamental attribution error is the
tendency to overclaim credit when things go right and blame others when things go wrong. Other dangerous biases
may include anchoring adjustment, availability heuristic, escalation of commitment, hindsight, correlation and
causality bias, overconfidence, framing, satisficing, familiarity (greater willingness to harm strangers), and
discounting (minimizing or ignoring decisions that do not have immediate consequences). Recognizing the existence
of these biases or heuristics, a moral person can seek to consciously avoid them when identifying and selecting a
moral alternative.

Principle of Moral Discernment

Moral discernment involves discerning (discovering, judging) which goals (ends, intentions) and means (actions)
really are conducive to human fulfillment and according to God’s will. Deliberately chosen actions are means to
some goal. In Black Womanist Ethics, theologian Katie Cannon (1988) writes of generations of black women and
their ability to discern their moral situations in the context of their historical time, setting, and roles in life.  Cannon
suggests that the capacity to discern—to observe and make sense or meaning—is central to one’s ability to make
ethical choices and to take moral action. 

Moral Development and Abstract Dilemmas

James Rest (Rest and Narvaez 1994), a developmental psychologist who studied moral and ethical development,
identified four components of moral development:

 Moral sensitivity—the ability to interpret a situation in moral and ethical terms;

 Moral judgment—the ability to determine a course of action in the context of what is just;
 Moral motivation—the ability to select an appropriate course of action among multiple good
alternatives; and
 Moral character—the courage and skills to follow a course of action in response to a situation.

Six Principles of Discernment

1. State in life – There are many different states in life, some temporary, some long-lasting, and some permanent.
We may be single, married, a priest, or a religious. We may be young or old, healthy or frail. We may be a student, a
parent, a worker, a boss. We may be rich or poor. Being clear about our state in life can help us discern if a call is
from God or not.

2. Gifts and talents – People have different combinations of virtues, talents, gifts, and skills. In discerning the will
of God regarding a course of action or accepting an offer/opportunity, we ought to carefully ponder whether it
makes good sense based on our skills and talents.

3.  Desire – That desire can be a principle of discernment is a surprise to some people. We are often suspicious of
our desires—and not without reason. When it comes to most things in the realm of moral law and doctrine, our
desires and feelings are largely irrelevant and should not be used to discern God’s will. For example, that we should
not commit adultery remains the clear will of God no matter how much we might desire it. That Jesus is God is true
no matter how we feel.

4.  Organic development – This principle simply articulates that God most often moves us in stages rather than in
sudden, dramatic ways. Although there are times of dramatic change, loss, and gain in the life of most people, it is
more typical for God to lead us gently and in stages toward what He wills for us.

5.  Serenity – When God leads us, the usual result is serenity and joy. In my own priestly life, I have at times been
asked to move from one assignment to another. At such times there was great sadness, because I had to say goodbye
to people I greatly loved. Yet when it was God’s will that the time had come for moving on, in spite of my sadness I
also felt a deep inner peace, a serenity.
6.  Conformity to Scripture and Tradition – Some may think that this principle should be at the top of the list and
you are free to put it there, but I prefer to say that the Word of God and the teachings of the Church have the last
word in any decision.

Discernment Process

A. OBSERVE

1. Identify the Problem

2. Acknowledge Feelings

3. Gather the Facts

B. DELIBERATE

4. Consider Alternatives

5. Examine Values

6. Evaluate Alternatives

C. ACT

7. Articulate the Decision

8. Implement the Plan

Principle of Well-Formed Conscience

The formation of a good conscience is another fundamental element of Christian moral teaching. “Conscience is a
judgment of reason by which the human person recognizes the moral quality of a concrete act” (CCC, no. 1796).
“Man has in his heart a law inscribed by God. His conscience is man’s most secret core, and his sanctuary” (GS, no.
16).

Conscience represents both the more general ability we have as human beings to know what is good and right and
the concrete judgments, we make in particular situations concerning what we should do or about what we have
already done. Moral choices confront us with the decision to follow or depart from reason and the divine law. A
good conscience makes judgments that conform to reason and the good that is willed by the Wisdom of God. A
good conscience requires lifelong formation. Each baptized follower of Christ is obliged to form his or her
conscience according to objective moral standards. The Word of God is a principal tool in the formation of
conscience when it is assimilated by study, prayer, and practice. The prudent advice and good example of others
support and enlighten our conscience. The authoritative teaching of the Church is an essential element in our
conscience formation. Finally, the gifts of the Holy Spirit, combined with regular examination of our conscience,
will help us develop a morally sensitive conscience. The Church equips its members to address political and social
questions by helping them to develop a well-formed conscience. Catholics have a serious and lifelong obligation to
form their consciences in accord with human reason and the teaching of the Church. Conscience is not something
that allows us to justify doing whatever we want, nor is it a mere “feeling” about what we should or should not do.
Rather, conscience is the voice of God resounding in the human heart, revealing the truth to us and calling us to for
what is good while shunning what is evil. Conscience always requires serious attempts to make sound moral
judgments based on the truths of our faith.

The formation of conscience includes several elements. First, there is a desire to embrace goodness and truth. For
Catholics, this begins with a willingness and openness to seek the truth and what is the right by studying Sacred
Scripture and the teaching of the church as contained in the Catechism of the Catholic Church. It is also important to
examine the facts and background information about various choices. Finally, prayerful reflection is essential to
discern the will of God. Catholics must also understand that if they fail to form their consciences in the light of the
truths of the faith and the moral teachings of the church, they can make erroneous judgments- from Forming
Conscience for Faithful Citizenship. As stated in the Catechism of the Catholic Church, “Conscience” is a judgment
of reason whereby the human person recognizes the moral quality of a concrete act that he is going to perform, is in
the process of performing, or has already completed. In all he says and does, man is obliged to follow faithfully what
he knows to be just and right. There are some rules to follow in obeying one’s conscience. First, always follow a
certain conscience. Second, an incorrect conscience must be changed if possible. Third, do not act with a doubtful
conscience. We must always obey the certain judgments of our conscience, realizing that our conscience can be
incorrect, that it can make a mistake about what is truly the good or the right thing to do. This can be due to
ignorance in which, through no fault of our own, we did not have all we needed to make a correct judgment.

The Rights of Conscience

Conscience is a Human Judgment

“Conscience is a judgment of reason whereby the human person recognizes the moral quality of a concrete act”
(CCC 1778). Conscience is an act of the human mind in which a person discerns what is right and wrong to do.
Conscience is therefore something interior to the personal self. Your conscience and my conscience are not the same
because each person has to judge what is right and wrong for him or her to do. Yet conscience is not just about
private opinions or feelings. Conscience is a judgment or reason that depends upon the understanding of truths that
are accessible to all people. By virtue of our shared human nature, all people can perceive the principles that should
guide human choice. We can all recognize the goodness of protecting and sustaining life and health, living together
in peaceful cooperation, and pursuing knowledge of the truth.

Conscience Must Be Formed

“Conscience must be informed and moral judgment enlightened. A well-formed conscience is upright and truthful. It
formulates judgments according to reason, in conformity with the true good willed by the wisdom of the Creator”
(CCC 1783). Conscience is an act of the mind and the mind is directed to true understanding. Our minds can only
understand truth when we are well informed and rightly educated. The information necessary for the right judgment
of conscience begins with the moral principles we naturally apprehend. However, due to our natural limitations and
the limitations that result from original sin, we also need to be taught by wise educators and guided by the revelation
of God that is handed down to us in the Church.

Right Conscience Reveals God’s Will

“Deep within his conscience man discovers a law which he has not laid upon himself but which he must obey…
There he is alone with God whose voice echoes in his depths” (CCC 1776).

Though conscience is a human judgment, it is also, when rightly formed, an expression of God’s will. God is the
author of truth and goodness and when we are able to judge what is truly good, we are participating in God’s
wisdom and guiding our actions in accordance with God’s love. Conscience therefore has an authority that is not just
from ourselves. It comes from God and communicates God’s law. It follows that conscience must always be obeyed,
for when we do what we judge to be good we do what we perceive to be the will of God for us.

Conscience should be Free from Coercion

“The Christian faithful, in common with all other men, possess the civil right not to be hindered in leading their lives
in accordance with their consciences” (Dignitatis Humanae 13). Respecting the freedom of a person’s conscience is
part of respecting his human dignity. The dignity of the human person is most clearly expressed in his ability to
judge rightly about what is right and good for him to do. It is then that voice of God is spoken in his heart and the
will of God is accomplished in his acts. It is then that he is seen to be created in God’s image. This most
quintessential human activity should not be suppressed. To do so, to force a human being to act contrary to her
conscience, is an act of violence. There can sometimes be exceptions to this rule, cases in which someone’s
conscientious judgment cannot be reconciled with the good of the human community. Such exceptions, however, are
rare, for the good of the human community is the good of free persons who express their freedom and their dignity
most perfectly when they conscientiously pursue what is truly good.

Strategies of Moral Decision-Making Process

Ethical decision-making refers to the process of evaluating and choosing among alternatives in a manner consistent
with ethical principles. In making ethical decisions, it is necessary to perceive and eliminate unethical options and
select the best ethical alternative.
The process of making ethical decisions requires:

 Commitment: The desire to do the right thing regardless of the cost

 Consciousness: The awareness to act consistently and apply moral convictions to daily behavior.
 Competency: The ability to collect and evaluate information, develop alternatives, and foresee potential
consequences and risks.

Good decisions are both ethical and effective:

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

Steps in Ethical Decision-Making

1. State or define the problem/issue

2. Gather information ("facts") from all sides

3. Delineate all possible resolutions.

4. Apply different values, rules, principles, regulations to the different options.

5. Resolve conflicts among values, rules, etc.

6. Make a decision and act.

Previous research has identified a wide array of cognitive reasoning strategies that can promote ethical decision-
making. Using these studies to inform their work, Mumford and colleagues consolidated the list of reasoning
strategies to a set of seven distinct cognitive reasoning strategies and established that these strategies can promote
ethicality (cf., Antes, Brown, Murphy, Hill, Waples, Mumford, Connelly, & Devenport, 2007). The strategies are 1)
recognizing personal circumstances, 2) anticipating consequences, 3) considering others’ perspectives, 4) seeking
help, 5) questioning your own judgment, 6) dealing with emotions, and 7) examining personal values.

Meaning and Service Value of Medical Care

In the last 10 years, value has played a key role in the health care system. In this concept, innovations in medical
practice and the increasing importance of patient centeredness have contributed to draw the attention of the medical
community. Nonetheless, a large consensus on the meaning of “value” is still lacking: patients, physicians, policy
makers, and other health care professionals have different ideas on which component of value may play a prominent
role. Yet, shared clinical decision-making and patient empowerment have been recognized as fundamental features
of the concept of value. Different paradigms of health care system embrace different meanings of value, and the
absence of common and widely accepted definition does not help to identify a unique model of care in health care
system.

Value-based healthcare is a healthcare delivery model in which providers, including hospitals and physicians, are
paid based on patient health outcomes. Under value-based care agreements, providers are rewarded for helping
patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an
evidence-based way. Value-based care differs from a fee-for-service or capitated approach, in which providers are
paid based on the amount of healthcare services they deliver. The “value” in value-based healthcare is derived from
measuring health outcomes against the cost of delivering the outcomes. According to value-based principles, a
health care system should co-create and measure outcomes that are meaningful for patients with similar needs along
the whole care pathway. A value-based health system should refer to three important principles. First, its proper goal
should be the value it provides to the patient. In health care, the meaning of value varies along a continuum where
psychological and physical outcomes meet costs. In fact, we can refer to value either from a psychological or from
an economic perspective. Following Porter’s idea, value is expressed as the best “health outcomes achieved per
dollar spent.” By “health outcomes”, it is meant the health results that matter for the patient’s condition over the care
cycle, and by “costs”, they refer to the total costs of care for patient’s condition over the care cycle.

Benefits of Value-Based Health Care Delivery

1. Patients spend less money to achieve better health.  Managing a chronic disease or condition like cancer,
diabetes, high blood pressure, COPD, or obesity can be costly and time-consuming for patients. Value-
based care models focus on helping patients recover from illnesses and injuries more quickly and avoid
chronic disease in the first place. As a result, patients face fewer doctor’s visits, medical tests, and
procedures, and they spend less money on prescription medication as both near-term and long-term health
improve.

2. Providers achieve efficiencies and greater patient satisfaction.  While providers may need to spend
more time on new, prevention-based patient services, they will spend less time on chronic disease
management. Quality and patient engagement measures increase when the focus is on value instead of
 volume. In addition, providers are not placed at the financial risk that comes with capitated payment
systems. Even for-profit providers, who can generate higher value per episode of care, stand to be
rewarded under a value-based care model.

3. Payers control costs and reduce risk.  Risk is reduced by spreading it across a larger patient population.
A healthier population with fewer claims translates into less drain on payers’ premium pools and
investments. Value-based payment also allows payers to increase efficiency by bundling payments that
cover the patient’s full care cycle, or for chronic conditions, covering periods of a year or more.

4. Suppliers align prices with patient outcomes.  Suppliers benefit from being able to align their products
and services with positive patient outcomes and reduced cost, an important selling proposition as national
health expenditures on prescription drugs continue to rise. Many healthcare industry stakeholders are
calling for manufacturers to tie the prices of drugs to their actual value to patients, a process that is likely to
become easier with the growth of individualized therapies.

5. Society becomes healthier while reducing overall healthcare spending.  Less money is spent helping
people manage chronic diseases and costly hospitalizations and medical emergencies. In a country where
healthcare expenditures account for nearly 18% of Gross Domestic Product (GDP), value-based care has
the promise to significantly reduce overall costs spent on healthcare.

Allocation of Health Resources

Ethical Principles in Making Health Care Allocation Decisions

Within contexts of diverse values, beliefs, and interests, pediatricians are faced with a variety of ethical decisions in
daily practice. From how to offer parental advice when beliefs differ (e.g., in vaccine refusal) to who is best
equipped to make decisions for a child, his or her family, and society (e.g., in chronic fatal disease), pediatricians
must use ethical principles to consider the views and values of all involved parties. Resolving ethical dilemmas
involves comprehensive reflection and use of the bioethical principles of autonomy, beneficence, nonmaleficence,
and justice. These commonly accepted 4 principles provide guidance for assessing and balancing potential harms
and benefits within medical care.

Autonomy requires that patients can make medical decisions free from coercion. This is of paramount importance in
pediatrics because of the careful consideration that decision-making for children entails. Since parents serve as
surrogates for their children, they must be fully informed. Presenting a plan of care that reflects the reduction of
risks and harms builds a foundation of trust in the pediatrician-patient relationship. Nonmaleficence serves to
analyze potential harms, beneficence is aimed at the goal of providing and encouraging positive steps to achieve the
best medical outcomes, and justice is used to examine the limits of medical resources.

Issues on Resource Allocation in Health Care

When resources are limited and demand exceeds supply, allocation becomes a problem. How that problem is solved
depends largely on the nature of the resources themselves. When the resources are construed as social goods,
allocation may proceed either in terms of competition between individuals on the basis of the relative strengths of
their competing rights, or on an aggregate basis by evaluating which distribution would (be likely to) produce the
greatest amount of good for the greatest number of people. When the resources are construed as commodities, the
allocation problem assumes a different orientation. Notions of competing rights or of maximizing the aggregate
good drop out of the picture and economic considerations take their place. On the microlevel, allocation is then
resolved on the basis of the ability to pay; on the macrolevel, the question becomes whether the economic structure
that governs the cost/price relationship for the commodities is sufficiently robust to allow for the survival of the
economic enterprise that is associated with the production and sale of the goods in question.
These considerations apply to healthcare as much as they do to anything else. Healthcare resources, whether
understood in material or in human terms, are limited, nor is this a function of how healthcare is delivered. The fact
of limitation is inherent in the human condition. Whether healthcare is delivered in a private or in a public setting –
or even in a mixture of both – the number of people who can deliver the care is always limited because not everyone
can be a healthcare professional (and even healthcare professionals may fall ill and require care, thus making them
unavailable as healthcare providers). The number of resources will always be limited because there is a limit to the
number of facilities that can be constructed, the number of instruments that can be manufactured, or the number of
organs, amount of blood, etc. that will be available. The demand for healthcare resources, therefore, will always and
necessarily exceed supply. That means that limitation is not an artifact, and that there will always be an allocation
problem. How is it to be resolved?
Traditionally, the issue has been dealt with by a complex mix of approaches that try to balance competing rights and
duties with cost and outcome measures. However, if the current literature and current policy discussions are
anything to go on, these attempts cannot really be considered successful. The issue requires an overall solution that
can be consistently applied across the whole field of healthcare, not something that works in isolated instances and
that can be applied in only selected areas and in a piecemeal fashion. In this article, I want to explore why the
healthcare resource allocation problem has so stubbornly resisted solution, and sketch the beginnings of a solution.
Allocation of Limited Medical Resources

A physician has a duty to do all that he or she can for the benefit of the individual patient. Policies for allocating
limited resources have the potential to limit the ability of physicians to fulfill this obligation to patients. Physicians
have a responsibility to participate and to contribute their professional expertise in order to safeguard the interests of
patients in decisions made at the societal level regarding the allocation or rationing of health resources.

Decisions regarding the allocation of limited medical resources among patients should consider only ethically
appropriate criteria relating to medical need. These criteria include likelihood of benefit, urgency of need, change in
quality of life, duration of benefit, and, in some cases, the number of resources required for successful treatment. In
general, only very substantial differences among patients are ethically relevant; the greater the disparities, the more
justified the use of these criteria becomes. In making quality of life judgments, patients should first be prioritized so
that death or extremely poor outcomes are avoided; then, patients should be prioritized according to change in
quality of life, but only when there are very substantial differences among patients. Non-medical criteria, such as
ability to pay, age, social worth, perceived obstacles to treatment, patient contribution to illness, or past use of
resources should not be considered.

Allocation decisions should respect the individuality of patients and the particulars of individual cases as much as
possible. When very substantial differences do not exist among potential recipients of treatment on the basis of the
appropriate criteria defined above, a "first-come-first-served" approach or some other equal opportunity mechanism
should be employed to make final allocation decisions. Though there are several ethically acceptable strategies for
implementing these criteria, no single strategy is ethically mandated. Acceptable approaches include a three-tiered
system, a minimal threshold approach, and a weighted formula. Decision-making mechanisms should be objective,
flexible, and consistent to ensure that all patients are treated equally.

The treating physician must remain a patient advocate and therefore should not make allocation decisions. Patients
denied access to resources have the right to be informed of the reasoning behind the decision. The allocation
procedures of institutions controlling scarce resources should be disclosed to the public as well as subject to regular
peer review from the medical profession.

The Provision of Adequate Health Care

Because society has an obligation to make access to an adequate level of health care available to all of its members
regardless of ability to pay, physicians should contribute their expertise at a policy-making level to help achieve this
goal. In determining whether particular procedures or treatments should be included in the adequate level of health
care, the following ethical principles should be considered:

(1) degree of benefit (the difference in outcome between treatment and no treatment),
(2) likelihood of benefit,
(3) duration of benefit,
(4) cost, and
(5) number of people who will benefit (referring to the fact that a treatment may benefit the patient and others who
come into contact with the patient, as with a vaccination or antimicrobial drug).

Ethical principles require that a just process be used to determine the adequate level of health care. To ensure justice,
the process for determining the adequate level of health care should include the following considerations:

(1) democratic decision making with broad public input at both the developmental and final approval stages,
(2) monitoring for variations in care that cannot be explained on medical grounds with special attention to evidence
of discriminatory impact on historically disadvantaged groups, and
(3) adjustment of the adequate level over time to ensure continued and broad public acceptance.

Because of the risk that inappropriate biases will influence the content of the basic benefits package, it may be
desirable to avoid rigid or precise formulas to define the specific components of the basic benefits package. After
applying the five ethical values listed above, it will be possible to designate some kinds of care as either clearly
basic or clearly discretionary. However, for care that is not clearly basic or discretionary, seemingly objective
formulas may result in choices that are inappropriately biased. For that care, therefore, it may be desirable to give
equal consideration (e.g., through a process of random selection) to the different kinds of care when deciding which
will be included in the basic benefits package. The mechanism for providing an adequate level of health care should
ensure that the health care benefits for the poor will not be eroded over time.

Issues Involving Access to Health Care

Health services are much improved in terms of results: people now live longer and are treated faster, healthcare
institutions have advanced and professionals specialize in treating patients’ conditions, and in general healthcare
practices are evidence-informed and are implemented through evidence-based practice. Access to health care has
been an important dimension in public health policy in many healthcare settings. As Aday and Anderson discuss,
access to healthcare from equity perspectives should fulfil three assumptions: first, this is a fundamental right to
healthcare; second, health resources [3Ms: minute (time), manpower, materials] are always limited; and third, health
policy should be evidence-based in practice. One argument behind such assumptions is that the ‘modern healthcare
system may in fact be ineffectual or even deleterious in effecting health in patients who use it. It still does matter
how one assesses people’s healthcare needs, and who plans for and delivers such needs. With whom (partnership
and networking), and at what levels – central, regional or local - are equally important in terms of how people gain
access to healthcare, and the impacts on their health and wellbeing. Access generally relates to people’s ability to
use health services when and where they are needed. It is also concerned with the normative goal of healthcare
systems. Several authors argue that determinants of healthcare access are the types and quality of services, including
the costs, time, distance (ease of travel) as well as regular interface between service users and healthcare providers.

Given the policy impetus, it is imperative for healthcare providers to consider their role in facilitating access which
could include the provision of meaningful information to support patients to make decisions about their own care.
For inequalities in access to be reduced, cultural competency of services must increase and therefore should be a key
objective for local service commissioning and delivery. Care pathways are complex interventions and as a means of
improving quality and maximizing resources are necessarily context based. Local services therefore may find that
broadening the understanding of concordance within a culturally competent framework and applying it to the local
system as a whole is a useful approach to planning and achieving effective access to care. Understanding how this
can lead to reduced inequalities in access requires an evaluation of the care pathway as a complex intervention so
that the mechanisms which bring about improvements can be identified and supported. The fundamental question,
however, remains unanswered, i.e., how can we measure access to healthcare, and what methods should be utilized
within the complexities of its meaning, as access to healthcare appears rather a political than an operational. While
conceptualizing its meaning, two aspects are often emerged in many literatures: first, people often try to equate it
with the demographic profiles of the population (for example, income, race, residence); second, it relates to health
systems (distribution of resources, available services including health and non-health human resources).

Challenges in Access to Health Care

 Limited Appointment Availability, Office Hours

Many healthcare organizations offer a typical set of office hours for patient visits. But for the working
adult or parent, a clinic that is open between 8 a.m. and 6 p.m. is not always useful. Patients need
convenient office hours that allow them to visit the doctor outside of their work or school schedules.

 Distance and Transportation

Rural populations are more likely to have to travel long distances to access healthcare services, particularly
subspecialist services. This can be a significant burden in terms of travel time, cost, and time away from
the workplace. In addition, the lack of reliable transportation is a barrier to care. In urban areas, public
transit is generally an option for patients to get to medical appointments; however, these transportation
services are often lacking in rural areas. Rural communities often have more elderly residents who have
chronic conditions requiring multiple visits to outpatient healthcare facilities. This becomes challenging
without available public or private transportation.

 Poor Health Literacy

Health literacy can also be a barrier to accessing healthcare. Health literacy impacts a patient's ability to
understand health information and instructions from their healthcare providers. This can be especially
concerning in rural communities, where lower educational levels and higher incidence of poverty often
impact residents. Low health literacy can make residents reluctant to seek healthcare due to fear of or
frustration related to communicating with a healthcare professional. Additionally, navigating the healthcare
systems can be difficult without health literacy skills.

 Social Stigma and Privacy Issues

In rural areas, there is little anonymity; social stigma and privacy concerns are more likely to act as barriers
to healthcare access. Rural residents can have concerns about seeking care for mental health, substance
abuse, sexual health, pregnancy, or even common chronic illnesses due to unease or privacy concerns.
Patients' feelings may be caused by personal relationships with their healthcare provider or others working
in the healthcare facility. Additionally, patients can feel fear or concerns about other residents, who are
often friends, family members, or co-workers, who may notice them utilizing services for health conditions
that are typically not openly discussed, such as counseling or HIV testing services. Co-location or the
integration of behavioral health services with primary care healthcare services in the same building can
help ease patient concerns.
  Workforce Shortages
Healthcare workforce shortages impact healthcare access in rural communities. One measure of healthcare
access is having a regular source of care, which is dependent on having an adequate healthcare workforce.

REFERENCES
Antes, A. (2011). Sensemaking Strategies for Ethical Decision-Making. Retrieved from https://

www/ncbi.nlm.nih.gov/pmc/articles/PMC4527650/#:~:text=Ethical%20Decision%2D

making%Strategies&text=The%20strategies%2- are%201)% 20recognizing,and%207)

%20examining%20personal%20values. December 5, 2020

AMA Code of Medical Ethics (2011). Opinions on Allocating Medical Resources. Retrieved

from https://journalofethics.ama-assn.org/article/ama-code-medical-ethics-opinions-

allocating-medical-resources/2011-04. December 5, 2020

Archdiocese of Saint Paul and Minneapolis (n.d). What Does it Mean to Have a Well-Formed

Conscience? Retrieved from https://www/archspm.org/faith-and-discipleship/catholic-

Faith/what-does-it-mean-to-have-a-well-formed-conscience/. December 5, 2020

Flaman, P. (2004). Moral Discernment and Culpability. Retrieved from https://journals.sagepub.

Com/doi/abs/10.1080/20508549.2004.11877699?journalCode=1qra. December 5, 2020

Health Ethics Guide (2000). A Framework for Ethical Discernment. Retrieved from https://www.

chac.ca/Ethics/docs/appendix%201framework.pdf. December 5, 2020

Heath S. (2018). Top Challenges Impacting Patient Access to Healthcare. Retrieved from https://

patientengagementhit.com/news/top-challenges-impacting-patient-access-to-healthcare.

December 5, 2020

Kluge, E. (2007). Resource Allocation in Healthcare: Implications of Models of Medicine as a

 Profession. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1925021/.

December 5, 2020

Knefelkamp, L. (2014). Moral Discernment: Essential Learning for a Principled Society.

Retrieved from https://www.aacu.org/diversitydemocracy/2014/summer/knefelkamp.

December 5, 2020

Marzorati, C. & Pravettoni, G. (2017). Value as the Key Concept in the Health Care System:
How
it has Influenced Medical Practice and Clinical Decision-Making Processes. Retrieved
from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367583/. December 5, 2020
Mederer, H., Scholl, J., & Scholl, R. (2016). Leadership, Ethics, and Decision-Making.
Retrieved from https://www/researchgate.net/publication/308035581 Leadership Ethics and
Decision-Making/link/5af1d2910f7e9ba36645d3a2/download. December 5, 2020

NEJM Catalyst (2017). What Is Value-Based Healthcare? Retrieved from https://catalyst.nejm.

org/doi/full/10.1056/CAT.17.0558#:~:text= Value%2Dbased%20care%20differs%20from.
cost%20of%20delivering%20the%20outcomes. December 5, 2020
Olsson, J. & Ransom, H. (2017). Allocation of Health Care Resources: Principles for Decision-

Making. Retrieved from https://pedsinreview.aappublications.org/content/38/7/320.

December 5, 2020

Pollock, J. (2018). The Rights of Conscience. Retrieved from https://www/healthcareministry.

org/the-rights-of-conscience/. December 5, 2020

Pope, C. (2018). Six Principles of Discernment. Retrieved from http://blog.adw.org/2018/01/six-

principles-discernment. December 5, 2020

Randhawa, G. & Regmi, K. (2013). Access to Healthcare: Issues of Measure and Method.

Retrieved from https://www/iomcworld.org/open-access/healthcare-issues-of-measure-and-

Method-2167-1079.1000136.pdf. December 5, 2020

Redondo, B. (2020). Well-Formed Conscience. Retrieved from https://www/scribd.com/

Presentation/454961986/Ethics-pptx. December 5, 2020

RHIhub (2019). Healthcare Access in Rural Communities. Retrieved from https://www/rural

https://www.ruralhealthinfo.org/topics/healthcare-access. December 5, 2020

UC San Diego (2016). Making Ethical Decisions: Process. Retrieved from https://blink.ucsd.
 edu/finance/accountability/ethics/process.html. December 5, 2020

Continuing Education Programs on Ethico-Moral Practice in Nursing

Lobbying/Advocating for Ethical Issues Related to Health Care

Definition of Advocacy

 Advocacy means a coordinated combination of problem identification, solution creation, strategy

development, and actions taken to make positive change.
 In the context of nursing practice, it is a distinction made between “case advocacy” directed at individual
patients, and “class advocacy” directed at changing policies and social conditions.

Case Advocacy

 It is well known to nursing professionals, being part of the field’s traditions and continuing professional
values.

Class Advocacy

 A more overtly political approach, is quite different. Instead of focusing mainly on the client’s opportunity
choices, class advocacy focuses on changing the system of opportunities itself to further the interests of
larger groups, organizations, or communities.

EXAMPLE

 A community health nurse doing immunizations at a homeless shelter encounters a resident with serious
environmental health concerns. All three of the resident’s children are asthmatics. From the time the family
was forced to seek residence in the shelter, the children-particularly the youngest-have had multiple, acute
episodes of asthma. The shelter manager is unwilling to correct the building’s problems of dust, mold, and
inadequate heating, and has in fact told residents that they will be evicted if they complain to the city about
the conditions. There is a waiting list for the shelter, the only one available within the city limits. The
mother sees no way out for herself and her children. Anxious and distraught, she asks the nurse for help.
 Set up an appointment with the mother to explore the situation further and provide support.
 Give her “user friendly” information about causes and care measures for asthma, and answer her question.
 Get more information about the mother’s financial status, legal status as a resident, her relationship with the
shelter manager and other residents, and her abilities for decision making and autonomy.
 Get more information about the shelter environment and the timing and intensity of the children’s asthma
episodes;
 Based on the information discussed, help the client explore other housing options, make her aware of
relevant supports such as legal aid organizations, and assist her in moving toward decision making to solve
the problem.
 Provide on-going encouragement as the mother attempts to implement her problem-solving plan.
Basis of Nursing Advocacy

1. Preserving human dignity

2. Patient equality
3. Freedom from suffering

Nursing Advocacy

 May defend a patient’s right in a general way by speaking out against policies or action that might
endanger their well-being or conflict with rights.

What is Lobbying?

In the principles of ethical conduct of lobbying developed by Georgetown’s Woodstock center: lobbying “means the
deliberate attempt to influence political decisions through various forms of advocacy directed at policymakers on
behalf of another person, organization or group.

Lobbyist

Are individuals who communicate and advocate certain views to members of the government in the hope of
influencing policy at local, state or federal levels.

Lobby and Advocacy Similarities and Differences

 Lobbying usually involves attempting to influence legislation.

 Advocacy covers a much better range of activities that might not include lobbying.
 One way of differentiating between the two terms is to understand that lobbying always involves advocacy
but advocacy does not necessarily involve lobbying.

Health Care Lobbyist are Employed by:

 Insurance groups
 Drug companies
 Specialty organizations
 Public health groups
 Others who have a stake in health care legislation
 Lobbyists may lobby against certain taxes, such as those on insurance companies, or encourage funding for
programs, such as those that treat narcotics abusers.
 Sometimes, lobbyists are trying to do more than educate government officials. Lobbyists also may attempt
to delay votes, giving stakeholders time to bring their own concerns to the table and create a more complete
discussion on the topic.
 In health care, nurses who transition into lobbying are well-placed to represent and advocate for their
patients’ interests because of the nurse’s intimate knowledge of the field and understanding of the ways that
legislation impacts day-to-day organizational operations.
 Nurses also make good lobbyists because they come from a well-respected profession. In January 2017,
Gailup’s annual poll ranked nursing as the most trusted profession for the 15 th year in a row. The honesty
and ethical standards of nurses were reported as “high” or “very high” by 84 percent of respondents.
Consequently, nurses’ opinions on the direction of health care in the U.S. can carry a lot of weight.

Code of Ethics for Nurses

Ethics is an integral part of the foundation of nursing. Nursing has a distinguished history of concern for the welfare
of the sick, injured, and vulnerable and for social justice. This concern is embodied in the provision of nursing care
to individuals and the community. Nursing encompasses the prevention of illness, the alleviation of suffering, and
the protection, promotion, and restoration of health in the care of individuals, families, groups, and communities.
Individuals who become nurses are expected not only to adhere to the ideals and moral norms of the profession, but
also to embrace them as a part of what it means to be a nurse.

Since the early days of the nursing profession, a concern with a code of ethics has been central to nursing practice to
serve as a guide for incorporating ethical principles into practice. The “Nightingale Pledge,” a modification of the
Hippocratic Oath (5th to 6th century BC), was first developed in 1893 and named in honor of Florence Nightingale.
The “Nightingale Pledge” was modified in 1935 to slightly modernize the language (replacing shall with will and
adding reference to aiding the physician while widening the role of the nurse to include public health, “missioner of
health”):
This
“Nightingale Pledge” has been recited by nurses for generations as is or with some modification. However, a more
formal code of ethics was not developed until 1950. The code of ethics developed by the American Nurses
Association (ANA) is an evolution of earlier attempts to delineate ethical standards for nurses. Although ethical
standards had been suggested earlier, they were not codified and ratified until 1950 by the ANA as A Code for
Professional Nurses.

In 2001, the first substantive revision in 25 years was completed and included interpretive statements. The latest
revision (2015) has resulted in the current Code of Ethics for Nurses with Interpretive Statements and more
accurately reflects the reality of today’s nursing practice, across all settings and in a wide range of roles.
Principles of the Nursing Code of Ethics

Revised in 2015 to include 9 provisions, the ANA’s nursing code of ethics now includes interpretative statements
that can provide more specific guidance for nursing practice. 

Currently, the nurse’s code of ethics contains 9 main provisions:

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of
every person.

2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or
population.

3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes
action consistent with the obligation to provide optimal patient care.

5. The nurse owes the same duties to self as to others, including the responsibility to promote health and
safety, preserve wholeness of character and integrity, maintain competence, and continue personal and
professional growth.

6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical
environment of the work setting and conditions of employment that are conducive to safe, quality health
care.

7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry,
professional standards development, and the generation of both nursing and health policy.

8. The nurse collaborates with other health professionals and the public to protect human rights, promote
health diplomacy, and reduce health disparities.

9. The profession of nursing, collectively through its professional organization, must articulate nursing values,
maintain the integrity of the profession, and integrate principles of social justice into nursing and health
policy.

ICN Code of Ethics for Nurses

An International Code of Ethics for Nurses was first adopted by the International Council of Nurses (ICN) in 1953.
It has been revised and reaffirmed at various times since most recently with this review and revision completed in
2012.

Elements of the Code

1. Nurses and People. The nurse’s primary professional responsibility is to people requiring nursing care.
2. Nurses and Practice: The nurse carries personal responsibility and accountability for nursing practice, and
for maintaining competence by continual learning.
3. Nurses and Profession: The nurse assumes the major role in determining and implementing acceptable
standards of clinical nursing practice, management, research and education.
4. Nurses and Co-workers: The nurse sustains a collaborative and respectful relationship with co-workers in
nursing and other fields.

Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and personal
attributes of every person, without prejudice.

1.1 Respect for Human Dignity. A fundamental principle that underlies all nursing practice is respect for the
inherent dignity, worth, and human rights of all individuals. The need for and right to health care is universal,
transcending all individual differences. Nurses consider the needs and respect the values of each person in every
professional relationship and setting; they lead in the development of changes in public and health policies that
support this duty.

1.2 Relationships with Patients. Nurses establish relationships of trust and provide nursing services according to
need, setting aside any bias or prejudice. When planning patient, family and population centered care, factors such
as lifestyle, culture, value system, religious or spiritual beliefs, social support system and primary language shall be
considered. Such considerations must promote health, address problems and respect patient decisions. This respect
for patient decisions does not require that the nurse agree with or support all patient choices.

1.3 The Nature of Health. Nurses respect the dignity and rights of all human beings regardless of the factors
contributing to the health status. The worth of a person is not affected by disease, disability, functional status, or
proximity to death. Nurses assess, diagnose, plan, intervene, and evaluate patient care in accord with individual
patient needs and values. Respect is extended to all who require and receive nursing care whether in the promotion
of health, prevention of illness, restoration of health, alleviation of suffering, and provision of supportive care to
those who are dying. Optimal nursing care enables the patient to live with as much physical, emotional, social, and
religious or spiritual well-being as possible and reflects the patient’s own values. Supportive care is extended to the
family and significant others and is directed toward meeting needs comprehensively across the continuum of care.
This is particularly important at the end of life in order to prevent and alleviate the cascade of symptoms and
suffering that are commonly associated with dying. Nurses are leaders who actively participate in assuring the
responsible and appropriate use of interventions in order to optimize the health and well-being of those in their care.
This includes acting to minimize unwarranted or unwanted medical treatment and patient suffering. Such care must
be avoided and advance care planning throughout many clinical encounters helps to make this possible. Nurses are
also leaders who collaborate in alleviating systemic structures that have a negative influence on individual and
community health.

1.4 The Right to Self-Determination. Respect for human dignity requires the recognition of specific patient rights,
in particular, the right of self-determination. Patients have the moral and legal right to determine what will be done
with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an
informed decision; to be assisted with weighing the benefits, burdens, and available options in their treatment,
including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence,
duress, coercion, or prejudice; and to be given necessary support throughout the decision-making and treatment
process. Such support includes the opportunity to make decisions with family and significant others and to obtain
advice from expert/knowledgeable nurses and other health professionals. The acceptability and importance of
carefully considered decisions regarding resuscitation status, withholding and withdrawing life-sustaining therapies,
forgoing medically provided nutrition and hydration, aggressive pain and symptom management, and advance
directives are widely recognized. Nurses provide patients with assistance as necessary with these decisions. Nurses
should promote conversations around advance care planning and must be knowledgeable about the benefits and
limits of various advance directive documents. The nurse should provide interventions to relieve pain and other
symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may
not act with the intent to end life even though such action may be motivated by compassion, respect for patient
autonomy, or quality of life considerations. Nurses have invaluable experience, knowledge, and insight into
effective and compassionate care at the end of life and should be actively involved in related research, education,
practice, and policy development. Nurses have an obligation to be knowledgeable about the moral and legal rights of
patients. Nurses preserve, protect, and support those rights by assessing the patient’s understanding of both the
information presented and the implications of decisions. When the patient lacks capacity to make a decision, a
formally designated surrogate should be consulted. The role of the surrogate is to make decisions as the patient
would, based upon the patient’s previously expressed wishes and known values. In the absence of an appropriate
surrogate decision maker, decisions should be made in the best interests of the patient, considering the patient’s
personal values to the extent that they are known. Nurses include patients or surrogate decision-makers in
discussions, provide referrals to other resources as indicated, identify options, and address problems in the decision-
making process. Support of patient autonomy also includes respect for the patient’s method of decision-making and
recognition that different cultures have different understandings of health, autonomy, privacy and confidentiality,
and relationships as well as varied practices of decision-making. For example, nurses reaffirm the patient’s values
and respect decision-making including those that are culturally hierarchical or communal.

1.5 Relationships with Colleagues and Others. Respect for persons extends to all individuals with whom the nurse
interacts. Nurses maintain professional, respectful and caring relationships with colleagues and are committed to fair
treatment, integrity-preserving compromise, and the resolution of conflicts. Nurses function in many roles and many
settings, including direct care provider, care coordinator, administrator, educator, researcher, and consultant. In
every role, the nurse creates a moral environment and culture of civility and kindness, treating others, colleagues,
employees, co-workers, and students with dignity and respect. This standard of conduct includes an affirmative duty
to act to prevent harm. Disregard for the effect of one’s actions on others, bullying, harassment, manipulation,
threats or violence are always morally unacceptable behaviors. Nurses value the distinctive contribution of
individuals or groups, and collaborate to meet the shared goal of providing efficient, effective, and compassionate
health services seeking to achieve quality outcomes in all settings.

Provision 2: The nurse’s primary commitment is to the patient, whether an individual, family, group,
community, or population.

2.1 Primacy of the Patient’s Interests. The nurse’s primary commitment is to the recipients of nursing and
healthcare services—the patient—whether individuals, families, groups, communities, or populations. Any plan of
care must reflect the fundamental commitment of nursing to the uniqueness, worth and dignity of the patient. Nurses
provide patients with opportunities to participate in planning and implementing care and support that is acceptable to
the patient. Addressing patient interests requires recognition of the patient’s place within the family and other
relationships. When the patient’s wishes are in conflict with others, nurses help to resolve the conflict. Where
conflict persists, the nurse’s commitment remains to the identified patient.

2.2 Conflict of Interest for Nurses. Nurses may experience conflict arising from competing loyalties in the
workplace, including conflicting expectations from patients, families, physicians, colleagues, healthcare
organizations and health plans. Nurses must examine the conflicts arising between their own personal and
professional values and the values and interests of others including those who are also responsible for patient care
and healthcare decisions, and perhaps patients themselves. Nurses address these conflicts in ways that ensure patient
safety and promote the patient’s best interests while preserving the professional integrity of the nurse and supporting
interdisciplinary collaboration.

2.3 Collaboration. In health care the goal is to address the health of the patient and the public. The complexity of
healthcare requires effort that has the strong support and active participation of all health professions. Nurses should
actively foster collaborative planning to provide high quality, patient-specific health care. Nurses are responsible for
articulating, representing and preserving the unique contribution of nursing to patient care and the nursing scope of
practice. The relationship with other health professions also needs to be clearly articulated, represented and
preserved.

2.4 Professional Boundaries. The nature of nursing work is inherently personal. Within their professional role,
nurses recognize and maintain appropriate personal relationship boundaries. Nurse–patient relationships and
collegial relationships have as their foundation the protection, promotion, and restoration of health and the
alleviation of suffering. Professional relationships are therapeutic in nature yet at times remaining within
professional boundaries can be tested. The intimate nature of nursing care, the involvement of nurses in important
and sometimes highly stressful life events, the mutual dependence of colleagues working in close concert, all may
contribute to the risk of boundary violations.

Provision 3: The nurse promotes, advocates for, and protects the rights, health and safety of the patient.

3.1 Protection of the Rights of Privacy and Confidentiality. Privacy is the right to control access to and disclosure
or nondisclosure of information pertaining to oneself, and to control the circumstances, timing, and extent to which
information might be disclosed. The need for health care does not justify unwanted or unwarranted intrusion into
people’s lives. Nurses safeguard the individuals, families, and community’s right to privacy. The nurse advocates for
an environment that provides sufficient physical privacy, including privacy for discussions of a personal nature.
Nurses also participate in the maintenance of and policies and practices that protect both personal and clinical
information at institutional and societal levels. Confidentiality pertains to the nondisclosure of personal information
that has been communicated within the nurse–patient relationship. Central to that relationship is an element of trust
and an expectation that personal information will not be divulged without consent. The nurse has a duty to maintain
confidentiality of all patient information, both personal and clinical in the work setting and off duty in all venues,
including social media or any other means.

3.2 Protection of Human Participants in Research. Stemming from the right to autonomy or self-determination,
individuals have the right to choose whether or not to participate in research as a human subject. Participants or legal
surrogates must receive sufficient and materially relevant information to make informed decisions and to understand
that they have the right to decline to participate or to withdraw at any time without fear of adverse consequences or
reprisal. Information needed for informed consent includes the nature of participation, potential harms and benefits,
available alternatives to taking part in the study, and how the data will be protected. It must be communicated in a
manner that is comprehensible to the patient. Prior to implementation, all research must be approved by a formally
constituted and qualified review board to ensure participant protection and the ethical integrity of the research.

3.3 Performance Standards and Review Mechanisms. Professional nursing is a process of education and formation
that involves the ongoing acquisition and development of the knowledge, skills, dispositions, practice experiences,
commitment, relational maturity, and personal integrity essential for professional practice. Nurse educators must
ensure that basic competence and commitment to professional practice exist prior to entry into practice.

3.4 Professional Competence in Nursing Practice. Nurses must lead in the development of policies and review
mechanisms to promote patient health and safety, reduce errors, and create a culture of excellence. When errors
occur, nurses must follow institutional guidelines in reporting errors to the appropriate authority and ensure
responsible disclosure of errors to patients. Nurses must establish processes where mistakes or errors are revealed
and nurses are personally accountable, and any system factors that led to error are rectified. Error should be
corrected or remediated, not punished.

3.5 Protecting Patient Health and Safety by Action on Questionable Practice. Nurses must be alert to and take
appropriate action in instances of incompetent, unethical, illegal, or impaired practice or any actions that place the
rights or best interests of the patient in jeopardy. To function effectively, nurses must be knowledgeable about The
Code of Ethics of Ethics for Nurses, standards of practice of the profession, relevant federal, state and local laws and
regulations, and the employing organization’s policies and procedures.
3.6 Patient Protection and Impaired Practice. Nurses must protect the patient, the public, and the profession from
potential harm when a colleague’s practice appears to be impaired. When another’s practice appears to be impaired,
the nurse’s duty is to take action to protect patients and to ensure that the impaired individual receives assistance.

Provision 4: The nurse has authority, accountability, and responsibility for nursing practice, makes
decisions, and takes action consistent with the obligation to provide optimal care.

1.1 Authority, Accountability, and Responsibility. Nurses bear primary responsibility for the nursing care that their
patients and clients receive and are accountable for their own practice. Nursing practice includes independent direct
nursing care activities, care as ordered by an authorized healthcare provider, delegation of nursing interventions,
evaluation of interventions, and other responsibilities such as teaching, research, and administration.

1.2 Accountability for Nursing Judgments, Decisions, and Actions. In order to be accountable, nurses act under a
code of ethical conduct that includes adherence to the scope and standards of nursing practice and such moral
principles as fidelity, gratitude, and respect for the dignity, worth, and self-determination of patients. Nurses are
accountable for judgments made and actions taken in the course of nursing practice, irrespective of other providers’
directives or institutional policies.

1.3 Responsibility for Nursing Judgments, Decisions and Actions. Nurses are accountable for their judgments,
decisions, and actions; but, in compromising circumstances, responsibility may be borne by both the nurse and the
institution. Nurses accept or reject specific role demands and assignments based on their education, knowledge,
competence, experience, and assessment of patient safety.

1.4 Delegation of Nursing Activities or Tasks. Nurses are accountable and responsible for the assignment or
delegation of nursing activities. Such assignment or delegation must be consistent with state practice acts,
institutional policy, and nursing standards of practice.

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health
and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and
professional growth.

5.1 Duty to Self and Others. Moral respect accords moral worth and dignity to all human beings regardless of their
personal attributes or life situation. Such respect extends to oneself as well: the same duties that we owe to others we
owe to ourselves. Self-regarding duties primarily concern oneself and include promotion of health and safety,
preservation of wholeness of character and integrity, maintenance of competence, and continuation of personal and
professional growth.

5.2 Promotion of Personal Health, Safety, and Well-Being. As professionals who assess, intervene, evaluate,
protect, promote, educate, and conduct research for the health and safety of others and society, nurses have a duty to
take the same care for their own health and safety. Nurses should model the same health maintenance and health
promotion measures that they teach and research, seek health care when needed, and avoid taking unnecessary risks
to health or safety in the course of their customary professional and personal activities.

5.3 Wholeness of Character. Nurses have both personal and professional identities that are integrated and embrace
the values of the profession, merging them with personal values. Authentic expression of one’s own moral point-of-
view is a duty to self. Sound ethical decision-making requires the respectful and open exchange of views among all
those with relevant interests: nurses must work to foster a community of moral discourse. As moral agents, nurses
are an important part of that community and have a responsibility to express moral perspectives, especially when
integral to the situation, whether or not those perspectives are shared by others and whether or not they might
prevail.

5.4 Preservation of Integrity Personal. Integrity is an aspect of wholeness of character; its maintenance is a self-
regarding duty. Nurses may face threats to their integrity in any healthcare environment. Threats to integrity may
include requests to deceive a patient, to withhold information, to falsify records, to misrepresent research aims, as
well as enduring verbal abuse by patients or coworkers.

5.5 Maintenance of Competence and Professional. Growth Maintenance of competence and professional growth
involve the control of one’s own conduct in a way that is primarily self-regarding. Competence affects one’s self-
respect, self-esteem, and the meaningfulness of work. Nurses must maintain competence and strive for excellence in
their nursing practice, whatever the role or setting. Nurses are responsible for developing criteria for evaluation of
practice and for using those criteria in both peer and self-assessment.

5.6 Personal Growth. Nursing care addresses the whole person as an integrated being; nurses should also apply this
principle to themselves. As such, professional and personal growth reciprocate and interact. Activities that broaden
nurses’ understanding of the world and of themselves affect their understanding of patients; those that increase and
broaden nurses’ understanding of nursing’s science and art, values, ethics, and policies also affect the nurse’s self-
understanding.
Provision 6: The nurse, through individual and collective action, establishes, maintains, and improves the
moral environment of the work setting and the conditions of employment, conducive to quality health care.

6.1 The Environment and Moral Virtue and Value. Virtues are universal, learned, and habituated attributes of
moral character that predispose persons to meet their moral obligations; that is, to do what is right. There is a
presumption and expectation that we will commonly see virtues such as integrity, respect, temperance, and industry
in all those whom we encounter. Virtues are what we are to be and make for a morally “good person”. There are
more particular attributes of moral character, not expected of everyone, that are expected of nurses.

6.2 The Environment and Ethical Obligation. Virtues focus on what is good and bad in whom we are to be as
moral persons; obligations focus on right and wrong or what we are to do as moral agents. Obligations are often
specified in terms of principles such as beneficence or doing good; nonmaleficence or doing no harm; justice or
treating people fairly; reparations, or making amends for harm; fidelity, and respect for persons.

6.3 Responsibility for the Healthcare Environment. Nurses are responsible for contributing to a moral environment
that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult
issues that includes on-going formation of staff in ethical problem solving. Nurse executives have a particular
responsibility to assure that employees are treated fairly and justly, and that nurses are involved in decisions related
to their practice and working conditions.

Provision 7: The nurse, whether in research, practice, education, or administration, contributes to the
advancement of the profession through research and scholarly inquiry, professional standards development,
and generation of nursing and health policies.

7.1 Contributions through Research and Scholarly Inquiry. All nurses must participate in the advancement of the
profession through knowledge development, evaluation, dissemination, and application to practice. Knowledge
development relies chiefly, though not exclusively, upon research and scholarly inquiry. Nurses engage in scholarly
inquiry in order to expand the body of knowledge that forms and advances the theory and practice of the discipline
in all its spheres.

7.2 Contributions through Developing Maintaining, and Implementing Professional Practice Standards. Practice
standards must be developed by nurses and grounded in nursing’s ethical commitments and body of knowledge.
These standards must also reflect nursing’s responsibility to society. Nursing identifies its own scope of practice as
informed, specified, or directed by state and federal law, by relevant societal values, and by The Code of Ethics with
Interpretive Statements, and Nursing: Scope and Standards of Practice.

7.3 Contributions through Nursing and Health Policy Development. Nurses must lead, serve, and mentor on
institutional or agency policy committees within the practice setting. Nurses ought to participate in civic activities
related to healthcare through local, regional, state, national, or global initiatives. Nurse educators have a particular
responsibility to foster and develop students’ commitment to professional and civic values and to informed
perspectives on nursing and healthcare policy.

Provision 8: The nurse collaborates with other health professionals and the public to protect and promote
human rights, health diplomacy, and health initiatives.

8.1 Health is a Universal Right. The nursing profession holds that health is a universal human right and that the
need for nursing is universal. The right to health is a fundamental right to a universal minimum standard of health to
which all individuals are entitled. Such a right has economic, political, social, and cultural dimensions. It includes
public education concerning health maintenance and promotion; education concerning the prevention, treatment, and
control of prevailing health problems; food security; potable water; basic sanitation; reproductive health care;
immunization; prevention and control of locally endemic diseases and vectors; and access to health, emergency, and
trauma care.

8.2 Collaboration for Health, Human Rights, and Health Diplomacy. The nursing profession commits to
advancing the health, welfare, and safety of all. This nursing commitment reflects the intent to achieve and sustain
health as a means to the common good so that individuals and communities here and abroad can develop to their
fullest potential and live with dignity. Ethics, human rights, and nursing converge as a formidable instrument for
social justice and health diplomacy that can be amplified by collaboration with other health professionals.

8.3 Obligation to Advance Health and Human Rights. Nurses collaborate with others to change unjust structures
and processes that affect persons or communities. Structural social inequalities and disparities, inadequate social
policies, or institutional policies or practices exacerbate the incidence and burden of illness, trauma, suffering, and
premature death. Through community organizations and groups, nurses educate the public; facilitate informed
choice; identify conditions and circumstances that contribute to illness, injury and disease; foster healthy life styles;
and participate in institutional and legislative efforts to protect and promote health.
8.4 Collaboration for Human Rights in Complex and Extraordinary Practice Settings. Nurses must be mindful of
competing moral claims (that is, conflicting values or obligations) and bring attention to human rights violations in
all settings and contexts. Human trafficking; the global feminization of poverty, rape, and abuse as an instrument of
war; the oppression or exploitation of migrant workers; and all such human rights violations are of grave concern to
nurses.

Provision 9: The profession of nursing, collectively through its professional organizations, must articulate
nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing
and health policy.

9.1 Articulation of Values Individual. Nurses are represented by their professional associations and organizations.
These groups give united voice to the profession. It is the responsibility of a profession collectively to communicate,
affirm, and promote shared values both within the profession and to the public. It is essential that the profession
engage in discourse that supports ongoing critical self-analysis and evaluation. The language that is chosen evokes
the shared meaning of nursing, its values and ideals, as it interprets and explains the place and role of nursing in
society. The profession’s organizations communicate to the public the values that nursing considers central to the
promotion or restoration of health, prevention of illness, and alleviation of suffering. Through professional
organizations the nursing profession must reaffirm and strengthen nursing values and ideals so that when those
values are challenged, adherence is steadfast and unwavering.

9.2 Integrity of the Profession. The profession’s integrity is strongest when its values and ethics are evident in all
professional and organizational relationships. Nursing must continually emphasize the values of justice, fairness,
and caring within the national and global nursing communities, in order to promote health in all sectors of the
population. A fundamental responsibility is to promote awareness of and adherence to the codes of ethics for nurses
(the American Nurses Association and the International Council of Nurses).

9.3 Integrating Social Justice. It is the shared responsibility of professional nursing organizations to speak for
nurses collectively in shaping health care and to promulgate change to improve health care nationally and
internationally. Nurses must be vigilant and take action to influence legislators, governmental agencies, non-
governmental organizations, and international bodies in all related health affairs for addressing the social
determinants of health.

9.4 Social Justice in Nursing and Health Policy. The nursing profession must actively participate in solidarity with
the global nursing community and health organizations to represent the collective voice of U.S. nurses around the
globe. Professional nursing organizations must actively engage in the political process, particularly addressing those
legislative concerns that most impact the public's health and the profession of nursing. Nurses must promote open
and honest communication that enables nurses to work in concert, share in scholarship, and advance a nursing
agenda for health.

The Code of Ethics for Filipino Nurses

The professional code of ethics for Filipino nurses strongly emphasizes the fourfold responsibility of the nurse, the
universality of nursing practice, the scope of their responsibilities to the people they serve, to their co-workers, to
society and environment, and to their profession.

The Code of Ethics for Filipino Nurses embodies ethical principles and guidelines to be observed, stipulated under
seven (7) articles. The ethical principles are stated below.

Article I – Preamble

1. Health is a fundamental right. The Filipino RN, believing in the worth and dignity of each human being,
recognizes the primary responsibility to preserve health at all cost. This responsibility encompasses promotion of
health, prevention of illness, alleviation of suffering, and restoration of health. However, when the foregoing is not
possible, assistance towards a peaceful death shall be his/her obligation.

2. To assume this responsibility, RNs have to gain knowledge and understanding of man’s cultural, social, spiritual,
psychological, and ecological aspects of illness, utilizing the therapeutic process. Cultural diversity and political and
socio-economic status are inherent factors to effective nursing care.

3. The desire for the respect and confidence of clientele, colleagues, coworkers, and the members of the community
provides the incentive to attain and maintain the highest possible degree of ethical conduct.

Article II – Registered Nurses and People

1. Values, customs, and spiritual beliefs held by individual shall be represented.

2. Individual freedom to make rational and unconstrained decisions shall be respected.

3. Personal information acquired in the process of giving nursing care shall be held in strict confidence.
Article III – Registered Nurses and Practice

1. Human life is inviolable.

2. Quality and excellence in the care of patients are the goals of nursing practice.

3. Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.

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

5. Registered Nurses are aware that their actions have professional ethical, moral and legal dimensions. They strive
to perform their work in the best interest of all concerned.

Article IV – Registered Nurses and Co-workers

1. The RN is in solidarity with other members of the health care team in working for the patient’s best interest.

2. The RN maintains collegial and collaborative working relationship with colleagues and other health care
providers.

Article V – Registered Nurses, Society, and Environment

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

2. The establishment of linkages with the public in promoting local, national, and international efforts to meet
health and social needs of the people as a contributing member of society is a noble concern of a RN.

Article VI – Registered Nurses and the Profession

1. Maintenance of loyalty to the nursing profession and preservation of its integrity are ideal.

2. Compliance with the by-laws of the accredited professional organization (PNA) and other professional
organizations of which the RN is a member is a lofty duty.

3. Commitment to continual learning and active participation in the development and growth of the profession are
commendable obligations.

4. Contribution to the improvement of the socio-economic conditions and general welfare of nurses through
appropriate legislation is a practice and visionary mission.

Article VII – Administrative Penalties, Repealing Clause and Effectivity

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

Art. IV of R.A. 9173 – Examination and Registration Sec. 23. Revocation and Suspension of Certificate of
Registration/Professional License and Cancellation of Special/Temporary Permit. – The Board shall have the power
to revoke or suspend the certificate of registration/professional license or cancel the special/temporary permit of a
nurse upon any of the following grounds:

(a) For any of the causes mentioned in the preceding section

(b) For unprofessional and unethical conduct

(c) For gross incompetence or serious ignorance

(d) For malpractice or negligence in the practice of nursing

(e) For the use of fraud, deceit, or false statements in obtaining a certificate of registration/professional license or a
temporary/special permit

(f) For violation of this Act, then rules and regulations, Code of Ethics for nurses and technical standards for nursing
practice, policies of the Board and the Commission, or the conditions and limitations for the issuance of the
temporary/special permit

(g) For practicing his/her profession during his/her suspension from such practice

Provided, however, That the suspension of the certificate of registration/professional license shall be for a period not
to exceed four (4) years.
Rule III of Board Res. No. 425, Series of 2003, the IRR (Implementing Rules and Regulations)

Same as rule III of Board Res. No. 425, Series of 2003, the IRR except:

(f) For violation of RA No. 9173 and this IRR, Code of Ethics for nurses and Code of Technical Standards for
nursing practice, policies of the Board and the Commission, or the conditions and limitations for the issuance of the
special/temporary permit.

For this purpose, the suspension of the Certificate of Registration/Professional License shall be for a period not
to exceed four (4) years.

REFERENCES
American Nurses Association (2014). The Code of Ethics for Nurses with Interpretative
Statements. Retrieved from https://homecaremissouri.org/mahc/documents/Codeof
EthicswInterpretiveStatements20141.pdf. December 14, 2020
Board of Nursing (2004). Promulgation of the Code of Ethics for Registered Nurses. Retrieved
from https://www.prc.gov.ph/uploaded/documents/Board%20of%Nursing-CE.pdf.
December 14, 2020
Gaines, K. (2020). What is the Nursing Code of Ethics? Retrieved from https://nurse.org/
Education/nursing-code-of-ethics/. December 14, 2020
International Council of Nurses (2012). The ICN Code of Ethics for Nurses. Retrieved from
https://www.icn.ch/sites/default/files/inline-files/2012 ICN Codeofethicsfornurses %
 20eng.pdf. December 14, 2020
Kristallete, K. (2020). Continuing Education Programs on Ethico-Moral Practice in Nursing.
Retrieved from https://www.scribd.com/presentation/461657027/Continuing-
Education-Programs-on-Ethico-Moral-Practice-in-Nursing. December 14, 2020
Lockwood, W. (2020). Nursing Ethics. Retrieved from https://www/rn/org/course/coursematerial
-10026.pdf. December 14, 2020