VIDEO 4 - CHAPTER 4: ETHICAL
him with his parents
DECISION-MAKING PROCESS
BIOETHICS
- The principles that govern right and proper
conduct of a person regarding life, biology
and the health professionals.
How to make decisions safe for patients:
 Ethical issue: one that involves core values
of practice.
 Ethical reasoning is necessary to resolve
potential tensions between personal values
and professional values and among
professional values.
Example Case:
Case about a 16 year old boy with terminal
brain cancer (glioblastoma multiformw); medical
team wants to refer him to hospice; but parents
don’t want the boy to know; they want to put him
through an aggressive experimental surgical
procedure. But boy found out about his condition in
the internet; requested to have a talk with the
resident physician and nurse without his parents,
and asked them whether “he was dying?”.
RECOMMENDED STEPS IN ETHICAL DECISION
MAKING:
1.) Ask “what is the ethical question?’ (ex: should
the resident physician and the nurse disclose the
patient’s diagnosis)
2.) Ask “what should or ought to happen according
to the norms and standards?”
- what are the available evidence-based
treatments”
- should the minor know his diagnosis?
- what does your “gut” tell you to do?
*this is important because ethics and law
are different
3.) Gather relevant facts
- why is minor asking these questions?
- What is the law on decision-making by
minors?
4.) Ask “what are the values at stake in this
scenario?”
- In this case, battle between beneficence,
non-maleficence, autonomy v privacy and
confidentiality
- Justice is also important to allocate
resources only to beneficial treatment
5.) Ask “what are the options in this case?”
- Tell minor what they understand about his
condition
- Tell minor to ask his parents
- Tell minor what they will discuss his case to
Note: In the Philippines, a minor has no legal
personality yet to decide for his or himself
properly. (As a lawyer, I would recommend the
nurse and the physician to talk with the parents
because it is presume that the parents have the
best interest of the minor at heart, unless the
contrary is proven – Igor, 2021 Philippines).
6.) “what should I do?”
7.) “what justifies this choice?”
- The presumption is that adolescents should
be involved in their healthcare decision
making to the extent that they are capable
and desire to be involved
8.) “How could this ethical problems have been
prevented?”
*In the Philippines, the age of majority is 18 years
old (RA 6809, an act lowering the age of majority
from 21 to 18 yo, 1989). Anybody less than 18 yo is
a child (RA 7610, Special protection of child against
abuse and discrimination act, 1992).
*In civil law, a minor is incapable of gibing a valid
consent. Article 1327 of the New Civil Code (RA
386) provides: “The following cannot give consent
to a contract:
(1) unemancipated minors
(2) insane or demented persons, and deaf-mutes
who do not know how to write
As a consequence, a surgery or medical
treatment is a form of contract. If a minor cannot
enter to a contract, therefore, a minor cannot give
valid consent to surgical or medical procedure. The
parents have to be the one give the consent, if the
parents are dead, it has to be the closest relative of
the patient who are of course within the age of
majority.
Emancipated minors – 18 yo who has job or living
outside the family’s home
(Note: no more emancipated minors after passage
of RA 6809)
*Since a physician-patient relationship, or a nurse-
patient relationship, is contractual in nature,
consent of a minor cannot bind the parties involved.
The logical conclusion was that the authority to
consent to medical treatment on a minor’s behalf
must be vested in someone else.
*The power has devolved to the natural guardians
of the minor-his or her parents.
*Article 1394, New Civil Code RA 386: Ratification
may be affected by guardian of the incapacitated
minor. (Ratification: For example, a minor buy
something expensive and then the parents paid for
that)
*Minor – parents or minors who have suffered
miscarriage cannot have access to modern
methods [surgery] of family planning without written
consent from their parents or guardian/s.
*Parental consent and notification is favoured if the
minor is to receive follow-up care (ex: surgery)
*Even the patient’s bill of the rights published by the
Department of Health states that in case of minors
and incompetent persons, their informed consent is
not required; rather, the informed consent shall be
obtained from their parents or legal guardian/s
(Patient’s bill of rights, Department of Health).
*But in some treatment situations like treatment for
sexually transmitted diseases or the side effects of
birth control pills-family ties may be strained or
broken following disclosure or notification.
*It is not advisable to provide information to parents
without permission of minor (or court order, or
statutory directive)
NLE QUESTION 31.
Investigation of cognitively impaired individual
presented some ethical dilemmas. Which of the
following protocol would be considered unethical?
a. Recording interaction with the elderly with their
permission
b. Verbal permission from the subject is
unnecessary
C. Data coded and recorded solely by the
investigation
D. A written consent from the institution and a
significant other
PRINCIPLES TO BE CONSIDERED IN ETHICAL
DECISION MAKING
1. Utilitarianism
- the principle which is for the greatest good
for the greatest number
- this principle gives emphasis to prioritize
- maximizing strategies to achieve the
greatest amount of good
- medical success principle (who to save?):
good prognosis
- immediate usefulness
- conservation principle (save baby > adult)
- parental role (father > single)
2. Egalitarianism
- opposite to utilitarianism
- equalize
- both the means and the ends must be
justified
- restoring the equality of the people in need
- medical neediness (who to save? poor
prognosis)
- first come, first serve
- random selection
Note: Whatever principles you follow whether it is
utilitarianism or egalitarianism, make sure decisions
do not violate criminal laws (RA 3815 and other
statutes), civil law (RA 386), and administrative law
(RA 9173, Code of Ethics).
*If you are government employee, the
administrative law you should be familiar with is
Executive Order 292 which is the Civil Service Law
of the Philippines.
*If you are a private employee, you look at PD 442,
Labor Code of the Philippines.
PUNISHMENTS:
1.) Criminal (RA 3815)
- burden of proof: beyond reasonable doubt
(it means there must be proof beyond
certainty)
- condequence: prison (incarceration), fines
(to society)
2.) Civil (RA 386)
- burden of proof: based on a preponderance
of the evidence (it means while in criminal
law, the battle there is between the people
and the accuse, in civil law the battle here is
between one man against another man, the
heavier or weightier evidence)
- consequence: monetary
compensation/damages (to offended party)
CIVIL LAW DAMAGES
Damages
- daños in Spanish
- the amount of losing party has to pay for the
winning party
1.) Actual or Compensatory (Art 2199): actual
expense
- Article 2199. Except as provided by law or
by stipulation, one is entitled to an adequate
compensation only for such pecuniary loss
suffered by him as he has duly proved.
Such compensation is referred to as actual
or compensatory damages (RA 386)
- You can prove it using receipts. If this thing
is broken by the other party, you can
present the receipts as to what is the value
of that thing. If receipts is not available, then
you can present an expert which knows the
standard value of that thing at the current
time.
- Article 2205. Damaged may be recovered:
(1) For loss or impairment of earning
capacity in cases of temporary or
permanent personal injury
 (2) for injury to the plaintiff’s business
standing or commercial credit
2.) Moral Damages (Art 2217): most famous/most
expensive (for sleepless nights; suffering)
- Article 2217. Moral damages include
physical suffering, mental anguish, fright,
serious anxiety, besmirched reputation,
wounded feelings, moral shock, social
humiliation, and similar injury. Though
incapable of pecuniary computation, moral
damages may be recovered if they are the
proximate result of the defendant’s wrongful
act for omission (RA 386)
- There are certain cases wherein moral
damage can be awarded immediately such
as rape cases.
3.) Nominal Damages (Art 2221): when there is a
violation of a right, but incapable of pecuniary
estimation
- Article 2221. Nominal damages are
adjudicated in order that a right of the
plaintiff, which has been violated or invaded
by the defendant, may be vindicated or
recognized, and not for the purpose of
indemnifying the plaintiff for any loss
suffered by him (RA 386)
- Article 2223. The adjudication of nominal
damages shall preclude further contest
upon the right involved and all accessory
questions, as between the parties to the
suit, or their respective heirs and assigns.
4.) Temperate or Moderate Damages (Art 2224)
- Article 2224. Temperate or moderate
damages, which are more than nominal but
less than compensatory damages, may be
recovered when the court finds that some
pecuniary loss has been suffered but its
amount cannot, from the nature of the case,
be provided with certainty (RA 386)
- For example, gasto sa lamay but u were not
able to present the receipts, the court may
award temperate damages for the expense
of the funeral and the burial.
5.) Liquidated damages (Art 2226)
- Article 2226. Liquidated damages are those
agreed upon by the parties to a contract, to
be paid in case of breach thereof (RA 386).
For Sir Igor, this one is the easiest to prove
because there is already an agreement,
there is written stipulation of how much a
party should pay if the contract is breach.
- Article 2227. Liquidated damages, whether
intended as an indemnity or a penalty, shall
be equitably reduced if they are iniquitous or
unconscionable.
6.) Exemplary of Corrective Damages (Art 2229): to
warn public (ex: gross offense) (amount is decided
by court)
- Article 2229. Exemplary or corrective
damages are imposed, by way of example
or correction for the public good, in addition
to the moral, temperate, liquidated or
compensatory damages (RA 386)
- Article 2230. In criminal offense, exemplary
damages as a part of the civil liability may
be imposed when the crime was committed
with one or more aggravating
circumstances. Such damages are separate
and distinct from fines and shall be paid to
the offended party.
- Article 2231. In quasi-delicts (Philippine
version of American torts), exemplary
damages may be granted if the defendant
acted with gross negligence.
3. Administrative (RA 9173, PD 442 [labor code if
private] [civil service if public]
- Burden of proof: clear and convincing
standard
- Consequence: suspension or revocation of
licence
NLE QUESTION 5
When a nurse breaches the duty of confidentiality,
he or she can be disciplined by both the employer
and the Board of Nursing. In addition to this
discipline, he or she can:
A. be held responsible for any damages that result
B. be fined by the federal government
C. be sentenced for up to 1 year in jail
D. immediately lose his or her nursing license
NLE QUESTION 14
The nurse is in the hospital canteen and hears two
staff nurses talking about the client confined in
Room 612. They mentioned his name and
discussed details of his condition. Which of the
following actions should the nurse take?
A. Approach the two nurses and tell them that their
actions are inappropriate especially in public area
B. Wait till the nurses finish the discussion and
report the situation to the supervisor
C. Say nothing to avoid embarrassing the staff
nurse
D. Remain quiet and ignore the discussion
CASE: The nurse who failed to check the patient’s
respiratory status.
Our Lady of Lourdes Hospital v Spouses
Romeo and Regine Capanzana (GR 189218,
March 22, 2017), a nurse neglected to assess the
respiratory status of a patient experiencing
respiratory distress, and whose significant others is
complaining that such patient’s oxygen tank is
running empty. As a result, the patient suffered
cardiopulmonary arrest which caused her brain
damage and subsequent vegetative state, to wit:
“hypoxic encelopathydue to pulmonary edema.”
The nurse was held liable along with the hospital
for Php 299,102.04 for actual damages, Php
1,330,296.80 for compensatory damages, Php 100,
000 for moral damages, and Php 100,000 for
attorney’s fees.
 The doctors in the above case got out scot-
free, even if the RTC found out that they
failed to assess the patient’s heart disease
– a rheumatic heart disease with mitral
stenosis – which led to the patients
pulmonary hypertension, then pulmonary
edema, and eventually respiratory arrest; all
because the nurse didn’t assess the
respiratory function of the patient; an
assessment which, in my humble
asseveration, could and should, have been
done with greater accuracy and
thoroughness by the admitting physician.
 The lesson to be learned from this case, for
me, is that nurses must do everything in
their power not to be the “fall guy”, the
“stodge”, or the “scapegoat”. They must
assess each patient like their jobs, liberty,
and dignity depend on it; and must never
rely solely on the good doctor’s
proclamation that the “coast is clear”
NLE QUESTION 73
The Code of Nurses
A. delineates all obligations and responsibilities of
the nurse
B. is a binding oath, which tells nurses how to make
ethical decisions
C. assists the nurse in formulating a personal belief
system
D. supports the concept of respect for all persons
NLE QUESTION 50
Nurse Rita is successful in collaborating with health
team members about the care of Mr. Linao. This is
because she has the following competence:
A. Communication, trust, and decision making
B. Conflict management, trust, negotiation
C. Negotiation, decision making
D. Mutual respect, negotiation, and trust
NLE QUESTION 2
Among children candidates for organ transplant,
when all selected children have appropriate tissue
matches for the same donated organ, the basis for
the decision as to which child gets the organ is
given to the child who:
A. Will receive the most benefit from the new organ
B. Is most likely to die without the transplant
C. Is selected by the lottery system for available
organs
D. Is at the top of the list and has waited the
longest time
NLE QUESTION 53
The use of interpersonal decision making,
psychomotor skills, and application of knowledge
expected in the role of a licensed health care
professional in the context of public health welfare
and safety is an example of:
A. delegation
B. supervision
C. responsibility
D. competence
CASE: Imbong v Ochoa Jr. (GR 204819, April 8,
2014)
Republic Act (RA) No. 10354, otherwise
known as the Responsible Parenthood and
Reproductive Health Act of 2012 (RH Law), was
enacted by Congress on December 21, 2012.
A perusal of the foregoing petitions show
that the petitioners are assailing the constitutionality
of RH Law on the following grounds: The RH Law
violates the right to life of the unborn, the right to
health and the right to protection against hazardous
products, and to religious freedom, equal protection
clause, involuntary servitude among others.
It is also contended that the RH Law
threatens conscientious objectors of criminal
prosecution, imprisonment and other forms of
punishment, as it compels medical practitioners: 1]
to refer patients who seek advice on reproductive
health programs to other doctors; and 2] to provide
full and correct information on reproductive health
programs and service, although it is against their
religious beliefs and convictions.
Records of the Constitutional Convention
also shed light on the intention of the Framers
regarding the term “conception” used in Section 12
Article of the Constitution. From their deliberations,
it clearly refers to the moment of “fertilization.”
From the deliberations, it is apparent that
the Framers of the Constitution emphasized that
the State shall provide equal protection to both the
mother and the unborn child from the earliest
opportunity of life, that is, upon fertilization or upon
the union of the male sperm and the female ovum.
It is also apparent is that the Framers of the
Constitution intended that to prohibit Congress from
enacting measures that would allow it determine
when life begins.
Conversely, contraceptives that actually
prevent the union of the male sperm and the female
ovum, and those that similarly take action prior to
fertilization should be deemed non-abortive, and
thus, constitutionally permissible.
A component to the right to life is the
constitutional right to health. In this regard, the
Constitution is replete with provisions protecting
and promoting the right to health.
Section 15, Article II of the Constitution provides:
Section 15. The State shall protect and promote the
right to health of the people and instill health
consciousness among them.
A portion of Article XIII also specifically provides for
the States’ duty to provide for the health of the
people, viz:
Section 11. The State shall adopt an integrated and
comprehensive approach to health development
which shall endeavour to make essential goods,
health and other social services available to all the
people at affordable cost. There shall be priority for
the needs of the underprivileged, sick, elderly,
disabled, women, and children. The State shall
endeavour to provide free medical care to paupers.
ARTICLE 13
- Section 12. The State shall establish and
maintain an effective food and drug
regulatory system and undertake
appropriate health, manpower development,
and research, responsiveness to the
country’s health needs and problems.
- Section 13. The State shall establish a
special agency for disabled person for their
rehabilitation, self-development, and self-
reliance, and their integration to the
mainstream society.
Finally, Section 9, Article XVI provides:
Section 9. The State shall protect consumers from
trade malpractices and from sunstandard or
hazardous products. [these provisions are self-
executing] [don’t need a law to implement them]
The OSG counters that the redention of pro
bono services envisioned in Section 17 can hardly
be considered as forced labor analogous to slavery,
as reproductive health care service providers have
the discretion as to the manner and time of giving
pro bono services. Moreover, the OSG points out
that the imposition is within the powers of the
government, the accreditation of medical
practitioners with Phil Health being a privilege and
not a right.
SUPREME COURT
- The point of the OSG is well-taken.
- It should first be mentioned that the practice
of medicine is undeniably imbued with
public interest that it is both a power and a
duty of the State to control and regulate it in
order to protect and promote the public
welfare. Like the legal profession, the
practice of medicine is not a right but a
privileged burdened with conditions as it
directly involves the very lives of the people.
A fortiori, this power includes the power of
Congress to prescribe the qualification for
the practice of professions or trades which
affect the public welfare, the public health,
the public morals, and the public safety; and
to regulate or control such professions or
trades, even to the point of revoking such
right altogether.
- Moreover, as some petitioners put it, the
notion of involuntary servitude connotes the
presence of force, threats, intimidation or
other similar means of coercion and
compulsion. A reading of the assailed
provision, however, reveals that it only
encourages private and non-government
reproductive healthcare service providers to
render pro bona service. Other than non-
accreditation with Phil Health, no penalty is
imposed should they choose to do
otherwise.
- While the rendering of such service was
made a prerequisite to accreditation with
PhilHealth, the court does not consider the
same to be an unreasonable burden, but
rather, a necessary incentive imposed by
Congress in the furtherance of a perceived
legitimate state interest.
- Consistent with what the Court had earlier
discussed, however, it should be
emphasized that conscientious objectors
are exempt from this provision as long as
their religious beliefs and convictions do not
allow them to render reproductive health
service, pro bona or otherwise.
 - At any rate, as earlier expounded, the RH
Law does not sanction the taking away of
life. It does not allow abortion in any shape
or form. It only seeks to enhance the
population control program of the
government providing information and
making non-abortifacient contraceptives nire
readily available to the public, especially to
the poor.
RH Law is CONSTITUTIONAL
Wherefore, the petitions are PARTIALLY
GRANTED. Accordingly, the Court declares RA No.
10354 as NOT UNCONSTITUTIONAL except with
respect to the following provisions which are
declared UNCONSTITUTIONAL.
SOME PROVISIONS ARE UNCONSTITUTIONAL
(STRUCK DOWN)
For example:
[1] Section 7 and the corresponding provision in the
RH-IRR insofar as they: a) require private health
facilities and non-maternity specialty hospitals and
hospitals owned and operated by religious group to
refer patients, not in an emergency or life-
threatening case, as defined under Republic Act
No. 8344, to another health facility which is
conveniently accessible [jig: so, if case is not
emergency, don’t have to refer for family planning]
And b) allow minor-parents or minors who have
suffered a miscarriage access to modern methods
of family planning without written consent from their
parent or guardians
[jig: meaning minor-parents or minors who have
suffered miscarriage cannot have access to
modern methods [surgery] of family planning
without written consent from their
parents/guardians]
[2] Section 23 (a) (I) and the corresponding
provision in the RH – IRR, particularly Section 5 .24
thereof, insofar as they punish any healthcare
service provider who fails and or refuses to
disseminate information regarding programs and
services on reproductive health regardless of his or
her religious beliefs [jig: this allows for religious
objectors]
[3] Section 23 (a) (2) (i) and the corresponding
provision in the RH – IRR insofar as they allow a
married individual, not in an emergency or life-
threatening case, as defined under Republic Act
No. 8344, to undergo reproductive health
procedures without the consent of the spouse [jig:
married individuals still needs the consent of the
spouse to undergo reproductive health procedures,
unless it is an emergency or life-threatening case,
as defined under RA 8344]
[4] Section 23 (a)(2)(ii) and the corresponding
provision in the RH – IRR insofar as they limit the
requirement of parental consent only to elective
surgical procedures. [jig: parental consent needed
for all surgical procedure]
[5] Section 23 (a) (3) and the corresponding
provision in the RH – IRR, particularly Section 5 .24
thereof, insofar as they punish any healthcare
service provider who fails and or refuses to refer
patient not in an emergency or life-threatening
case, as defined under Republic Act No. 8344, to
another health care service provider within the
same facility or one which is conveniently
accessible regardless of his/her religious beliefs;
[jig: religious objectors don’t have to refer]
[6] Section 23 (b) and the corresponding provision
in the RH – IRR, particularly Section 5.24 thereof,
insofar as they punish any public officer who
refuses to support reproductive health programs or
shall do any act that hinders the full implementation
of a reproductive health program, regardless of his
or her religious beliefs [jig: this allows for religious
objectors]
[7] Section 17 and the corresponding provision in
the RH – IRR regarding the rendering of pro bona
reproductive health service in so far as they affect
the conscientious objector in securing PhilHealth
accreditation; and [jig: religious objectors don’t
have to render pro bono reproductive health
service]
[8] Section 3.0 (a) and Section 3.01 G) of the RH –
IRR, which added the qualifier “primarily” in defining
abortifacients and contraceptives, as they are ultra
vires and, therefore, null and void for contravening
Section 4 (a) of the RH Law and violating Section
12, Article II of the Constitution [jig: this reflects the
Court’s and the law’s stance against abortion]
Section 12, Article 2 of 1987 Philippine Constitution
provides:
The State recognizes the sanctity of family
life ad shall protect and strengthen the family as a
basic autonomous social institution. It shall equally
protect the life od the mother and the life of the
unborn from conception. The natural and primary
right and duty of parents in the rearing of the youth
for civic efficiency and the development of moral
character shall receive the support of the
government.