FUNDAMENTAL CONCEPTS,

PRINCIPLES AND ISSUES IN

BIOETHICS
Revised Edition

JERRY Reb. MANLANGIT, MHA, PhD

2020

Copyright © 2020 - Fr. Jerry Reb. Manlangit, OP, MHA, PhD

ALL RIGHTS RESERVED. No portion of this book may be copied in any form or by any means –
mechanical, graphic, photocopying, electronic or stored in a database or any retrieval system – without
permission from the copyright owner.
Title.
1. Fundamental Concepts, Principles and Issues in BIOETHICS, 2020. 629pp.

Cover design: Fr. Jerry Reb. Manlangit, OP, PhD

Dedication

The highly-esteemed co-laborers

in the Vineyard of the Lord,
My Dominican confrères
and
All my students in
The UST Graduate School
Faculty of Medicine and Surgery
Ecclesiastical Faculties
and Makati Medical Center

In Memoriam
 My beloved parents:
+Rafael Pinal Manlangit
+Merced Rañola Reblora

My siblings:
+Edgardo
+Teresita
+Benjamin

FOREWORD AND ACKNOWLEDGMENTS

This is a newly revised version of the original Bioethics book and it
brings with it essentially the same character as a text and reference book that
can be used by students who embrace the wonder of life sciences, like
medicine, nursing, social work, pharmacy and by other allied health
professions. It can initiate, guide and consequently enrich them through the
lively and wonderful, often controversial world of the discipline of
Bioethics. It can be very useful also to the health practitioners who are
already immersed in the technically and ethically charged profession of
healing. The readers will find useful the rich and intelligent discussions of
bioethical concepts, principles and perennial and current issues and dilemmas
that usually confront health practitioners in educational, health and research
works. Those who encounter problems in these works on a daily basis will
find many enlightening and clarifying insightful views proffered, together
with the rich case studies well illustrated herein and which are considered to
be paramount in making ethical decisions in health care.
The incisive and rational discourse in this book is presumably a
source and repository of ethical knowledge that can be used locally and
globally. This book is a pioneering attempt to offer a compact course in the
subject of Bioethics that will certainly be a source of theoretical and practical
ethical knowledge applicable to all the episodes of one’s biological, moral
and spiritual life. It is especially meaningful to beginners, as it is rendered in
a relatively simple language they can easily understand.
This book is also useful to chaplains, priests and sisters doing
pastoral care services for the sick in hospitals and health care services, as this
will offer good insights on applying ethical principles in order to help
patients and families in their moral problems. This will help resolve the
usually uncomfortable dilemmas that deprive the patients and families of the
comfort and care they need.
This book is also useful to professors and teachers of ethics as
applied to health care. The outline of this book is comprehensive enough to
cover almost the fundamental concepts, principles and issues in Bioethics.
The more special issues will be tackled in the next volume as a sequel to this
book, especially those that touch on contemporary problems regarding human
cloning, death and dying issues, stem cell research, GMO, environment, etc.
The knowledge gained here serves as the basic foundational
framework for understanding the more complicated topics. It has twenty-
eight (28) chapters---the first seven will introduce initially the reader to
important concepts in Bioethics, while the next chapters (8 to 27) will deal
with the important principles and attendant issues of bioethics. Since this
will be applied for e-booking publication, the previous publication of two
volumes are integrated into just one whole book.
The chapters devoted to the concepts, principles and issues delving
on some popular issues like confidentiality, organ donation, contraceptives,
abortion, sexuality and death and dying, etc. have occupied more pages due
to their present controversies.
All of these chapters in the book are provided with case studies to
illustrate the application of concepts and principles in practice and to
demonstrate how they can be used in concrete situations in life sciences.
Every chapter of this book opens up with a gesture of welcome (to
readers), by way of a quotation culled from the Sacred Scriptures that is
either directly or indirectly related to the topic. This adds a spiritual
dimension to a highly rational discussion and engagement as an integral part
of the underlying advocacy of this book.
In all candor, this book works for the advocacy of the dignity
reposed in the great mystery and gift of human life. This is therefore a
humble tribute to human life and its nobility. “Greater love no man has than
to lay his life for his friends.” (Jn. 15:13)
It is hoped that this book will draw great interest among the reading
public and those who want to possess more knowledge about the lively yet
contentious subject and discipline of Bioethics.
Mabuhay and I offer my deepest thanks to those who in one way or
another have been part and parcel in crafting not an “opus magnum” but
simply an “opus humile”.
The following have contributed to the realization of this book. To
each one of them the author owes eternal gratitude:
To my Brothers in the Dominican Order, especially my confrères in
the Philippine Dominican Province who have generously shared with me
invaluable knowledge in Philosophy and Theology, especially Fr. Quirico T.
Pedregosa, OP, Former Provincial; Fr. Virgilio A. Ojoy, OP, STD, who
painstakingly edited the manuscript until he burned his midnight oil; Fr.
Fausto B. Gomez, OP, STD, my mentor, who corrected the manuscript with
all the sacrifice there is to make; Prof. Belen Tanco, PhD, who did a gracious
proofreading and final editing job; Prof. Elena P. Polo, PhD, for reviewing
the manuscript; the family of Wilcy, +Noel and Thea R. Torres, who
graciously support me in so many thousand ways; the Poorest of the Poor,
who serve as instruments of charity and beneficiaries of the scholarship
program through the financial revenues this book will earn; all those who
commended this book through their favorable comments; my family: +Papa
and +Mama, Manoy Ed, +Ate Tita, Manoy Willie, Manoy Dolph, Ben, Niña,
Bem-bem and Bob and their families, who shared in my pains even as they
themselves have to similarly struggle through life. May they be rewarded
with the noble things in life and beyond.
Gratitude is humbly offered to Mama Mary of La Naval and of
Manaoag, the Theotokos, whose maternal love abounds in great generosity.
May she always intercede in our behalf.
 May God, the Sancta Sophia, the divine wisdom and knowledge
enlighten the readers’ hearts and minds so that their dreams be focused only
on the lofty realities in life.
To God in Jesus Christ alone is power and glory!

J. R. Manlangit, OP,
MHA, PhD
N.B.:
In this book, the use of the masculine pronoun “he” or “him” already includes “she” or
“her,” the feminine gender. (The Latin term, “homo” (man, in general) is used here and not the Latin
term, “vir” (man as specific), as the case may be. It should not therefore be understood that “he” or
“him” as used in this book only belongs to the masculine gender and discriminates against its feminine
counterpart. The conscious choice to use the masculine pronouns alone is for readers to reduce
distractions in reading concentration and ensure fluidity in the processing and assimilation of
thoughts. More often than not, the use of “he/she” or “him/her”, him/herself digresses and detours the
mind. With due respect, understanding is hereby requested from the readers.

The names, institutions, events and circumstances mentioned in the case studies are
purely coincidental and are never meant to demean, mock, insult, offend or put anyone/anything in bad
light. Deepest apologies are asked for whatever omission this book may have unintentionally made.

TABLE OF CONTENTS
Page
Dedication iii
In Memoriam iv
Foreword and Acknowledgments v
Table of Contents ix
Prologue xix
Chapter 1 INTRODUCTION: BIOETHICS IN THE
HEALTH PROFESSIONS
Inroads of Bioethics in the Philippines 10
The Purpose and Implications of Bioethical Knowledge 13
The Need for Bioethics in Medical Schools
and other Health Sciences 15
Chapter 2 FUNDAMENTAL CONCEPTS IN BIOETHICS 23
The Concepts of Ethics, Bioethics and Christian
Bioethics 24
The Importance or Significance of Bioethics 26
The Rationale in the Study of Bioethics 27
The Nature of Human Act/s and Act/s of Man 30
The Constituent Elements of the Human
Act 31
The Nature of Morality or Ethics 33
The Sources of Morality/Determinant of Human Acts 33
The Concept of Standards of Morality 39
Nature of Law and Kinds of Law 41
The Standards of Morality/Ethics 47 Following One’s
Conscience 54
The Principle of Well-formed Conscience 57
Case Studies 59
Chapter 3 THE CONCEPT OF FREEDOM 63
Freedom and the Human Act 63
Freewill, Freedom and the Object of Freewill 63
Freedom and Morality 64
Freedom and Responsibility 65
Freedom and the Rule of Law 65
Freedom, Culture and Religion 67
Freedom and Conscientious Objection 68
Case Studies 69
Chapter 4 BIOETHICS AND THE HEALTH
PROFESSIONS 73
Professionalism in Medical Practice: What is it? 75
Core Values of a Medical Professional 79
Other Professional Values of the Medical Professional 82
Professional Fees 86
Challenges to Professionalism of the Health Professions 86
The Inherent Ethical Nature of the Profession of Healing 91
Case Studies 93
Chapter 5 HUMAN DIGNITY: THE GOAL OF
BIOETHICS 97
The Concept of Human Dignity 97
The Theological Bases of Human Dignity 100
Case Studies 104
Chapter 6 LIFE, HEALTH AND DISEASE 109
The Concept Human Life 109
The Beginning of Life, What Scientists Say 112
The Sacred Character of Life 113
Health and Disease 116
Disease and Illness 118
Case Studies 120
Chapter 7 THE PRINCIPLES OF BIOETHICS 125
The Concept of a Principle 125
Categories of the Principles of Bioethics 127
The Interrelatedness of the Principles of Bioethics 129
Hierarchy and Conflicts among the Principles of Bioethics 130
Principles of Bioethics: Bases for Codes of Conduct
for Health Professionals 131
Case Studies 131
Chapter 8 THE PRINCIPLE OF HUMAN DIGNITY 135
The Principle of Human Dignity 136
Maslow’s Hierarchy of Needs: a Re-visit 137
The Case of the Dignity of the Unborn 140
Case Studies 141
Chapter 9 THE PRINCIPLE OF STEWARDSHIP
AND CREATIVITY 145
The Principle of Stewardship and Creativity 146
Stewardship, not Absolute but Shared 147
Case Studies 151
Chapter 10 THE PRINCIPLE OF THE TOTALITY
AND INTEGRITY OF THE HUMAN
PERSON 155
The Principle of the Totality and Integrity
of the Human Person 155
The Case of Cosmetic Surgery: Boon or Bane,
Necessity, Vanity or Insanity 158
The Case of Genital Mutilation 161
Psychological, Social and Occupational Considerations
for Cosmetic Surgery 162
The Case of Transsexual Surgery 163
Sex Reassignment and Requirements 164
Transsexual Surgery and its Ethical Dimension 165
Holy Scriptures and Transsexualism 168
Case Studies 169
Chapter 11 THE PRINCIPLE OF DOUBLE-
EFFECT 175
The Requisite Conditions in the Use of Double-effect 176
The Classic Case of a Surgery on Ectopic Surgery 181
Last Note on the Concept of the Harmful or Evil Effects 184
Case Studies 186

Chapter 12 THE PRINCIPLE OF LEGITIMATE

COOPERATION 191
The Principle of Legitimate Cooperation 192
The Case of Referral to Another Health Provider 195
The Case of a General Hospital and an Abortion Clinic 195
Case Studies 197
Chapter 13 THE PRINCIPLES THAT GUIDE HUMAN
ORGAN DONATION AND
TRANSPLANTATION 203
A Brief History of Organ Transplantation 204
The Principles Underlying the Organ Donation
and Transplantation 206
The Altruistic Nature of both the Donor and Donee 213
The Republic Act 7170 or the Organ Donation Act
 of the Philippines 214
What the Church Teachings Say about Organ Donation 215
On Xenotransplants 216
Case Studies 217
Chapter 14 THE PRINCIPLE OF AUTONOMY OF PATIENTS 223
The Requirements for the Use
of the Principle of Autonomy 225
The Rank of the Value of Autonomy among Western
Countries 232
Case Studies 232
Chapter 15 THE PRINCIPLE OF TRUTH-TELLING
AND PROFESSIONAL
COMMUNICATION 239
The Goal of the Principle of Truth-telling
and Professional Communication 241
Truth-telling in Medical Advertising
(Physicians in Advertisements) 245
Case Studies 248

Chapter 16 THE PRINCIPLE OF CONFIDENTIALITY

AND PRIVACY 255
The Oath of Hippocrates on Confidentiality 256
The Patient Record and the Health Care Professionals 257
The Principle of Confidentiality and Privacy 258
Grave Causes, Reasons for Breaking Confidentiality 261
Case Studies 263
Chapter 17 THE PRINCIPLE OF JUSTICE
IN THE ALLOCATION OF HEALTH CARE RESOURCES
267
Justice in the Mind of St. Thomas Aquinas 268
The 5 M’s of Health Care Resources 268
Paradigms of Health Care Resources Allocation 270
The Principle of Justice in the Allocation of Health
Care Resources 279
Theories of Justice in the Allocation of Health Care
Resources 281
Disregard for Justice in the Allocation of
Health Care Resources 286
Pope John Paul II’s View of the Allocation of
Donated Organs 287
Case Studies 288
Chapter 18 THE PRINCIPLE OF SUBSIDIARITY
OR SOLIDARITY 295
The Principle of Subsidiarity or
Solidarity 295
The Principle of Subsidiarity Concretized
in Health Care 300
Case Studies 302
Chapter 19 THE PRINCIPLES THAT GUIDE RESEARCH
ON HUMAN SUBJECTS 309
The Principles that Guide Research on
Human Subjects 311
The Case of the Tuskegee Syphilis Research 318
The Case of the Willowbrook Research 322
The Hitler’s Nazi Experiment Involving
Human Subjects 324
The Contents of the Experiments 324
The Aftermath of the Nazi Experiment 329
Current Ethical Issues 330
Case Studies 331
Chapter 20 THE PRINCIPLE OF PROFESSIONAL
RELATIONSHIP IN HEALTH CARE 335
The Patient-doctor Relationship 336
The Doctor-colleague Relationship 337
The Ethical Referral System among Health Professionals 339
The Principle of Doctor-patient Relationship 341
The Health Care Professional a
and the Pharmaceutical Industry 342
The Medical Professional Fee 344
Paradigms for Charging Professional Fee 346
Further Wisdom on Professional Relationship 347
Case Studies 348
Chapter 21 THE PRINCIPLE OF MORAL DISCERNMENT 351
The Nature of the Principle of Moral Discernment 351
Making Conscientious Moral Discernment 353
Case Studies 357
Chapter 22 RIGHTS, HUMAN RIGHTS
AND PATIENT RIGHTS 363
The Concept of Human Right 363
An Objective Understanding of the Concept
of Human Right 364
The Moral Bases of Human Right 366
The Right to Life 370
The “Right to Die” 371
The Patient Rights 372
Categories of Patient Rights 372
Corollary Concepts of Patient Rights 375
A Tribute to the Patient 375
The Universal Patients’ Bill of Rights 376
The Rights of the Physician 378
Case Studies 379
Chapter 23 ABORTION AND ITS ETHICAL DIMENSION 385
Clarification of Terminologies 385
Methods of Abortion 387
A Brief History and Complexity of Abortion 389
Motivations for the Legalization of Abortion by Pro-Choice 390
Consequences of the Ideology of Abortion 395
Refutations of Abortion Arguments by Pro-Life 397
Good News in the Aftermath of Abortion
around the World 410
Some Famous Abortion Cases/Issues in Modern History 414
Ethical Assessment of the US Supreme 419
The Aftermath: Who is Roe in Roe vs. Wade? 420
The Malthusian Theory: The Culprit of it All 430
Setting the Value of the Unborn Person vs. Abortion 431
Postscript to the Moral Repugnance of Abortion 432
Case Studies 435
Chapter 24 THE PRINCIPLE OF HUMAN
CREATIVE SEXUALITY 441
Distinction and Clarification of Concepts 441
Fundamental, Divine and Anthropological Truths
about Sexuality in Genesis 443
Sex, a Natural and Supernatural Desire for Intimacy 445
Basic Values Recognized Human Sexuality 447
The Principle of Human Creative Sexuality 449
The Destructive Views and Perverted Practices
of the Gift of Sexuality 451
The Celebrated Case of Baby M. 454
A Brief Legal and Ethical Assessment of Surrogacy 455
Artificial Birth Control (ABC) or Contraceptive Methods 455
The RU-486 Morning after Pill and how it Works 457
Why Artificial Birth Control Methods
are Frowned upon as Immoral 458
The Natural Family Planning, the Alternative to
Contraceptives 459
The Case of Transgender and Transsexual Persons 460
The Catholic Church’s Stand and Humane Vitae 462
Sex Education with or without Values 465
The How of Sex Education 467
The Case of the Sexual Revolution of 1820’s 469
The Predictive Nexus/Link between Contraception
and Abortion 491
Sexuality and Responsibility 473
Case Studies 475
Chapter 25 THE BIOETHICS OF DEATH AND DYING 481
The Controversies in the Care of the Terminally-ill 481
The Need for Clarification of Values in the Face
of Death and Dying 483
Goals Assigned to Medicine 485
The Concepts of Euthanasia, Dysthanasia and
Orthothanasia 486
A Historical Brief about Euthanasia 487
Categories of Terminal Illness 489
The Concept of Fatal Pathology 490
The Concept of Ordinary and Extraordinary Means of
Sustaining Life 492
The “Ordinariness” of Nutrition, Hydration
and Respiration 494
The Patient’s Living Will and Advance Directives 496
The Case of the Cardio Pulmonary Resuscitation (CPR)
and Do Not Resuscitate (DNR) Order 497
The Three Celebrated Cases of Quinlan, Cruzan and
Schiavo 501
The Case of the Patient-Assisted Suicide (PAS) 506
The Ethical Dimension of Patient-Assisted Suicide 509
Important Notes to Ponder 510
Brief Answers to the Questions Posed Above 510
The Stages in the Dying Process 513
Case Studies 518
Chapter 26 BIOETHICS OF SUFFERING
AND THE MYSTERY OF DEATH 521
The Nature of Pain and Suffering 521
The Necessity of Suffering and its Value 523
Why does Man Die? 525
What is Death? 526
A Poem about the Mystery of Death 530
Final but not “Dead” Remarks 531
Case Studies 532
Chapter 27 THE MEDICAL DIMENSIONS AND VIRTUES
OF HEALTH PROFESSIONALS 535
The Medical Dimensions and Corresponding Virtues
of the Health Professional 536
Case Studies 541
Chapter 28 THE BIOETHICS COMMITTEE 545
The (General) Functions of the Bioethics Committee 548
The Members of the Bioethics Committee 550
The International Bioethics Committee (IBC) 551
Decision-Making in Bioethics Committee
and Justification Tips 553
Case Questions 555
EPILOGUE 557
Last Word of Exhortation and Caution 559
A Prayer 563
SELECTED REFERENCES 565
APPENDICES 575
Appendix I THE OATH OF
HIPPOCRATES 575
Appendix II THE INTERNATIONAL CODE OF ETHICS 577
Appendix III THE DECLARATION OF GENEVA 580
Appendix IV THE DECLARATION OF
HELSINKI 581
Appendix V THE NUREMBERG CODE 587
Appendix VI THE CODE OF MEDICAL ETHICS
IN THE
PHILIPPINES 589
Appendix VII THE FLORENCE OF NIGHTINGALE
PLEDGE 604
Appendix VIII PRAYER OF A
PHYSICIAN 605
What the experts say . . .
606
About the Author Back Cover
 PROLOGUE
The saint Pope John Paul II throughout in his papacy and especially
in his encyclical letter Evangelium Vitae has strongly denounced an
appalling global conspiracy against human life. In his pronouncement, he has
courageously unraveled such evil scheme as much as he unequivocally
spelled out its execution in a massive scale around the world involving rich
nations with their billionaire citizens with the view to global domination that
will preside on population control through contraceptives, abortifacients and
many other procedures with the willing assistance of the government. No
wonder, for the immediate several decades, these rich nations, mostly of the
west, have been mobilizing all ways and means at their disposal to
systematically alter world view by radically destroying values esteemed
traditionally sacred by civilized men and women. Politics, science,
economics, technology and media are being used as weapons to betray and
trample upon the sanctity and dignity of human life. Even unsuspecting
educational institutions have not been spared nor insulated from them by
making funds available for them to be used for teaching the young to be
promiscuous, amoral and care-free and finally reject the value of life. Indeed,
this new imperialism seeks nothing but to subdue life, hegemonize third
world countries and divert their destiny with the view to trampling them
underfoot. It comes not as a surprise that artificial contraceptives and
abortifacient technologies and other scientific means have proliferated in
unprecedented proportions in the name of implausible reasons and disguises.
Even science and medicine that must be at the service of humanity have
become disciplines without regard for the intrinsic dignity and inalienable
rights of persons and their destiny. Constant brainwashing of the young in
schools has never seen such intensity as the current dispensation.
It is enough that these schemes should send discomforting shivers
and tremors to any men and women of goodwill. Whether we like it or not,
these new imperialists are slowly but gradually reaping the fruits of what they
have sown decades ago. Anti-life ideologies have been reigning unrestrained
in all for and media. Values have changed radically. What before was
considered murder of the innocent is now called “reproductive rights” or
more specifically, “women’s rights”. What before was a repugnant and
perverted gay relationship is now called “new and alternative lifestyle”.
What before was simply called abortion is now called “women’s sexual
freedom or human development”. Unarguably, nobility and virtue, though
considered ideals have been consigned to children’s books and have not been
palatable topics for discussions in scientific fora or even in coffee breaks.
This ungodly imperialism and liberalism had understood well
enough that the only way to “kill” God was to change people’s beliefs and
values. Supposing that he can turn in his grave, Friedrick Nietsche must have
realized that ideas alone cannot do it. A different route was more efficient.
Thus, the most efficient way to “kill” God is to destroy men and their moral
values as civilized beings. Nevertheless, when men lose their sense of right
and wrong they destroy what is noble and sane in them. When this happens,
the tragedy can augur well towards a new history – the “final death of God.”
It should still give us comfort in knowing that not everything is
lost. Neither is the war against distorted and convoluted ideas about human
life a lost cause. Indeed, in spite of the many distortions waged against it,
one can have assurance in knowing that still a multitude of people of
goodwill have not really lost their sense of right and wrong, and are apt to
continuously dedicate themselves to the cause of the dignity of human life.
The path to moral knowledge is narrow, arduous and demanding. But this
should never be a reason to simply shirk, surrender and quit. As children
born in the image and likeness of God, there is no place for a loose brick in
God’s edifice. We are all essential part of it.
The revised edition of this book has been done after ten (10) years.
Many developments and evolutions of ideas on the concepts, principles and
issues in Bioethics have arisen and need to be responded to. There had been
significant additions to the previous edition and must be articulated as they
are owed to the lovers of Bioethics. Photos have also been added to add
more diversion and neutralize monotony of bland pages. Welcome to the
newly revised edition.
 Chapter 1
Your word is a lamp for my steps
and a light for my path.
Ps. 119:105

INTRODUCTION:
BIOETHICS IN THE HEALTH PROFESSION

alk about controversies and

conflicts in any professional discipline and one will immediately
expect to find them relentlessly in the field of Ethics. Whether or not
Ethics is mired under the purview of politics, economics, religion, and
the like, it should not come as a surprise that Ethics is familiarly
ubiquitous and cannot simply be ignored because Ethics is concerned
and interested in human behaviors that are basically subject to the
determination of judgment of right or wrong, reward or punishment,
virtue or vice. It is to anyone’s awareness that any human behavior
that is performed under or with knowledge, freedom and
voluntariness, is within the ambit of moral or ethical judgment. It is
for this reason why no human act escapes Ethics. This discipline is
extensively far-reaching due to its sphere of relevance and
significance. Since political, economic or religious acts are human
acts, they are subject to the long arm of Ethics. For indeed, by the
time a person under the age of reason wakes up in the morning until
he goes to bed at night, and then does the same ritual all over again,
all his actions, be they big or small, are subjected to the determination
(or in usual sense) of good or evil, right or wrong.
Indeed, Ethics is not without controversies and conflicts
because nothing is certainly absolute and definite under any human
judgment. Humans that we are, we are essentially flawed from many
angles and can commit errors or mistakes consciously or
unconsciously. And even if we feel we are right, we cannot escape
criticism and questioning. It behooves us then that the facts of the
case have to be considered in the debate in order to have basis to
make a genuine and true judgment. It is for this reason why we
should educate or train our conscience or sense of judgment and not
just theoretically know what should or should not guide us.
Definitely, we must be educated in virtue so that we can act with ease,
competence and confidence. It is only in this way that we can
habitually act well and reduce mistakes and errors in all our human
struggles. It is imperative that in any endeavor and undertaking, we
must be aware of any human weakness and limitation that can hamper
even our most candid and purest acts and intentions. For there are
apparent “good” that are actually evil. To choose that “good” will
therefore be a tragedy and disaster. Wisdom is the better part of valor
in the arena of human behaviors. It is a part of human wisdom that
knowledge of Ethics, no matter how human and limited, is very
essential and should aid us well in our pursuit for perfection,
happiness and satisfaction as humans.
Knowledge is always an advantage. He who knows well
reduces mistakes and errors well, let alone abet rightness and
correctness. He who lacks knowledge makes more mistakes and
errors. And when one possesses knowledge, he possesses a base of
power. He becomes more powerful than those who have none. Even
great military leaders rely well on those who are knowledgeable in
war and combat. The same can be said in any human endeavor like
politics, economics or religion or any human industry. In this case,
one who possesses knowledge in Ethics possesses the base of power.
He can have more edge than others. Such is the case of knowledge in
the practice of Medicine, more so when he possesses Ethics besides
having the technical knowledge of it.

The
years 2003 and 2004 have never been more controversial and
contentious in the history of modern medicine in the Philippines than
they were in recent memory, especially for its medical practitioners
and their allied professionals. At the core and height of this
controversy and contention is the House Bill No. 4955, being
introduced, entitled, “An Act Punishing the Malpractice of Any
Medical Practitioner in the Philippines and for Other Purposes.”
This bill had actually been languishing in the House of
Representatives since 1992, but it had suddenly resurrected to life in
2004, and espoused by certain influential broadcast journalists and
politicians, and reportedly by insurance companies believed to make a
killing in the health insurance business known as Health
Maintenance Organization (HMO). Furthermore, in 2008, House
Bill 5043, on Reproductive Health was introduced to force the
government and unsuspecting citizens to submit to the so-called
“reproductive rights” and which do not mince words by threatening to
imprison anyone, including doctors and other health professionals
who would oppose its provisions by way of conscientious objection,
even at the prospect of restraining the constitutional provision of
freedom of speech and the conscientious objection based on moral
and religious beliefs.
 Going back to the House Bill 4955, the medical practitioners
and their allied health professionals raised protracted howls of
protests as this bill they believed, would adversely affect their
practice or the profession of medicine. Allegedly, this bill threatens
to destroy the very nature and basic element in the doctor-patient
relationship anchored on mutual trust. Furthermore, the practitioners
charged that the said bill, if enacted, would also usher in an era of
“defensive medicine” which those in the profession believe is never a
good (practice of) medicine at all. Further, this bill will unnecessarily
drive a wedge between the health professional and the patient, whose
relationship should be fundamentally characterized by mutual trust
and cooperation. Sadly, this bill may even make the health
professionals’ conscience or conscientious objection irrelevant. In
addition, this bill, according to many doctors who intimated their
apprehensions, if legislated, would deprive thousands of medical and
allied professionals of their basic constitutional right to Equal
Protection of Law and violate the constitutional provision on Double
Jeopardy, as any person, not directly involved could harass the
medical practitioner with a legal suit, even if the patient’s family does
not want to do so. As if these were not enough, any medical or allied
personnel, if found guilty, would be punished by prision mayor, the
cancellation of the license to practice the medical and allied
profession and a fine ranging from Five Hundred Thousand Pesos
(PhP500,000) to One Million Pesos (Php1,000,000). Many other
reasons had been advanced and even saw relentless broadcast (both
pro and con) in the tri-media, as well as, in the ubiquitous social
media and in many conferences. In the meantime, lobbying activities
became the order of the day among the doctors and these were
expected to last a long time. Fortunately or unfortunately, heated
debates were there to stay and it is not about to end soon.
On the other hand, it cannot be denied that scores of patients
have really suffered injuries, loss of limbs, disabilities and death, in
the hands of medical or allied professionals, due to negligence and/or
malpractice, although not too many of the culprit land in the courts of
law or have been punished with incarceration or other penalties. This
may be due to the patients’ ignorance of their rights, or because some
chose for extra-judicial settlement, usually in terms of monetary
indemnity or compensation, rather than go through the rigors and
headaches of long drawn court battles that are, sadly, very
characteristic of the Philippine judicial system.

Historically, this bill became unpopular and has not been passed into
law either because not too many people were eager to push for its
passage or due to the unanticipated shortage of time in the 12th
Congress that ended in the year 2004. Even in 2006, the bill
continued to be in hiatus. And it is already 2020, it is still there and
just lies there. No one knows if this will prosper soon enough.
The rift between the advocates of this bill spearheaded on one
side by a popular broadcast journalist who was backed-up by a few
legislators and, on the other side, the medical practitioners and their
allies led into an impasse. To date, their relationship has stagnated
and has not gone any better. As a matter of fact, there have been
some plans in the current Congress to re-file and resurrect this bill
along with bills that are deemed prejudicial to medical practitioners.
One can therefore expect more stinging debates in the media and
other volatile scenes in our social milieu in the years ahead. In the
meantime, the advocates of the bill have to search for sponsors in the
House of Representatives. Moreover, they will have to use
propaganda outfits that could double their time and energy, if only to
gain popularity and publicity mileage, for the advocates and their
cause.
Why should a legal problem of this sort in medicine and its
allied profession come to this point? There are varied reasons. The
medical professionals have reasons to oppose the bill. Those who
have been victims of medical malpractice and negligence have also an
axe to grind, hence the introduction of the bill. We can understand
both parties in their predicament as charges in violation of the bill are
serious, and enough to enable felons to lose freedom through
incarceration, or their occupation ended, not to mention the expensive
monetary implications. One of the important things that we have to
consider is the fact that, in many instances, a legal problem in medical
practice begins with an ethical or moral problem. No medico-legal
problem starts on a purely legal angle. It has always at its root some
ethical or moral basis. It is for this reason that it is essential to take a
critical look at the very cause of the legal problem.
While it is true that a legal problem starts with an ethical
problem, it is also true that a moral problem becomes even worse
when it looks only for a legal solution. Let us take heed of what a
noted American Bioethicist, Kevin D. O’Rourke (1994) has to say:
Avoid at all costs the dominance of law and the
courts as the forum for ethical debate. Sending ethical
cases to the courts for decisions has been catastrophic
in the United States. In the first place, the courts
usually use the wrong principle for their decisions,
and secondly, lawyers seek to apply these decisions in
a legalistic manner that oppresses people experiencing
the same dilemma. Hopefully, there will be more
cultural cooperation in bioethics which will lead to a
more humane and compassionate practice of medicine.
In other words, to allow the law and judiciary to take care
of people’s health is a tragedy. It is unimaginable in fact to allow law
and judiciary alone to be the presiders over the life and health of
people, let alone generate jurisprudence from them. What is the
meaning of the discipline and science of medicine if these issues end
up in the courts of law?

However, contrary to diverse opinions, it is not true that

medicine has nothing to do with ethics. A good physician is an
ethical physician. An ethical physician respects the nobility of his
profession, as a legitimate way of practicing the art and science of
medicine meant primarily to alleviate pain and suffering and accord
comfort to those whose body and mind are in a discomforting
condition. Moreover, even if a physician practices medicine in a legal
way, but is found wanting in the ethical requirements of the practice
of medicine, he would always fall short of what is expected by those
who entrust their lives to him. As it has been popularly said, an
ethical physician is likely to avoid a legal problem. If only physicians
are really ethical and full of compassion, they would not need
insurance policies, or happily, should not fear lawsuits. Indeed, a
legal problem always begins with an ethical problem. A doctor
who does not feel inhibited by spending for and sending flowers to a
patient will save thousands of pesos for malpractice insurance fees.
An ethical or unethical physician is not created overnight. An
ethical physician happens after some long and arduous study and
assimilation in time of the values that are attendant to his profession.
For the knowledge and practice of one’s profession, on the one hand,
entail substantial disposal of time, energy, commitment and devotion
to engrain valuable elements of ethics, character and probity in one’s
human life and activities. On the other hand, an unethical physician
becomes personified due to a long protracted ignorance and contempt
for ethical values. He practices as if medicine is but a technical job
that can stand alone by itself, even when bereft of moral dimension.
However, it is worth noting that “a doctor without ethics is a mere
technician. A doctor with ethics is properly called a physician.” A
physician is one who is an expert of the essence on the physical
nature (physica), especially life, hence the term, physician. Who
could be more expert about the nature of life than a physician whose
life is spent in the understanding of the human body, including the
embodied mental capacity? Properly, a physician is an expert on the
nature of life, hence he is deemed well-founded on the knowledge of
biology, the science of life. A doctor therefore is a biologist, an
expert in the science of life. And since he is not just a technician but
a physician, he must necessarily be grounded in Bioethics, which is
the ethics of life, including the many life issues correlated and
attendant to it. Ashley and O’Rourke (1999) have emphasized the
interconnectedness between the technical and ethical aspects of
medicine when they succinctly stated, “Healthcare professionals have
the knowledge and skill to make technical decisions, but every
healthcare decision involves human needs and human values that are
subject to choice. Therefore, health caring is also an ethical decision
and is fraught of deontology towards his fellows.”
In view of the above, Fr. Jerry R. Manlangit, OP, PhD, echoed
in his address to the fellows of American Surgeons in 2003, Manila
Garden Hotel and the Philippine Private Hospital Association in
Manila Hotel (2006) and firmly emphasized (an anonymous
proposition) that “a grocery man who refuses free food to the hungry
is normally not denounced. The builder does not deserve scorn by
failing to give shelter to the homeless. The tailor is not normally
expected to give away clothes to those who have none and he is not
detested for it. A car manufacturer does not earn derision for not
offering a ride to the commuters. But if a doctor turns away a sick
person for any reason, especially if he has no money, he is highly
reviled and denounced. It should stand to reason, that when he sees
someone in pain or suffering on the road, he does not walk away
from him but stands by for him, be he unknown or an enemy.” This
is so because the profession of medicine is essentially ethical and
characterized by deontological imperatives and oftentimes
persuasions.
Be that as it may, it is important that a doctor must have spent
time in the study and practice of bioethics as an important dimension
of the profession of medicine. Unarguably therefore, since bioethics is
considered conditio-sine-qua-non in the whole spectrum of the
practice of medicine, all of the medical curriculum must include some
courses or unit-loads as requirements for anyone who wishes to
practice the same, more so when its loci are the health care
organizations like hospitals, where human health care resources are
necessarily at the helm. It is here that they can be initiated and
introduced to the essentials of bioethical concepts, principles and
values that they will find very significant and useful in the application
of the art and science of healing of humanity. As early as they can,
medical students must be able to acquire bioethical knowledge, both
theoretical and practical, so that in due time, they would become
accomplished physicians and not just technicians of an ailing human
body and mind. This becomes more significant when one considers
that in the future, they will be working in human organizations, like
the private or public health care facilities which, whether they love it
or not, are abounding in human resources that are essentially gifted
with dignity.
Inroads of Bioethics in the Philippines. Since the 1990’s in the
Philippines, it has been observed that there has been an unusually
marked increase and heightened interest and need for Bioethics
expertise in the health sciences, particularly in medicine, nursing,
pharmacy and physical therapy, including the use of health care
facilities. Moreover, people especially patients have become more
and more conscious and aware of their patient rights and privileges,
and they clamor for quality health care, that is effective, safe, reliable,
affordable, accessible, and above all, ethical. Parallel to this, there
had been a marked enthusiasm by other parties, who are equally
interested in health care. Herein, we can include the HMOs,
judiciary, public health and other health advocates for women and
children, in both private and public sectors. Indeed, the increase in
ethical problems involving malpractice and negligence by doctors
abetted an increase in patients’ demands for bioethics knowledge and
expertise.
The unusual rise and voluminous complaints lodged before the
Philippine Regulation Commission (PRC) and the Philippine Medical
Association, currently and in recent past, not to mention the lawsuits
pressed by patients in the courts of law, against medical practitioners
and other health care givers are sure examples of the paucity of
knowledge in Bioethics among the medical practitioners, as well as
patients. This is a clarion call for ethical direction. convergence of
these various elements have factored in many and complex problems
and apparent disarray in medical practice in the recent decade. This
explains why a marked desire for knowledge in Bioethics has become
discernibly manifested today. It is for this distinct reason that many
doctors and health professionals have demonstrated interest in
Bioethics by attending post-graduate courses, medico-moral
conferences, Bioethics training modules and other varied continuing
medical education (CME) courses. This is certainly a manifest
expression that good medicine includes essentially ethical medicine.
For both medicine and ethics aim at the overall well-being of
persons. This should give credence to the fact that man (the patient)
is not only a biological being, but a moral being himself, let alone a
spiritual one. The intrinsic connection between medicine and ethics is
a conditio-sine-qua-non in the healing/curing of patients. Moreover,
as Kevin D. O’Rourke, OP (1994 in his article, “Bioethics Today” in
Bioethics: A Growing Concern, Bioethics Forum 1, inferred,
“though medicine concentrates more on the physiological and
psychological well-being of the patient, it does not abstract from or
ignore the social and creative aspects of the patient. Good
physiological function usually makes it possible for a person to
pursue the other goods of life which lead to human fulfillment.” For a
person (including patients and doctors) to realize these goods, it
necessitates a good knowledge with ethical dimension.

At present, there
is paucity and insufficiency of database of ethical knowledge among
medical and health practitioners, despite the many grand rounds and
conferences they conduct that includes ethics in diagnostic and
therapeutic practices. The various bioethical conferences this author
has given as a lecturer, has in fact brought him not only around the
Philippines but also to foreign countries. Naturally, it is presumed
that this observed lack of ethical knowledge data base among medical
practitioners is also true with medical students. Who will inculcate to
them such knowledge if the very mentors themselves, as the dearth of
literature attest, do not have sufficient competence in Bioethics that
medical students need to acquire and apply? And how can students
become competent, if they themselves have not been taught?
As noted, Bioethics or medical ethics in the Philippines is
relatively a new discipline. The recognition of its importance in the
medical field came only in the late 80’s in the United States and
cascaded around the world including the Philippines in the early
90’s. It can be said however, that there had been many early attempts
to introduce ethics in the medical school, but it was only in the late
80’s and early 90’s that its popularity rose to unprecedented
proportions and this was due to many factors that arose during those
periods, such as, new and modern technologies, modalities and
methodologies coupled with new discoveries and researches in the
medical sciences that revolutionized medical diagnostic and
therapeutic procedures, modalities and techniques. It can be added
that the many legal implications in the practice of medicine
compounded such demand for more inputs from Bioethics. As a
result, more and more are becoming aware of the significance or
importance of Bioethics in the field of medicine. Given such, one can
say that Bioethics is here to stay.
Unfortunately, because this discipline of bioethics is relatively
new, knowledge of bioethics in the Philippines, especially in the
medical schools is also fledgling, not only among the students, but
also among the present medical practitioners. This can be readily and
obviously observed in the many fora and postgraduate courses in
bioethics that have been conducted in the recent past. Well expressed
demands for more lectures and conferences have steadily been rising.
Many hospitals and medical societies in Metro Manila and in many
parts of the country include topics in Bioethics in many of their
scientific meetings. Moreover, there are now initial moves by the
Commission on Higher Education (CHED) to include Bioethics not
only as a regular part of the medical curriculum, but also as
permanent component of the medical board licensure examinations.
The dearth of bioethical baseline data among medical students,
medical and allied health practitioners cannot be overemphasized.
The medical profession or medical schools in the Philippines cannot
be completely faulted for this because the discipline of Bioethics is
matter-of-factly still in the infancy stage of development in the
country, but it is gaining ground and is become more mature.
The Purpose and Implications of Bioethical Knowledge. This
book aims at encouraging those concerned especially, the health
professionals and patients to give importance to the study and
application of Bioethics as the knowledge gained here will contribute
substantially to the holistic care of patients and their significant
others.
While it is greatly important to imbue the knowledge of
Bioethics to students and health professionals, it is also of paramount
importance to know how this knowledge will affect their future or
current professional practice as important human resources in health
care organizations. It is significant as it is obvious, that those who
have more ethical knowledge related to their brand of professional
practice do have more edge and advantage over those who have
none. It cannot be denied that those who excel in the workplace, be it
locally or globally, are those who possess more of such knowledge.
Peter Drucker, the modern management guru, has intimated this
thought a couple of decades ago. This is all the more true in the
practice of medicine because, medicine’s purpose is not only to cure
an organ or component of the human body, not even solely his
diseased physical attributes, but the totality of the patient’s
personhood, including his or her mental and even spiritual well-
being. Needless to say, the practice of healing in this aspect includes
the environment or the health care infrastructure, in which the
physician practices his craft. This is where one understands why
“health” is foremost in the minds of those who have been entrusted by
the society to take care of their dear lives. The term, health, comes
from the French word, “hal”, meaning, “sound” or “whole”. In
other words, the sole object of medicine is soundness or wholeness of
the person in his or her physical, social, moral and spiritual well-
being. Thus, when a person is pained, handicapped or is
incapacitated in his potentialities or his activities due to illness, injury
or the like, it is the avowed duty of the doctor to help restore the
patient to that original state or to a condition that approximates it, by
way of scientifically accepted therapy, so that he can be integrated
back to the human society in which he belongs. Thus, it can now be
inferred that those who will excel in the practice of medicine are those
who are equipped with those capacities, capabilities or qualities that
can offer assistance and fulfill the human needs of the person as
individuals and as members of the human society. Corollary to this,
it can be said that those who are found outstanding, effective and
efficient in the care of patients are those who are both technical and
ethical in ethos and praxis.

Philosophically,
“bonum est diffusivum sui,” that is, “good is self-diffusive”. Since
knowledge is good, nature has its distinct way of diffusing or
disposing it to where it is beneficially good and to which it is in
homeostasis. In the same fashion, those who have this knowledge
will eventually diffuse it in many a varied way that will benefit those
who can avail of it. Needless to say, the ethical knowledge that one
possesses will surely have implications on the profession or practice
of medicine, as well as, on the health environment.
Sad to say, the tragic debacles in the practice or malpractice in
medicine would not have happened if Bioethics has occupied central
importance and significance in many of the health care professionals’
activities. The many experimentations involving human subjects
without regard for human dignity perpetrated by Hitler, Willowbrook
research, and the Tuskeegee syphilis experiment could not have ended
in fiasco if Bioethics were considered an inherent pillar of medical
research. The same can be said about the misfortunes that befell on
Roe v. Wade, Doe v. Bolton, Karen Quinlan, Nancy Cruzan and Terri
Schiavo cases. The recent health related ethical breaches that
happened in the country could not have become a national shame if
Bioethics has been regarded as an essential dimension of health
practice, especially in the likes of the cheating disaster in the 2007
national nursing board exam, the 2008 canister scandal through kinky
sex in a Cebu hospital, the botched surgery on a sex organ in a
reputable hospital in Metro-Manila and many other malpractice suits
litigated in the courts of law. If health care has to gain the full trust
of the society which gives health practitioners the power to practice
their trade then, Bioethics must be the single attribute that must be
always present in every step of

the health professional

activities.
The Need for Bioethics in Medical Schools and other
Health Sciences. As observed, the study or inclusion of Bioethics in
Medicine (and other health professions) is not in any way a new
endeavor. In the Philippines, Bioethics has incisively gotten strong
into the domain of medical education in the 1990’s. Up until now,
stronger gains in terms of ethical awareness or consciousness have
been noted, not only in medical schools, but also among educational
institutions of the allied health care professions. Bioethics has
penetrated, even the non-medical schools, especially in health care
facilities, as hospitals and public health. What with the many
conferences, post-graduate courses and seminars conducted in the
immediate past decade in the country in order to drill in ethical
knowledge into the consciousness of healthcare professionals! This
only emphasized some sad realities in the medical world about the
dearth of ethical knowledge and practice, let alone the many complex
legal conflicts and problems due to medical malpractice and
negligence in the healthcare workplace hurled by unsatisfied patients
and their families. In view of the above, it is well to note that
Bioethics has in recent year’s generated enormous interest not only in
the medical schools but also among the various sectors in the
country. Inclusion of Bioethics in the medical curriculum was as
natural as “discovering a new and effective nutrient for the well-being
of the body.”
Says a noted American bioethicist, Kevin D. O’Rourke, OP
(1994),
Ethics in medicine is not something new.
Indeed, because both medicine and ethics aim at the
overall well-being of persons, they are intrinsically
connected. Though medicine concentrated more on
the physiological and psychological well-being of the
patient, it did not abstract from or ignore the social
and creative aspect of the patient. Good physiological
function usually made it possible for a person to
pursue the other goods of life which lead to human
fulfillment.
This went on without saying that human integration and
fullness included not only the things of the body, but everything that
led to the fulfillment of human needs, including the moral and
spiritual dimensions of the human person.
The need for Bioethics has been observed by a professor of
anatomy at the University of Sto. Tomas Faculty of Medicine and
Surgery, Manila (UST FMS), the late Dr. Natividad E. Santos (1994),
who in her article, “Bioethical Problems in Teaching”, Forum
Bioethics 1, 29-30, acknowledged that “the extreme variations of
values and behavior coupled with democratic space in schools and
hospitals may cause some students to fail in their decisions and
evaluation of what they see and hear.” Further, she affirms that
indeed “there is a need to strongly and firmly instill ethical principles
into the minds of the students, looking for ways and means through
which they would be fully motivated to appreciate the value of
Bioethics. Due to individual differences, they may be allowed to
choose their own way of being moral within the prescribed ethical
norms. With the world becoming complicated over numerous
opinions, brand new ideas, high-strung emotions . . . some may arrive
at ethical decisions that run contrary to what is prescribed.” What
could be worse than making decisions and applying in practice those
that were scandalously unacceptable and unnerving to one’s moral
sensitivity?
An eminent bioethicist, Fr. Fausto B. Gomez, OP) (1994) in
“Bioethics in Medical Education,” Forum in Bioethics 1, 81-9, saw
clearly the reason and the need for Bioethics in medical school, and
he said, “We offer Bioethics to our medical students because it is a
necessary part of medicine; and the physician – every physician –
ought to be an ethical person, a good professional.” Quoting Edmund
Pellegrino (1990), Fr. Gomez continued, “Medicine is an art,
informed both by science and ethics; it applies the knowledge
obtained from science and ethics to the alleviation of suffering, or the
cure, or prevention of human illness.”
Accordingly, most schools of medicine today, at least in the
First World, offer Bioethics to their students and a substantial
proportion of them offer some form of spirituality in medicine. A
Hastings Center Survey (1974), of 107 American medical schools
reported that ninety-seven (97%) of them were teaching medical
ethics in some form. In 1983, a special report published in The New
England Journal of Medicine stated that “formal teaching of ethics
in the medical school curriculum has increased greatly during the past
fifteen (15) years. Yet, schools varied in how much attention they
give the subject, and even those that did offer courses vary
considerably in the form and content of their curricula. Actually,
there is still much to be desired in this area.
In an unequivocal term, Crisp, in 1985 rightly affirmed that
“there is now a consensus in the medical profession that ethics should
be taught to medical students.”
Consequently, as educational institutions, medical schools
must be committed to offer professional training that incorporates as a
conditio-sine-qua-non ethical values and sense of selfless service to
individuals and to society to which it is indebted the privilege and
right to educate. Bioethics therefore must be at the core of such
medical offerings. Medical schools must be charged with connecting
and combining profane sciences with divine truth. Thus, it is must be
charged with the mission of promoting creatively and dynamically
both human and divine values.
The venerable Pope John Paul II (1990) in Ex Corde
Ecclesiae, the Apostolic Constitution on Catholic Universities, has
said:
If, in fact, the Medical Faculty of any
University is institutionally destined to prepare
competent doctors, such as Faculty in Catholic
University, should resolve specifically to have as a
goal the preparation of doctors and health care
workers not only on the human level, but also in view
of, and at the service of, the person’s religious and
transcendent dimension. Hence, in all the Faculties of
Medicine in all Universities efforts should be made to
assure a scientific formation in the light of the
Christian message.
Therefore, Fr. F. B. Gomez (1994) inferred that “we teach
Bioethics to our students from a human and Christian perspective,
respecting always the right of every human being to religious freedom
and freedom from conscience. Pope John Paul II (1990) in
Redemptoris Missio, the Mission of the Redeemer, wrote powerfully,
“the Church addresses people with full respect for their freedom. Her
mission does not restrict freedom but rather promises it. The Church
proposes; she imposes nothing. She respects individuals and cultures,
and she honors the sanctuary of conscience.”
It is noteworthy that since medical practice is ethical practice,
physicians cannot be ethical without having assimilated knowledge of
Bioethics. For him to do that, a formal or even informal training and
education on Bioethics is necessary. Herein, it must be asserted that
indeed Bioethics ought to be an essential part of medical education.
“Medicine,” as Leon R. Kass (1985) said, “is a moral enterprise.”
And “The ought or ethical dimension, is an integral part of the
medical decision,” according to Kevin O’Rourke (1987) in the “Role
of Ethics in Medical Decision Making,” Ethical Decision in Health
Care, 9:3. “Without a correct moral line,” Dr. Gregorio Maranon
(1985) in Vocacion y Etica, wrote, “the best professional is always
bad. Without the moral source, the very technical efficiency of the
profession fades away and disappears. Professional ethics springs
forth from the profession like spontaneous flower.”
The great Protestant moralist Paul Ramsey advised the
physician in this manner thus:
Physicians must in greater measure become
moral philosophers, asking themselves some quite
profound questions about the nature of proper moral
reasoning and how moral dilemmas are rightly to be
resolved. If they do not, the existing medical ethics
will be eroded more and more by what it is alleged
must be done and technically can be done.
 We know
that “Bioethics is concerned with both correct doctrine and correct
practice, i.e., orthodoxy and orthopraxis,” asserted Fr. Gomez
(1994). The great German axiologist, Max Scheler (as quoted by A.
Deeken in Process and Permanence in Ethics, 1974) exclaimed and
questioned himself by saying, “Ethics is a damned bloody affair, and
if it cannot give me direction on how I ought to be and to live in this
social and historical contest – well what meaning does it have then?”
Now we know that to be exemplary physicians, medical
students have to know Bioethics and eventually be ethical. “Why do
we have to be ethical?” Fr. Gomez (1994) inquires, “Because we have
to be human; because a knowledgeable but unethical physician will
not care for long about practicing medicine ethically.”
Consequently, Bioethics tries to help physicians become a
knowledgeable and compassionate professional. Indeed, Fr. Gomez
(1994) continued, “Bioethics ought to be included as a necessary
subject in medical education”.
In the article, “Teaching Medical Ethics: A Review of the
Literature from North American Medical Schools with Emphasis on
Education,” in the Journal of Medicine, Health Care and Law,
2:239-254, D.W. Musick (1999) emphasized the need to formalize
instruction in medical ethics. However, the discipline of medical
ethics education is still searching for an acceptable identity among
North American medical schools; in these schools, no real consensus
exists on its definition. Medical educators are grappling not only with
what to teach (content) in this regard, but also with how to teach
(process) ethics to the physicians of tomorrow.
Further, a literature review focused on medical ethics
education among North American medical schools reveals that
instruction in ethics is considered to be vitally important for medical
students. Agreement by medical educators on a possible “core
curriculum” in ethics should be explored. To develop such a
curriculum, “deliberative curriculum inquiry” by means of a targeted
Delphi technique may be a useful methodology. However, the
literature revealed that medical curricular change is notoriously slow.
General implications for medical ethics education as a discipline are
discussed.
An absolutely marvelous proposition has been intimated by
Dr. Oscar Javier Martinez-Gonzalez in “The Teaching of Bioethics in
Medical Schools,” Instituto de Humanismo en Ciencias de la
Salud, Universidad, Anahuac, Mexico. He declared that:
Ethics cannot be reduced to a mere obligation
or to a duty; or to express what is permitted or
forbidden. It could not be applied merely to suffering,
pain and death, because suffering, pain and death by
themselves, escape from any norm and law.
Physicians must have to turn their clinical and
professional activity into an ethical aspect; not only
because they can relive the pain in their patients, but
because with their help, patients can transform pain
and suffering into a meaning and into a value that
gives them a true meaning.
He continued by asking, “Why should we teach Bioethics in
Medical Schools?” And he frankly answered, “The purpose of
Medicine should always be to fight against illness, to relieve pain and
suffering and to console the patient even if he cannot be healed.
Success cannot become the ultimate and fundamental principle in the
work of physicians, to which the other principles must subordinate.
Ethics should never be subordinated to success. Ethics can
contribute to success but cannot warrant it, because ethics is not
directly related to success, ethics is always related to do good.
As Bioethics teachers in different Medical Schools, we should
try to unify Medicine and Ethics again, in order to fill the gap that
exists today between new technology and forgetting what human
nature is in its essence.
Bioethics emerges as the science that can create a new attitude
in physicians, in order to serve the human being as a whole, with all
the knowledge that mankind has reached” and should enjoy.
Finally, he capped it up by saying, “we need to be simple; we
need to promote family values, because the family is the first
Bioethics school. We also need to have faith in God, if we want to be
good Bioethics teachers.”
It is therefore hoped that being a good Bioethics teacher will
be a solid framework for good medical or health care practice.

Chapter 2
One does not live by bread alone
but by every word that comes forth
from the mouth of God.
Mt. 4:4

FUNDAMENTAL CONCEPTS IN BIOETHICS

t is important that some concepts that are commonly accepted for
I use in the study of Ethics or Bioethics should first be discussed for
proper understanding. These will offer added knowledge and
affirmation to the deposit of accepted knowledge for the beginners
and the already initiated, respectively.
The Concepts of Ethics, Bioethics and Christian Bioethics. The
term, ethics is derived from the Greek word “ethos” which means
“behavior” or “custom” that is “permanent.” This behavior is more
specifically attributed to human behavior and is therefore understood
as inherent to human being, hence, attributed to human acts. The
term, “ethos” has an equivalent meaning in Latin’s “mos” or
“moris”, hence, the derivative word of “morals” or “morality.” The
same can be said of “ethics” as derived from “ethos”. Therefore,
“ethos” or “mos” does not refer to etiquettes, social manners,
conventions or fashions which are understood according to specific
culture of nations. Rather they are to be understood as basic human
behaviors that are specifically and inherently human as in the case of
respecting life and property, honoring parents, helping those in
distress or taking care of one’s offspring. As specific and inherent
human behavior, they are supposed to be natural to humans and
therefore, should be promoted as they confer and develop goodness in
them, and eventually, virtue.
In view of the above, ethics or morals of man therefore can be
understood as a mental-set, disposition or set values and convictions
to which is attributed “a sense of right and wrong” and from which
human actions proceed. As a science, Ethics or Morals (moral
philosophy), deals with the study of the morality (the rightness or
wrongness) of the human act. As a discipline, it is meant for the
exercise of a human conduct that is good or evil, or ethical or
unethical. As a philosophical study, Ethics guides both the
speculative and practical intellect in the acquisition and application of
ethical principles in concrete human conduct. Ethics therefore points
the way to moral living and compels man to practice it in his life and
in the society he finds himself in. They are like traffic signs in life’s
highways that point or direct him to either turn right or left, go ahead
or stop as the case may be.
 When Ethics is prefixed with “Bio”, it becomes Bioethics and
assumes distinctly and immediately a rather specific domain. Thus, it
is called the “ethics of life”, or of life sciences. Ethics is more generic
than Bioethics. And Bioethics is understood as a kind of professional
ethics specific to health care and other life sciences. This is why,
Bioethics is sometimes called Health Care Ethics, Medical Ethics or
life ethics, (italics mine) according to Fuchs. Currently, bioethics can
be seen even in other human endeavors like business, economics and
technology.
Bioethics is not a fundamentally new ethics, but the
application of ethics and its basic principles to the new possibilities
opened by modern biology and biotechnology with regard to human
life. However, Bioethics extends its domain not only because of the
modern biology and biotechnology but also to the challenges that
ensue among physicians, other health carers and scientists in their
relationship with one another and their patients. Hence, it is also
understood as a professional ethics for health scientists or is simply
called Medical Ethics.
Warren Reich (1988) extends the content of Bioethics to the
value-related problems that arise in all professional, biomedical and
behavioral research, a wide range of social and legal issues, including
environment, public health, and also ethical problems related to
animal and plant life.
Sometimes, Bioethics can be made by way of extension as Christian
Bioethics because the principles it uses are basically grounded in
Scriptures and theological constructs under the light of Christian faith
and sacred traditions. Its principles do not only use paradigms of
reason but basically faith. Christian bioethicists claim that in the
understanding of life issues and usage of ethical principles, reason
alone is not sufficient. It has to be buttressed by faith. When
bioethics does not have any use of faith then it only becomes Medical
Humanities or simply Medical Ethics, as many medical schools
unarguably would rather use more comfortably. This kind of concept
leads Medical Ethics into what is essentially characterized as secular
Ethics, bereft of deeper meaning culled in Christian faith.
The discipline or science of Bioethics is the response to the
quest for rectitude in the perceived excesses and abuses in the practice
of life sciences, especially in medicine, nursing or other health care
institutions and professions. Bioethics leads the health practitioner to
the right way of their practice as professionals. In this special group
of professionals, the practitioners have a distinct mission to fulfill and
that they must be prepared for such by formal education or by special
avocation. It behooves therefore that these professionals learn why
and when their actions are right or wrong, in accordance with the
nature of their professional goals.
The Importance or Significance of Bioethics. The sudden surge of
interest of the world community, in general, and of many health
societies in the discipline of Bioethics, in particular, has led to the
convergence of a realization that this discipline is important, not only
to put right order and direction in the practice of an ethical profession,
but also to recognize the society’s awareness of its significance to
those who seek holistic medical care. The following are some
elements that give importance to the study of Bioethics, namely:
1. The importance derived from the subject matter of
Bioethics, that is, the health care procedures done by health
professionals and their corresponding right conduct in the
practice of health care. Since health care is so extensive in scope,
Bioethics subject matter strangely covers all areas in which health
care is practiced, be it in the preventive, curative or rehabilitative
spheres. The health care acts or procedures are judged in reference to
right reason (or faith as the case may be). Bioethics principles can
be applied not only in life sciences, but also in many areas of human
life.
2. Nothing can be more significant to the society,
especially the health care practitioners than the possession of
health or wholeness of the health seekers or patients entrusted to
them, and the way to it is a good knowledge of Bioethics. Medical
practice is essentially ethical practice as Chapter 1 (ad supra) has
previously emphasized. Separation of the two will lead to a
dichotomy of such practice, and will make health care only as a
technical profession rather than as an integrally technical and ethical
profession.
3. The world of health profession and life, in general, can
only be possibly practised and lived by recognizing the ethical
dimension in them through which they can regulate human
actions and relations. Truly, no profession can thrive unless the
practice of moral virtues among the practitioners are in order and
geared towards the well-being of the society. For ethical conduct is
the final link towards humanity’s aspiration for harmony and
wholeness, a.k.a., health.
4. The study of Bioethics deserves careful recognition
especially by those who have not been well versed in the
complexities of the medical or health care professions. All persons
deserve to be initiated into the nature of health care practice no matter
how imperfect it may be and the pluralism its moral dimension is
particularly revered. A health practice bereft of ethics is highly
questionable. While the patient may not know the complexities of
health practice, the professionals who derive their power to practice
from the society should accord the members of the society a humane
treatment so that it can continue to trust them.
The Rationale in the Study of Bioethics. For Bioethics to be a
significant and a meaningful discipline one must know the reasons
through and for which it is learned. The following are the distinct
rationale in which Bioethics may be of benefit to health caring and
eventually to the promotion of human dignity and needs of society.
1. To address the perennial and hopefully, current ethical
problems, issues and dilemmas confronting health and pastoral
workers. As in any human affairs like economics, politics, or
technology, health care is not without problems, issues and
dilemmas. These do no only arise from its technical, legal and
cultural nature of the art of healing, but more substantially from the
ethical dimension. The many life issues that arise from the
controversial topics about the moment of conception, contraception,
abortion, population, death and dying, to capital punishment or gay
marriages would be greatly overwhelming if doctors, nurses or social
workers do not know even the very rudimentary concepts or
knowledge of Bioethics. Knowledge of Bioethics then becomes
essential if one has to function ethically in the workplace of health
caring. Knowledge is always an edge. To possess knowledge is to
possess power. Indeed, knowledge is the final base of power not only
personally but also corporately or socially. Knowledge of Bioethics
is indeed a powerful tool for the ethical practice of health care.
2. To address legal problems in health care with ethical
concerns. No legal problem starts purely on legal grounds. Any
legal problem, especially in health care begins with a moral or ethical
problem. If all doctors are ethical they would almost always avoid
legal problems. Hence, knowledge and practice of Ethics in health
care by doctors and allied health care professionals is almost a
condition-sine-qua-non for a more ideal practice of the nobility of
the art of healing or medicine. Had doctors been more compassionate
and dedicated to their patients, hardly anyone would ever think of
doctors being charged for negligence and malpractice and eventually
hurled into the courts of law and even into prison. For a doctor to be
charged in court is bad enough. To be found guilty is even worse.
Consequently, medicine which has always been viewed as a noble
profession can become a tragedy and may only be viewed as a
business endeavor that patient will see it only as a human enterprise
where profit is sublime. It has been observed that injuries and deaths
could have been reduced to the very minimum, if only Bioethics
served as a central core of the guiding principles for those who
practice medicine.
3. To address the challenge of modem technology. Modern
technology in health care has grown in leaps and bounds for the past
three decades. We hear about medical-technological breakthroughs
in diagnostics and therapeutics that can see through the inner
chambers of the human body with accuracy and clarity as the
ultrasound, CT Scanner, Magnetic Resonance Imager (MRI),
Petscanner, Gamma Knife in the past two decades. Linnear
Accelerator, Brachitherapy and Cobalt Therapy to treat cancer cells
have made significant inroads in the treatment of cancer patients and
that resulted in a better quality and longer life for them.
Contraceptive technologies like pills, injectables, IUD and other
pharmaceutical, herbal and mechanical means have made its dent in
the management of the so-called “unplanned” pregnancies. Abortion
procedures have been made legal and have been practiced by the
western countries using technologies invented and dedicated
especially to deliberately destroy unborn babies and they are easy to
use. Even patient-assisted-suicide procedures use modern
technologies to make patients as comfortable allegedly as they can
while slowly succumbing to a planned death.
 Bioethics then steps in
into these inroads created by technology and challenges it by
declaring an almost “ex-cathedra” pronouncement, “What is
technologically possible is not always ethically justifiable.”

Indeed, there are medical technologies which may

be practical, affordable and may require less hospital stay and yet in
the eyes of Bioethics may never be utilized because they violate
certain ethical or moral principles, like the Principle of double-effect,
free and informed consent or autonomy of patients. The use of
technology in research involving human subjects could very well be a
challenge to Bioethics. And this is so because many in the research
field see Bioethics as obstacles to scientific advances.
4. To address and enhance professional development and
ethical values of the health professionals. It has been said that a
doctor without ethics is only a technician, but with ethics, he is
properly called a physician. A physician is one who is an expert in
the nature of things, hence the term, physica, which means nature.
Now, nature here can be understood in its generic term to refer to
everything of the created nature. But when physica is applied to the
profession of medicine, then a physician is called an expert in human
life, for what can be more nature-laden than human life itself. Thus,
one can also infer that a physician is or must also be an expert in
biology, more specifically, the biology of human life. Nevertheless,
human life is as we all know is not all physical body composed of
neurons, tissues, muscles, systems or organs. Beyond these is another
dimension that makes humans distinct from the animals – the
dimension of the spirit. In other words, a physician must not only be
adept in the physical dimension of the human person but also of the
dimension of the spirit. He can only respond to that spirit if he
becomes an expert in the affairs of the spirit which is also human.
This can only happen if the physician is knowledgeable not only in
the technical aspect of his art but also in its ethical aspect. Thus, a
physician who is both technical and ethical is a compleát professional
healer. He ennobles not only his person but also his profession. More
than that, as a compleát professional, he also uplifts his values and
promotes the nobility of his profession and thus develops himself and
fulfills his needs for self-actualization according to the great
psychologist Abraham H. Maslow (1908-1970). He is more likely to
be admired and well-liked by the society and earns the esteem of
those he serves.
The Nature of Human Act/s and Act/s of Man. Morality or Ethics
is distinctly focused on the exercise of one’s freewill and its
consequent freedom. Such presupposes conscious knowledge of the
person or agent doing a particular act or acts. A person who does an
act out of freedom and knowledge is a person who performs a human
act. Thus, a human act is a conscious and free exercise of one’s
faculties. Such is planned or designed and therefore the agent is
aware and has control over that which he does including the means
used and the ends to which that act is directed. In a word, a human
act is a conscious and free act. When a person decides to go and
consult a doctor, he truly knows and is free to do so. When a doctor
accepts him as a patient, the doctor also knows and freely takes him
into his medical regimen. Both of them therefore should be
responsible for those actions they choose to do.
On the other hand, an act of man is an act that is beyond one’s
consciousness and freedom. They happen as a result of human
instinct, without him deliberating on it or without his knowledge or
the consequent exercise of his free will. Classic examples are
digestion, respiration, nutrition, blood circulation, breathing, sleeping
or dreaming, even if through some special human skills and some
people can control them for a limited span of time are acts of man
because the will has no control upon them. Someone who falls into a
pit while walking in his sleep will not be responsible for its harmful
consequences. Winking of an eye is not a human act as it happens
without a conscious deliberation of the human agent. Unarguably,
morality or ethics is more concerned with human acts rather than acts
of man. And only acts done with knowledge and freedom are
properly human acts and therefore within the ambit of morality. Only
then can they be considered moral good or evil.
The Constituent Elements of the Human Act. Ethicists recognize
that there are three constituents of the human act, namely:
1. Knowledge. Knowledge resides in the intellect and is a
cognizance or mindfulness of what the moral agent is doing, thinking
or willing. He recognizes or knows what he wants to do and the end
to which this act is directed, including some calculated consequences
or collateral effects, be they direct or indirect, depending on what
extent the agent knows it. Knowledge is important in the assessment
of the human act as the absence of which makes the act only an act of
man. Anything that is willed however must first be present in the
intellect. Accordingly, “nihil volitum quid prius in intellectum” that
is, what is in the will is first in the intellect. This is where the
importance of knowledge is found in the whole scheme of human act.

2.
Freedom. When the free will controls the act in its performance, then
one can say that the person is free. Freedom therefore is a quality of
the freewill by which one is able to choose between one or two or
more alternatives. When one should choose from one alternative, or
when all alternatives were odious or repulsive one could not exercise
freedom and a human act would be nullified. When one chooses
under duress or force and does it against his will, freedom is absent.
Freedom is violated when one does not agree or does not submit to a
crime committed (or a crime already committed), as in the case of
rape. When someone submits to abortion procedures under pressure
or threat, that act nullifies responsibility due to the absence of
freedom. The same can be said of surgical procedures performed
without prior free and informed consent by the patient. Such could be
a case of medical malpractice, and those responsible must be
accountable.
3. Voluntariness. Voluntariness is a quality of the human act
whereby any commission or omission of an act is a result of the
knowledge which an agent has of the end. It requires full
consciousness or advertence of the nature of one’s act and its
consequences. When one knows the end for which the act is done,
and the agent purposely pursues it, the voluntary character of his
action is present. Thus, a voluntary act is an act of the will and not
simply a willed or wished act. It comes from one’s own choice or
full consent. A voluntary manslaughter for instance is done by design
or intention and not therefore accidental. Thus, a voluntary act results
in some achieved internal or external performance of an act.
Sometimes it occurs with the complete collaboration of the external
senses of sight, hearing, taste, touch and smell. A voluntary agent is
one who is able to will or has power of free choice.
Nature of Morality or Ethics. Operationally, morality refers to a
“sense of rightness or wrongness of an act.” We say that an act is
moral because with reference to a moral standard, it is right or
justified. And an act is immoral because with reference to a moral
standard, it is wrong or unjustified. Morality therefore is a quality of
a human act that is either good or bad, or right or wrong based on
some norms that are either inherent in the act, in the human agent or
are observed due to some individual or social conventional
acceptance. It becomes a scandal when such unacceptability by the
society exists.
Sometimes, the term morality is interchangeably used with
ethics. That is why, what is moral is ethical, or what is immoral is
unethical. The context by which these terms are used must be
carefully understood to get their proper usage. Sometimes they are
interchangeably utilized or understood. However, there are times that
they cannot be interchanged because it is not merely a semantic
matter by which these two are utilized. The term, morality however is
more generically used compared to Ethics, thus it is more extensive in
scope. Ethics is used in a more proper and specific context. One
neither say “legal morality”, but rather, “legal ethics”, nor “business
morality” but “business ethics”. Although, philosophically, there is
no difference between the two but their difference lies only in the
context in which they are both used.
Sources of Morality/Determinants of Human Acts. The concept
of the “sources of morality” refers to the “determinants of the human
act”. In other words, the goodness or badness of the human act takes
into consideration the object of the act, the motive of the agent and
circumstances of the act. These determinants or sources
characterize the moral order and make the human acts good, evil or
indifferent.
The following are the determinants or sources of morality,
namely;
1. The Object of the Act. The object of the act is the very
substance of the act. It answers the question “what was performed by
the moral agent?” Thus, it specifically asks the very nature of what
was done down to its distinct species. It does not only say that the
agent intentionally killed the man, but it says the agent murdered the
man. Nor does it say that he deprived the owner of his property, but
he stole it. In other words, the object of the act refers to what was
distinctly and specifically done and hence understood to be
appropriate act and not just understood in general terms. Thus “an
object of the act,” according to St. Thomas (S.T., I-II, 18), “is good
when it is in conformity with reason or when it fulfills or fits the
demands of reason. Otherwise, the object of the act is evil.”
 An example may illustrate the concept of the “object of the
act”. The object of therapy is to treat diseases or relieve pain.
Treating diseases or relieving pain is in accordance with reason. This
is good inasmuch as therapy is what medical practice wants to finally
accomplish. The object of abortion is to kill an unborn baby. This is
bad because it is in disagreement with reason since murder is evil.
The object of contraception is to render the sexual act ineffective.
This is wrong because it is against the reason to which a sexual act is
ordained.
Now a human act could be good, evil or indifferent depending
on the moral nature of the act independent of any law, regulation or
order. An object of the act is good when it is in conformity with the
nature or the purpose for which it was done. Otherwise an object is
evil. Examples of good acts are compassion for the patient, medical
mission, solidarity with the indigent patient, advocacy for the weak or
organ donation. Evil acts are procured abortion, euthanasia, medical
negligence or malpractice or embryonic stem cell research.
Indifferent acts are eating, walking or sleeping especially when the
agent is unconscious of the end for which they are done.
2. Motive of the Agent. This refers to the purpose for which
a human agent does an act. Humans perform acts to achieve a
purpose, which fortunately or unfortunately are sometimes different
from the object of the act itself. The motive of the agent answers the
question “what specifically does the agent personally want to
accomplish.” The motive therefore is the factor for which the agent
acts. It is the moving element in the whole spectrum of the proposed
action. The motive is either morally good or evil.
An example of a good motive of the agent in which it agrees
with the nature of the act is almsgiving in which the agent wants to
help a hungry person. But sometimes the motive is different from the
object of the act. Thus, if the agent gives alms to a hungry girl in
order to seduce her makes the act bad, although almsgiving is good
when the object alone is considered.
Now, it must be well noted that in any human act, the means
to the purpose and the purpose itself must be good. A good means
does not make a good act, neither does a good motive make a good
act, as well. Both must be good to make a good act.
3. The Circumstances. Accordingly, circumstances of the
human acts refer to events, occasions or conditions that make the act
concrete. They are present in the consummation of the said human
acts making the act experiential. They modify acts either by
increasing or diminishing responsibility of the agent. They either
lighten or aggravate the weight of the moral accountability of the
performer. However, the circumstances of the act do not change the
specific nature of the human act. Whether or not the person unduly
deprives another in order to help the poor, or whatever is the intention
attendant to the act, such act is by nature stealing. For instance, there
is nothing wrong if the doctor asks the patient to disrobe to have a
better diagnostic management of a woman’s disease or illness. But
there may be impropriety, if the doctor is himself the one undressing
the woman. This can be done by the patient herself, or if not by her
relative or guardian. The doctor will unwittingly open himself to
serious vulnerabilities like sexual harassment or lustful and improper
act and could even be sent to the courts of law and finally to jail for
such unprofessional actuation.
The concept of the circumstances in Bioethics plays a very
important role in the management of patients as they can affect the
appropriateness or inappropriateness of one’s behavior with the
patients or medical practice in general. They provide the definite
space and time, the reasons why doctors do what they do, the manner
through which an act was done, or even the patient to whom it was
done. The doctors should never forget that although patients, for a
long time in the past, were very yielding to what the doctors demand,
the patients presently are becoming more and more aware of their
rights so much so that ideally, no medical procedures can ever be
done unless with expressed permission from the patient or guardians
themselves, except those which are presumed to be normally
necessary and should be assumed to be normally permitted. This is
the so-called paternalism. But, doctors must be very sensitive to the
circumstances of the act so that the trust which is given by the patient
to them is not unnecessarily or improperly broken. Such trust as
everyone knows is the very anchor through which patient-doctor
relationship is grounded. Without trust, no good medical care could
be possible. Without trust, patients and doctors will become enemies
rather than allies. The absence of trust could well be the reason why
laws are enacted to arrest or counteract anomalies or irregularities in
health care and appear to be antagonistic to the medical as well as to
its allied profession.
The commonly accepted circumstances affecting the
increase or decrease of the moral responsibility for the act are:
1. WHAT. This circumstance answers what the intended
object of the act is. Was it procured abortion or just an indirect
abortion secondary to a major surgical act?
2. WHY. It refers to the why or the personal intention that
inspired or led the agent to move to an action. What was the intention
of the mother or the father in seeking contraceptive procedures
performed on her?
3. BY WHAT MEANS. This refers to the means the
various instruments, tools, or procedures were used, and by which
an act is done or performed. It may well be that the intention of the
agent is good, but the use of an unlawful or unethical means render
the act or the intention evil. This truism gives credence to our moral
act, “The end can never justify the means.”
4. HOW. This refers to modes of doing or acting under
which an act was done. Was the act done with freedom or consent, or
was it done under undue force or pressure? Was the act done with
violence, threat, fear, ignorance or some other passions?
5. WHEN. This refers to the time when the act was
performed. When did the felon do it? Was the crime done while
people were doing some religious activities? Was the medical
malpractice performed even when the prohibition to do it was still in
effect?
6. WHERE. This refers to the spatial setting in which the
act was done. Was it done in school in front of small children? Was
it perpetrated in a religious place where the sensitivity of people is
culturally and religiously held in high esteem? Was the scandal such
that it can ignite religious war because it was done with flagrant or
gross disrespect against the religious sensitivity of the people or the
sacredness or pride of place?
7. WHO. This refers to the person who does or receives
the act. According to Newstrom and Davis (1993), “People have so
much in common, like their being excited by an achievement, or they
are grieved by the loss of a loved one, but each person in the world is
also individually different, and we expect that all be different in their
ways, views and attitudes. Indeed, each one is different from all
others, probably in million ways, just as each of his fingerprints (or
DNA) is different, as far as we know. And these differences are
usually substantial rather than meaningless. The billion brain cells
that people have can have a billion possible combinations of
connections and bits of experience that are stored inside. This is a fact
supported by science.”

Persons may hold positions of authority, are

superiors or subjects, doctors or patients, priests or lay, rich or poor.
They have physical and mental perfections or imperfections. They
have different idiosyncrasies or eccentricities. There are VIP’s and
ordinary ones. They expect therefore to be treated accordingly. This
is the reason for the level of the variation of moral responsibility
among individual persons. And it Morality, the higher is the status of
a person, the more accountable he is. St. Thomas said, “corruptio
optimi pessima,” i.e., the corruption of a superior person is worst.
For example, there is a difference in the moral
responsibility between mere homicide and parricide or suicide.
An example can be illustrated here. A mother who aborts
her unborn baby is more responsible than if she probably committed
homicide against someone who is not her relative. The late Pope
John Paul II even considered abortion as an “unspeakable crime.”
Another example can be mentioned here. Suppose an old,
poor widow has one hundred pesos, the only money that she has to
purchase medicines necessary for her to live for the next few days.
Now, Mr. Bill Gates has got one hundred thousand dollars. A thief
steals both the money of the old, poor widow and that of Mr. Gates.
Which of the two acts of theft is graver – the one stolen from the
poor, old widow or that of Mr. Gates? Obviously, the one stolen from
the old, poor widow! Even if that amount stolen from Mr. Gates is
much bigger, it pales in comparison from that of the one hundred
pesos of the poor, old widow. This is where the circumstances of
WHO makes a significant difference in agent’s moral responsibility.
One has to consider very well the status or the condition of the person
who or to whom the act is done. For indeed, there is logical reason in
which Bioethics considers the person as the moral sensitivity changes
accordingly in the assessment of moral responsibility.
The concept of circumstances in Ethics is sometimes
understood in a rather distinct fashion. There are for example the so-
called mitigating circumstances (like ignorance, duress or absence
of consent), aggravating circumstances (like moral ascendancy,
helpless children or malice), reinforcing circumstances (like
legislations, ordinances or authority) or enabling circumstances (like a
person who bribes to encourage a person to do something bad). But
whichever they are called, they either increase or decrease the
responsibility of the agent but never change the specific nature of the
act performed.
Concept of Standards of Morality. In every human act performed,
be it at home or in the hospital or somewhere else, there are some
norms or standards of acting that people follow because said act could
either edify or upset themselves or others. It can make others happy
or simply react sadly. People sometimes are killed because not a few
do not behave in accordance with said standards. This is where we
see the significance and importance of the standards of acting
especially as people live in society with a sense of civility. When we
drive our cars, we follow driving standards and traffic rules. Without
those standards or rules, the streets will consequently become war
zones. There are for instance, traffic lights which motorists should
follow to ensure order in the street, avoid vehicular accidents or road
rage. In the Philippines, we follow the right lane drive. The same is
followed in Spain, Portugal, USA and Italy. Other countries follow
the left lane drive as in the case of Japan, Hong Kong, United
Kingdom, Malaysia, Indonesia, etc. When people do not drive the
way they should, it is almost expected that accidents are likely to
happen and that road rage will ensue which may cause the
unnecessary death of some people.

The same can be said with regard to the moral

behavior of people. Norms of moral actions are highly necessary if
people have to live in peace, order and harmony. Otherwise, as in
medical care, people get killed for not following norms of actions and
of relationship with others even as they use their skills and knowledge
against professional rules and conduct. Hence, such norms of moral
actions are a must for all who want to live in a society that value
peace, order and harmony, let alone civility.
Bioethicists accept norms of morality or of ethics not only
in living life in general, but also in their particular milieu, such as in
their workplaces or in their professional practices. This should
therefore be true in health care, research, and environment and even
in the political life of the society. For as long as human life is
involved and at stake, there should therefore be sensible
considerations for bioethical principles that should serve as norms for
acting and relating.
There are two norms of moral or ethical actions as
recognized and understood in Bioethics or Ethics in general. They are
Natural Law and Conscience. But before we discuss them, it is
important to understand the concept of law and its various
classifications.
The Nature of Law and Kinds of Law. There are various ways to
define the concept of law depending on how and where its usage is
relevant. One definition (as has been defined ad supra) is that it
refers to “a consistent set of universal rules that are widely published,
generally accepted, and usually enforced.” Obviously, this definition
is highly legalistic in nature. Some define it as “the official rules and
codes that govern citizens’ actions.” Similarly, this definition of law
is highly legalistic.
The great Dominican, St. Thomas Aquinas has in the 13th
century crafted a classic definition that subsumes both the legal and
moral dimension of the nature of law. He defined it as “an ordinance
of reason promulgated by a duly constituted authority for the common
good of the society.” In this definition, one finds five important
elements to consider, namely:
1. A law is an ordinance. As an ordinance, it possesses
the inherent power to compel people to follow. It possesses a
physical, psychological and even moral force so that it can be
enforced upon the subjects. Hence, it is called ordinance or order. It
also has power to impose disciplinary measures like monetary
penalties, punishments of incarceration, expulsions, or loss of
property, liberty and in extreme cases, life. This is the force of order
element without which any law, no matter how good, will be
dishonored or be consigned to obsolescence.
 The law on generics (on medicine) when flagrantly and
continuously violated and culprits are not punished, will soon become
irrelevant and will eventually lose its ordinantial element.
2. A law must be reasonable. For a law to be followed, it
must be in conformity with reason. An unreasonable law is difficult
to enforce and therefore can become eventually irrelevant. Thus, a
reasonable law should be humanly enforceable and should not be
abhorrent to human sensitivities, values and culture.
An example can be said about abortion that has become
legal in some western countries. No matter what the countries’
constitution or penal code say about abortion procedures and their
corresponding legal acceptance, such procedure will be contradictory
to human reason since abortion is the deliberate destruction of a live
fetus in or out of the womb of the mother. There will never be an
end to the debate about it since such practice is contrary to human
sensitivities, values and dignity.
Another example can be said about physicians who practice
solicitation of patients. This practice is improper, unprofessional and
illegal and such is against reason as it demeans the practice and
nobility of the profession of medicine.
3. A law must be promulgated. A law to be law and
consequently be followed, must not only be legislated or enacted but
must be known by the constituent subjects. It therefore requires
publication by any means, by which it can be generally spread for the
awareness of the subjects, not only of its contents, but also of how it
can be properly used to ensure equality of rights attendant to it for the
benefit of the society. Although it is true that “ignorantia legis
excusat neminem,” that is, “ignorance of the law excuses no one.”
The authorities have a moral duty that it be known by the subjects so
that adherence to it could be much easier and bereft with so much
complications. Although we cannot expect all people to know all the
laws, the law should not be so intricate as to be understood only by
those going to the law school. The services of legal counsels should
resolve this issue. It should behoove everyone that the legal counsels
can help people redress their grievances rightly and justly. It is their
duty to clarify the intricacies and implications of the law within the
level of the common people’s understanding and in a level of
language that they understand. It would be impossible for people to
follow the law if it is continuously hidden from the public and only
the courts know it.
Vehicles for the promulgation of law are the media and
other means that are readily and easily accessible to the people.
Inclusion of education to law in the schools and other institutions of
learning is laudable. This should make the law more binding.
Moreover, it must be well noted that the purpose of the law
is to put order in the society and avoid controversies. Thus, clarity
and consistency must be premium attributes of law. This can be
accomplished when law is made understood by those responsible for
its enforcement. One of the vaguest and controversy-laden bill called
the Philippines House Bill #10354, known as the Reproductive Health
Bill authored and supported by many unpopular congressmen who
were advocates of world-wide Reproductive Rights that include
abortion rights. Actually, this bill that has become a law was entitled
“The Responsible Parenthood and Reproductive Health Act of
2012,” a.k.a., known as the Reproductive Health Law or RH Law
in the Philippines. Eventually, because well-meaning people saw this
law that will lead people to disorderly sexual misconduct, they
challenged it before the Supreme Court and they won. Many of the
controversial provisions have been struck down especially those that
encouraged abortion.
4. A law must be enacted by a legitimate authority. Duly
constituted authorities are necessary for a law to be legitimate and
enforceable. Without such authority, a law would be highly
questionable and would be wide open for violation, even with great
impunity. He must be one in whom the legal or moral right to enact
law is reposed. Examples of which are the legislative bodies and the
President of the country which should give a stamp of approval. It is
logical that he be the one to do so as his authority subsumes all
subjects who profess allegiance to the whole country represented by
said authority. This should also be true to the microcosms of a
particular sovereignty or territorial locale, when a law or rule has to
be enacted, as a governor to a province, a dean to a college, a
professor to a class of students or CEO to a hospital. It is in this case
where they are recognized as duly constituted authority on their
particular social milieus.
5. A law must be for the common good. Logically, a law
cannot just favor a few to the prejudice and detriment of some. The
few elite and powerful cannot claim more rights under the law as this
will create frictions and divisions. That is why, for a law to be a real
law, it should be applicable to all (or some claim that it should at
least be for the majority), in order to promote common good.
Although this is not an accurate and straightforward understanding of
what common good is, it gives the impression that the majority rules,
even if the minority has also rights. This is the democratic
understanding of the common good. For if we expect a hundred
percentage of acquiescence to a particular goal of law, then it will
take endless work for a government to agree and thus enact a law.
The majority as usually understood to refer to as common good is the
minimalist view of securing legitimacy of a particular law. This
context is acceptable in all democratically constituted governments.
It must be understood that the concept of common good is never
equated with the concept of majority. The concept of common good
refers to the integral good of the person --- his physical, mental, moral
and even spiritual good.
Nevertheless, St. Thomas Aquinas (ST., I-II, 90) has
something to say about a common good as the ultimate object of law,
“the law must regard principally the relationship to happiness.
Moreover, since every part is ordained to the whole, as imperfect to
perfect; and since a man is a part of the perfect community, the law
must regard properly his relationship to universal happiness.
Wherefore the Philosopher (Aristotle), in the above definition of legal
matters mentions both happiness and the body politic; for he says (in
Ethica Nicomachea v, 1), that we call those legal matters "just, which
are adopted to produce and preserve happiness and its parts for the
body politic"; since the state is a perfect community, as he says in
Politica i, 1.”
 From the above view of St. Thomas, the connotation of
common good must be understood under the idea of man’s ultimate
happiness which unarguably, a concept that is commonly accepted as
good for humanity. Thus, a common good, be it a material good or a
human act, as in law, is that which should confers happiness to man,
not simply an earthly happiness, but a divine one. This view of St.
Thomas is rather far-reaching because he considered man not only as
an earthly citizen, but as somebody predestined to be heir of the
kingdom. Thus, a common good is that which confers on man his
ultimate reward, and not only as legislated to what confers political or
social order. This can very well be understood in the fact that there
are laws which may have been declared as that which confer
individual good and rights, but do not in anyway confer goodness
even to the majority of subjects. Even when a law seemed to be legal
in the minds of its dispensers, it still can be subject to the scrutiny and
challenge of those who believe that “legality does not always mean
morality.” For indeed, even if abortion is legal in the West, it cannot
confer the quality of morality on it, because, first, abortion is
intrinsically evil, and secondly, mere legal manipulations of the
political power does not necessarily mean acceptance by the society
especially under the purview of ethics or morality. That is why, for
law to be meaningful and acceptable, it must be based on man’s moral
or ethical nature.
In other words, the concept of common good is that which
is commonly understood within the purview of man’s natural pursuits
and that which confers perfection to him and the society he belongs.
It should never be understood to be dependent on the extent of
numbers, as even the majority change from time to time, according to
some caprices and whims of the leaders or of the subjects. Morality
or ethics is characterized by some stability or permanence and that
does not depend merely on people’s subjective and ephemeral
thinking as dictated by the flood-tide of emotion, impulsiveness or
fickleness of the human mind. The common good is transcendent in
character and it is larger than the individual good, both figuratively
and literally, because it is ethical in nature. Thus, common good
refers to the sum total of the human society’s political, economic,
social and moral benefits.
In view of the above, the Supreme Court Chief Justice
Ricardo Puno (2007, Phil. Daily Inquirer Jan. 10), in a speech
delivered at the celebration of “Ethics Day”, told the law enforcers
that “they should not allow themselves to be swayed by the mob
because what it says is not always right.” He continued by saying,
“the majority could be wrong and those who are right could find
themselves alone, but this should not bother them as long as they
know that they are doing the right thing. We who dispense justice as
judges should therefore not be terrorized by the tyranny of numbers.
Indeed, we will often find ourselves in the minority (but has common
good in mind, italics mine), but we must shake the paralysis of
powerlessness coming from lack of numerical support. Those who
rule on right and righteousness should consider popularity the least.
They should as well learn to forego the
 “comfort, safety
and delight” that come with being supported by a lot of people since
such feelings can be only temporary.” Further, the good Chief Justice
explained, “The reason is simple: the great truths – whether religious
truths, moral truths or political truths – are not determined by
popularity alone, because oftentimes the majority rests only on what
is momentarily delightful or what is pleasantly pleasurable. A wrong
popular good would not become right good because people support
it.”
There are various kinds of laws. More common
classifications are the following: Eternal or Divine Law, Natural
Law and Human Positive Law, under which are the constitutional
law and other criminal, civil and administrative laws of the land.
The Standards of Morality or Ethics. There are commonly
accepted norms or standards of morality in Ethics or Bioethics,
namely, Natural Law and Conscience. This is so because these two
confer the character of goodness in human actions or behavior.
Anything that falls short of such character is said to be unethical.
1. Natural Law. Before one can understand the meaning
of natural law, one must first know the meaning of eternal or divine
law. Accordingly, eternal or divine law refers to “the divine will or
command that directs all actions and movements in the universe. It
commands that the natural order of things be preserved and forbids
that it be disturbed.” (C. Faustum Manichaeum, 22, 27). This law
includes everything in the created world, the universe and even life
beyond. Therefore, the physical world is subsumed under it, for such
is subjected to the laws of nature and should necessarily abide by it.
The pattern of behavior of animals, plants or minerals follows such
actions or movements in accordance with the will of the divine
mind. They possess nature as is conferred to them by said divine
mind, and move and act in accordance with that nature. They follow
natural order in the universe and any aberration can create
irregularities or deformities, and consequently the natural order is
thrusted into various dysfunctions or mayhems. This eternal law
follows and bears the character of a law as understood above. It is
conceived in eternity, and is therefore applicable to all in the universe,
hence, it is called Eternal Law. It is unchangeable and universal.
This is the reason why the Natural Law is the objective norm of
morality, for it has God as its author and thus, cannot be erratic.
Consequently, reason proves and dictates that man
participates in eternal law to which he, as a creature of the universe is
a part and a subject. Thus, natural law is man’s participation in the
eternal law that commands that “the natural order of things be
preserved and prohibiting that it be disturbed.” Respect for nature
and its pattern of behavior is primacy in the precept of natural law
since disrespect for it would invite disaster, and humans will usually
be sure victims of its consequences as experience teaches us.
Imperative and attendant to this respect is having knowledge
necessary to understand how nature behaves, so that man can avoid
those which infringes and breaches it and thus avoid its consequent
natural reprisals and retributions.
A. Panizo (1964) has long ago beautifully expressed and
described natural law in the following:
Our universe is composed of an infinite variety
of beautifully arranged things. Indeed, nature shows a
constant order which is the result of a universal plan
and of immutable laws. To these natural laws are
subject al the movements and energies of the world,
 the behavior of atoms and molecules, the majestic
course of the planets, stars and other heavenly bodies,
the birth, growth, and eventually death of plants and
animals, the interaction of solids, liquids and gases,
the transformation of non-living elements into living
bodies and vice-versa, the continuous change of
energies and forces, and other natural phenomena
studied in the natural sciences as Physics, Chemistry,
Biology, Mechanics, Geology, Astronomy, etc.
Now, man is certainly a part of this universal scheme of
things in the order of nature. As an animate being, he certainly
follows the said natural law, otherwise he becomes just a freak of
nature without any meaning. But as a moral being endowed with
intellect and will, he recognizes the dictates of the laws governing
him and desires to follow them as they are distinctly designed for the
actualization and progress of his being. In other words, as man grasps
and understands the Eternal Law and wills to follow it, he participates
in such Law. This type of governance that subjects him to follow the
Eternal Law is what is called the Natural Moral Law. It is
particularly this law that governs man’s behavior, action or conduct
distinctly under the purview of right and wrong or moral and
immoral. Its goal is to direct it to man’s ultimate moral end. Man’s
participation in said law is a sign of his recognition that there is a
principle that guides him and that he should follow. If his response is
positive, it can lead him to satisfaction and ultimately to his moral
end. Anything that falls short of this response is either a sign of
indifference or defiance, or may contravene against the provisions of
that law. Unfortunately, it may abet a total contempt and disdain for
it. The consequence will be chaos and disarray in humans and
societies.
Moreover, the Natural Moral Law is not a humanly
authored law but is attributed to the One who created nature. God,
the Supreme Being, is its author, and therefore, natural moral law
enjoys eternal character, universality and immutability. Natural moral
Law can however be distorted and may be practiced differently from
what is inherently provided for, due to personal convictions, culture,
customs, social conventions, and pressure of legal or political forces.
But, this does not make natural moral law null and void, or invalid
and unfounded. For instance, human nature will always be the same,
although it may manifest itself differently in various forms and
circumstances under various conditions and modalities where it may
be found. Individuality can significantly differ from one group of
people to another, but essentially, they are the same. Understandably,
this is a part of the ordinance of natural moral law.
The following are the contents of the Natural (Moral) Law,
namely:

a. The Fundamental Principles of Action. This refers to

the basic principles by which man as man acts as he should as a moral
being. These actions are so basic that they essentially follow man’s
natural way of doing and pursuing what is good and beneficial for
him, for no one desires what is evil or harmful. An example of these
fundamental principles can be found in the proverbial: “Do good and
avoid evil.” In medical practice or health care, it is the principle of
beneficence and non-maleficence that makes it more concrete, that is,
“do good and avoid harm”. Sometimes, it is more of prohibition,
namely: “primum non nocere”, that is, “first, do no harm”.
b. The General Moral Principles of Relationship. These
principles guide a moral subject in sustaining and preserving basic
relationship with God, fellowmen, himself and creation. It guides
him on how he should behave as he has also responsibility with others
while pursuing harmony with those who also work to achieve it. This
relationship is not only limited to himself with other moral beings, but
also with the environment in which he lives as he is duty bound to
preserve harmony with it, both for the good of the environment and
for his own physical and moral-well-being. Examples of these
general moral principles are worship of a supreme being, honoring
parents, avoiding or preventing murder, multiplying one’s offspring,
protecting and educating one’s offspring, preserving one’s life, and
other provisions contained in the Decalogue. It also includes one’s
duty to mother earth and the concomitant environment to care for
them and not to destroy them.
c. Applications of the Fundamental and General
Principles to Particular Situations in Life and Society. The
applications of these fundamental and general principles are necessary
so that justice, human rights and human dignity would be honored
and preserved. Attendant to these are provisions of law in the civil,
ecclesiastical and international law where the divine will is respected
and integrated as the basis for genuine provisions of the principles of
acting and relating. The various principles of Bioethics are included
under this content of natural law, even as they enrich said
fundamental and general principles applied to specific situations.
These principles guide particularly the medical and allied
professionals in their practice of medicine or health care while they
primarily pursue the protection, respect, defense of human life and
society and their dignity. These principles will encourage them to be
solicitous of the need of the patients and their families in their
moment of pain and suffering, as they eventually integrate into the
human society.
 Apropos
these principles are the various codes and declarations that serve as
guides to medical moral actions. This may include the Oath of
Hippocrates, the medical codes of different countries, the
International Code of Medical Ethics, the Declaration of Geneva, the
Code of Helsinki, the Nuremberg Code and other codes of the allied
health professions and other professional societies.
d. Remote Conclusions. These are inferences derived
from philosophical and theological reasoning and other deep human
reflections based on some moral or ethical principles and concepts.
As remote conclusions, they can include the evil of abortion,
contraceptive practices, divorce, gay marriages, euthanasia,
embryonic stem cell research, transsexual surgeries, solicitation of
patients, ghost surgeries, excessive professional fees, trafficking of
human organs, etc. Remote conclusions are deductive in character as
they are derived or deduced from the general principles of Bioethics.
(For more in-depth discussion of Natural Law, see Fausto B. Gomez,
OP, the Journey Continues: Notes on Ethics and Bioethics. UST
Publishing House, Manila. pp. 49-77, 2009).
2. Conscience. This second norm of morality refers to “the
practical judgment that determines that an act is good, therefore to be
done, and evil, therefore to be avoided.” Etymologically,
conscience comes from two Latin terms, con and science, that is “a
judgment of knowledge”. An act of conscience is therefore an act
that has basis on some knowledge.
Nevertheless, conscience is said to be the subjective norm
of morality. This is because it is borne out of the mental judgment of
man and therefore may be erratic and prone to miscalculations by the
human reason. Further, conscience resides in the human intellect
which is imperfect and therefore prone to errors. Nevertheless, as
judgment of the intellect, it makes declaration of truth or untruth,
goodness or badness about the actions he wants to pursue, or about
thoughts or ideas he wants to believe.
Conscience is “the inner self of man” or “the little voice of
God” as metaphorically described. It does not only judge on the
goodness or wrongness of an act, but also exercises some legislative,
judicial and executive power. When conscience makes rules or
policies, it passes judgment and pronounces sentences on man’s
moral actions. It sometimes commends and approves on what people
do. It also rebukes and denounces, forbids and encourages, presses
charges and forgives. In all of these, conscience evaluates the quality
of the human act on whether it is desirable or undesirable.
Should a man follow his conscience, be it right or wrong?
Indeed, it can happen that a man may view something wrong as right
or vice-versa. The following or similar ruminations often take place in
our conscience. “It is right to practice contraception knowing that
another child will add more burdens to an already impoverished
family.” “It is not right to pay for donated organs, but I need one for
my survival. Thus, I might just as well compensate the donor with
high financial reward and not shortchange him.” “I need to perform
surgery on the mother who attempted abortion to remove the fetus.
But, if I help her, she might be doing it over again and I might be
accused of cooperation in an evil act. I might just as well send her to
another hospital that does it.”
It has been said that for as long as man sincerely believes
that he must commit or omit some action, he has to follow what he
believes must be done, whether this action is good or bad, now or
later. When conscience has reached this stage of judgment, there is a
moral obligation to follow one’s conscience. St. Thomas (ST, III, 12)
is unequivocal about this issue. “Every conscience, whether right or
erroneous, whether with regard to acts which are evil in themselves or
acts which are indifferent, is obligatory, so that he who acts against
his conscience does wrong.”
Following One’s Conscience. Following one’s conscience does not
come from a vacuum. Experience tells us that there are various
reasons/bases through which man can assert himself and allow him
“to follow his conscience”. An enumeration of these reasons/bases
can help understand what this statement means, namely:
1. To follow one’s conscience is to follow the law. In
many societies, the (civil) law is the (sole) norm of conduct of their
citizens. People are said to be law-abiding because they follow the
law. When people pay for instance, the right taxes, they feel that they
have already fulfilled their obligation. The same can be said when
they exercise their right of suffrage. For as long as the citizens do not
have brushes with law, they are alright and may live peacefully.
Thus, the law becomes the norm of human conduct.
The problem with this paradigm is that it is minimalistic
and is very socialistic in character. For as long as the balance of
living in the society is preserved and that citizens avoid unduly
disturbing others, then one can safely live one’s life as he wants.
Morality as we know is both personal and social in character. And
that legality does not always mean morality. Take the case of
abortion practices in many western countries. It may be legal, but
following it does not make one act well with good conscience.
 2. To
follow one’s conscience is to follow one’s cultural beliefs. Culture
is a complex whole of beliefs and practices of a particular society.
All humans are borne into a culture which has been passed from one
generation to the next. When culture withstands the test of time, it
molds people’s thinking and beliefs, and is consequently applied in
their practice as an essential component of their life. Ingrained as it is
in their life and practice, it becomes a basis or reason for making
judgment over right and wrong conduct. Any infraction against such
cultural practice may earn reprisals from the society and even
punishment, like discrimination and even sometimes death which can
even be perpetrated unfortunately by their close relatives. The reason
for which is to restore a damaged honor and dignity, and this is
especially true with some backward societies they dubiously call
honor-killing.
In view of the above, cultural beliefs that should punish
Jewish women in the Old Testament or Muslim women with death
among conservative religious societies may be observed for
commission of adultery. Pre-arranged marriages among Muslims are
still practiced by the parents with regard to their sons and daughters
even if the would-be partners have not seen each other. Some
conservative Chinese families also observe the same tradition even
until now.
 It should not therefore come as a surprise if culturally-based
societies make culture as basis in their judgment of right or wrong
actions. Thus to follow one’s conscience is to follow one’s cultural
beliefs.
The setback about this basis is when people become more
aware of equality rights, as in women’s rights, racial non-
discrimination or freedom from undue interference, etc.
3. To follow one’s conscience is to follow one’s feelings.
Feelings are so significant among humans that they sometimes
become the bases of one’s decision-making. Most of the time,
whether a person is young or old, he or she makes these as the sole
bases for acting and doing. Feelings however, belong to the domain
of emotions or passions. They therefore are very erratic and can
change depending on how the swing of moods presents itself to the
person. This can well be observed when people try to change partners
as if they change clothes. The same can be said about those who have
undergone transsexual surgery because they feel they are trapped in a
different body. They feel that they can solve it through surgical
operation. As a matter of fact, a man who believes he is a woman can
have gender re-assignment to make him a woman. However, if one
believes he is thirty years old even when he is actually sixty, does not
make him thirty years old. Thus, a judgment based on feelings is
highly unstable and can hardly be relied upon.
4. To follow one’s conscience is to follow one’s religious
beliefs. It is certainly good to possess religious beliefs as these are
supposed to be based on the principles of faith in God. For how can
man err if he truly follows the precepts of God? But this is not
always the case as experience tells us of so many instances in which
man can abuse such principles of faith and would even kill in the
name of God. We know that the language of God is always love and
peace. But the language of those who kill in the name of God is
hatred and violence. This is where religious beliefs can be distorted
by man that may be due to his concupiscence, greed and pride. It is
therefore difficult to base one’s conscience on purely religious beliefs.
A case at hand is about the parents of a 12-year-old boy
who got sick and was complaining of headache. The parents did not
bring the boy for medical care to the hospital, as they believed that
their boy would be healed by God. They so believed that God, being
powerful, can heal him as Christ did to the sick. Soon the boy’s
condition became so serious that when they brought the boy to the
hospital, it was too late. The boy died alter but could have been saved
if not for the erratic religious belief of the parents.
Here therefore, one finds that judgment of conscience based
solely on religious belief is hardly tenable.
If there is not one among the four bases above that can pass
to be ideal basis for one’s judgment of conscience, then what is it?
This can only be answered when we try to understand the concept of
the principle of a well-formed conscience. The principle below will
help us understand it.
The Principle of Well-formed Conscience. This principle states that
“to have a good judgment of conscience, one is obliged to form it
diligently in accordance with some reasonable processes, so that one
arrives at a right moral decision. Thus, to attain the true goals of
human life by responsible actions, in every free decision involving
ethical question, people are morally obliged to do the following (cf.
O’Rourke and Ashley, 2002):
1. Inform themselves as fully as possible about the facts
of the case and about the attendant ethical norms. Facts of the
case are the very backbone of truth. They are necessary if one’s
judgment has to stand to the rigors of scrutiny. There is no substitute
for truth as it can set people free. The closer the facts are to the
objectivity of truth, the better it is to make a good evaluation that
should lead to right decision. The lesser facts at hand will render
decisions weaker in substance, as in the case of incomplete evidence
or its lack thereof.
The right choice of the principles of Bioethics will make the
decision sound and therefore acceptable. Thus, knowledge of the
principles of bioethics and their right applications to facts are
conditio-sine-qua-non for good judgment of conscience. It is
therefore a must that those in health care, whether they are doctors,
nurses or the allied health professionals, learn the principles of
Bioethics in health caring. Ignorance of them renders the doctors and
other health carers simply technicians.

2.
Form a morally certain judgment of conscience on the basis of
this information. Forming certain judgment of conscience is
sometimes an arduous and challenging task. This can happen if there
is defect or weakness in the process. That is why, it is important that
health carers must educate their intellect to strengthen their mental
capacity to judge while they need moral courage to pursue said
judgment. The information that one possesses must include solidity
of facts. Any distortion may render distorted decision. Peripheral
details may be important, but one should not lose the central fact of
the issue as to veer away from the substance. In the collation of facts,
one must include not only the medical condition of the patient, but
also his familial, social and economic conditions, his cultural and
religious beliefs, as well as, his unfulfilled aspirations and goals.
3. Act according to this well-formed judgment of
conscience. The judgment of conscience can never be complete
unless action results from a well-formed conscience. Such action
must be bereft of too much emotion but filled with reason. Included
in this is moral courage, so that the patient does not unnecessarily
suffer undeserved and prolonged process. It is also good to consult
an Ethics Committee of the health care facility in which the patient is
admitted. In making decisions, all concerned must be consulted, like
the family, the attending doctor, the chaplain or bioethicists, the social
worker, the nurse and sometimes a lawyer with the administrator of
the health facility, depending on the need of the situation. It is
laudable to have a unanimous decision or at least a majority of the
decision makers. It is not a good practice to place the decision-
making in the hands of the courts of law, as it is not laudable to have
them preside over the health and illness, neither of the patient nor of
the society.
4. Be responsible for actions performed. When
responsibility of the action is placed on the collegiality of decision
makers, there will be less legal or ethical complications. Such
responsibility must be owned by those who made the decision based
on their conscientious judgment. Hardly, the collegial act of the
decision makers can be wrong and become liable to the legal and
moral scrutiny. Responsibility can be owned when they are based on
sound ethical processes and procedures and sound principles of
natural law. When that happens, then a well-formed conscience is
insured. Thus, “to follow one’s conscience is properly to follow
one’s well-formed conscience.”

Case Studies:
A. Conscience or Family
Ms. C. S. Dillon, works for a travel agency. As part of her
job, she would accompany tourists to places of interest. This time, she
accompanied a group of thirty-five international and local tourists to
an island resort called Tres Palmas. Unexpectedly, a group of armed
bandits suddenly arrived in the island and abducted all of them and
brought them to an isolated place where even basic necessities are
hardly available. The government has an outstanding “no ransom
policy” and does not want to negotiate with them, and so, it has
already taken more than a year of ordeal without them being
released. Word from her husband got into Ms. Dillon that her two
children have been looking for her as they are now very sickly. She
was greatly worried and nowhere is freedom from her captors
forthcoming.
One night she approached one of her captors and offered an
indecent proposal. She said that she was willing to give herself for a
night of rendezvous with him if she would be released later and be
with her family. The deal was sealed and it was done. Ms. Dillon
was freed and told everything to the husband about what happened.
The husband was initially apprehensive, but later welcomed her into
his arms and was even thankful that she was back home.
1. Talking about Ms. Dillon’s actuation, was her conscience
justified in making an indecent proposal so that she could later be
reunited with her family? Was it better to remain as hostage and
forget everything about her family?
2. Is the so-called “principle” of lesser evil a good choice
to follow in this situation? Why? Why not?
3. Is marital right something to sacrifice for the sake of
being reunited with loved ones?
B. The Crocodile Story
Young adults, Cris and Nicole are fiancées, and are about to
wed in three months. Once, Cris went with three of his friends to
have some adventure deep into the forest. As they were negotiating
the mountain, all of them fell off the cliff and died except Cris who
was badly wounded, had lost a lot of blood, and needed immediate
medical attention. Word came to Nicole who wanted to go and offer
Cris help. Nicole asked her friend to request the latter’s notorious
cousin who offers boat services that crosses the river full of
crocodiles. The cousin would not agree unless Nicole makes love
with him. Time was of essence and Nicole was worried that if help
did not reach Cris, he would die. Nicole agreed to the deal. Cris was
rescued and Nicole later told him about what happened. Cris became
so furious that he later parted with Nicole and called off the wedding
plans.
1. Who among the four characters had the worst attitude or
conscience? Why?
 2. If you were one of the characters, whom do you want to
be identified with and passed to be with the least moral
responsibility?
3. What ethical concepts are closely applicable in the case?
Elaborate.
C. Morals or Job
Ms. July A. Santos is a nurse who travelled to the United
States of America (USA) to work in order to help her family back
home. In the hospital where she works, she was asked to help in an
abortion procedure which was legal in US. Now, Ms. Santos is a
Catholic who does not believe in the procedure. Her conscience
dictates that cooperating in the procedure is cooperating in the killing
of the unborn child. Later, she was given instruction that since
abortion is legal, she may be committing an illegal act by her
uncooperative action and such may cost her job. This bothered her as
she may not be able to help her family back home.
1. Can Ms. Santos object to the hospital based on the
dictates of her conscience? Explain.
2. What can Ms. Santos conscientiously do to avoid such
dilemma?
3. Is sacrifice of her dignity better than seeing herself
unemployed? Or vice-versa? Explain?
D. Professional Value or Financial Gain
Dr. Alfons Alia was consulted by Ms. M. N. Chavez for a
medical complaint that has been bothering her for quite sometime
now. She has just gone previously to Dr. Borromeo, who has been
treating her for the past six months but she has not improved. Dr.
Alia tells her that the previous doctor has already been the subject of
so many complaints from other patients. Further, he tells her to just
remain with him for her next consultations and promised to even give
him fifty percent discount on professional fees. Later, Dr. Borromeo
learned about the unprofessionalism of Dr. Alia, and in retaliation, he
would also tell other patients not to go to Dr. Alia for incompetency
and dishonesty, and subsequently promised to give patients
substantial discount on professional fees.
1. What do you consider to be the lapses of conscience by
both doctors?
2. Do you think that appealing to their sense of conscience
would be an easy thing to do? What can you do then to help prevent
professional conflicts among doctors?
3. Is it ethically tenable to discipline both doctors by
warning, suspending or expelling them from the hospital as this is a
case of bad modeling?

Chapter 3
My brothers, you were called, as you know, to freedom;
But be careful, or this freedom will provide
an opening for self-indulgence.
Serve one another rather, in works of love.
Gal. 5:13

THE CONCEPT OF FREEDOM

he concept of freedom as elucidated below is highly important
T as it has a great bearing on the determination of the morality of
the health professionals’ conduct. As the person of the patient is
entrusted with the gift of freedom, so also are those of the health
professionals. Hence, a good understanding of the concept of
freedom and its attendant relation with the free exercise in making
decision regarding one’s health concerns is paramount for the
efficient and effective administration of health caring. This will help
abate the friction that may arise between the freedom of the patient
and that of the health professional.
Freedom and the Human Act. Understanding the concept of
freedom is not an easy thing to do and it can sometimes be elusive.
For freedom can be many things to many people. As there are a
number of people, so is the number of ways of understanding it. This
is so because a person can use freedom in everything he does in a
variety of ways. The extent by which the faculty of freewill can be
used is just overwhelmingly colossal. This is where we can say that
the understanding of freewill and the corresponding outcome that is
freedom is just too wide to be restricted into a number of limited
concepts. The following can help us understand albeit imperfectly
some concepts related to freedom.
Freewill, Freedom and Object of Freewill. The will is the human
faculty whose function is to will or to desire. When the will functions
in an autonomous fashion, then it becomes properly an act of the
freewill. The object of freewill is that which is good, either in itself
or as compared to other alternative good. Freedom therefore is that
quality of the freewill by which it is able to choose that which is good
for the human agent. It must be noted that no evil is ever desired by
the freewill. In reality though, the freewill chooses that which is evil,
inasmuch as it perceives and chooses it as an apparent good, or in

the context
of good. When man chooses to steal, he does not choose stealing as
evil in itself, but because he uses the act of stealing to bring
about something good out of it. If a doctor chooses to do abortion
procedure, even if she may know that it is evil, he does it not for
itself, but for a number of good that he can gain from it. This is how
freewill functions with the corresponding quality of freedom that
makes the act of desiring happen.
Evil can be a part of the object chosen by freewill, but not
through a proper use of the faculty, but a clear abuse or misuse of it.
Freedom and Morality. Man alone is capable of morality. Animals,
plants or minerals are incapable of a sense of right and wrong, for
they lack the essential element of rational knowledge and freewill.
Thus, man is a totally thinking and desiring being. Freedom is
essential in such act of desiring, if man has to pursue some particular
goals. Thus, without freedom, there is no valuation of morality; with
freedom, morality is present. Less freedom means less sense of
morality; full freedom means full sense of morality. By the rightness
and wrongness of an act, morality points to the path towards one’s
moral end, and thus, happiness or the loss of it.
Freedom and Responsibility. Responsibility is essentially attached
to freedom and vice-versa. It can be asserted that the more freedom a
man has, the more is his responsibility for acts done. Less freedom
means less responsibility; and more freedom, more responsibility.
Responsibility therefore is an inherent outcome of an act done
with freedom. All actions that springs from freedom have a moral
value, that is, moral responsibility. Man alone deserves merits for
good deeds, but is also liable for the bad ones. Since human actions
are essentially ordered to his moral good, then his moral acts are those
that are in accord with the order of human reason and are concretely
realized by the right choice of the freewill. Anything that lacks this
attribute will make man irresponsible and thus would find him
disloyal to his moral nature.
Freedom and the Rule of Law. There has observably an issue that
points to the irreconcilability of freedom and law. For some people
would ask, “How can law be reconciled with freedom when
essentially, law is restrictive of people’s free actions?” This
restrictive nature of law alone isolates freedom and cannot positively
be associated with law. The many prohibitions and strictures of law
drive people to a plethora of conflicts as these are perceived as usual
threats that can assault on the expression of their own identity or
privacy. Of course, it must be understood and eventually accepted
that no one possesses absolute freedom. No one can claim that he can
act the way he does because whether he likes it or not, he must relate
to others as he is a social or relational being. Now any human
relationship implies respect of the other person. Such implication of
respect immediately brings to the fore an idea of restriction. It is for
this reason that law has to be enacted so that such respect will be
protected and defended and that people would be constrained from
becoming abusive or violative of other’s rights. It is here that
everyone should see the necessity for a law that will require everyone
to act accordingly as an individual and as member of the bigger
community. If there is no law, ironically, people would lose their
freedom. What would happen if one day, all laws are suspended?
One will surely expect a lot of killings on the streets and it would
spell total mess and chaos. And people would not want to go out of
their homes to do their societal duties and responsibilities. They
would be scared to even step on the street as they would have to fear
for their lives. When there is no law, freedom is also broken. This is
why, freedom and law can be reconciled in spite of the consternation
of people who think otherwise. Even the act of following the law is an
exercise of freewill.
 Let us put in
classic context these concepts of freedom and law and their
indispensable connectivity. Suppose there is a very exceptionally
good basketball player who can really play basketball so well. He
dribbles the ball and handles it with amazing ability, runs fast and
moves with unmatched agility. He guards like a leech against his
opponents. With all creativity and imaginativeness, he can easily
shoot the ball and produce big scores every time he plays the game.
We can say that he is a great athlete. However, he plays outside the
legitimately sanctioned court without referees and much less rules.
Surely, whatever attributes that he has are naught gauging his game
from the circumstances by which he plays the sport.
Freedom, Culture and Religion. It is a fact that many of us will
only allow those types of healers who have the necessary education,
knowledge and skills as certified by proper government agencies to
practice the art of healing. This is because our idea of medicine is
substantially western where only evidenced-based medicine is the
only credible way of doing such art. But what makes of those with
different belief system from the practitioner with regard to the reality
of health, illness and therapy? It is a fact that not all those who are
legitimately accepted into the practice of medicine can really meet the
needs of the patient and can fully understand how the patients view
their lives vis-a-vis such illness, health or treatment? Culture and
religion are so important in the life of individuals because they are
often the bases for making free decisions beyond the technicalities of
medicine. As a matter of fact, even the most westernized societies
often carry with them the custom, tradition or even superstition of the
elders, which, are not always wrong, although improper. We must
remember that many of the treatments being done today have been
offshoots of long traditional beliefs and practices that have endured
for millennia in human history. Take the case of the traditional and
alternative medicines of the East which have been gaining huge
headway even in this very modern society. In fact, even the West
have been going back to the traditional treatment sources in order to
look for the wisdom and truth of the past, if only to find cogent
treatment of diseases which the present could not unlock. This only
goes to show that science is not the only basis for the treatment of
diseases, but is a combination of many factors including cultural and
religious beliefs concerning the over-all therapeutic process. Up until
now, many diseases persist and have no known permanent cures.
Common colds are a good example of these.
It is imperative that patients must be educated regarding
freedom and autonomy and must be empowered, so that they can
make some meaningful choices with regard to their health, illnesses
and their treatment. This agrees well with the idea of holistic
medicine which has been a very essential value both in western and
alternative medicine. There has to be a wide room for freedom to
choose as treatment is always related to the cultural and religious
beliefs of individuals. When these are not resolved, even if the
patients may have improved or have been cured of their illnesses, they
would still go out of the hospital unsatisfied. Unfortunately, many
practicing doctors do not have the faintest idea of what it is to be
carefully sensitive to the patients’ cultural and religious background,
and therefore deprive them of the freedom they so value. Good
medicine is scientific, cultural and religious in character. Freedom
based on the scientific, cultural and religious principles is at the helm
of upholding the best medical answers to people’s health
predicaments.
Freedom and Conscientious Objection. Conscientious objection is
an act of judgment that files a protest or presses disapproval over a
real, current or impending predicament to one’s moral belief. It can
be addressed to a person or group of persons or organizations. When
it is forced upon a person to accept, it can cause undue and real
assault against one’s moral upbringing, honor or dignity. It rests well
with the idea of freedom, as it is essentially an act of autonomy of the
person judging that something is sinister and should be disallowed. It
is an assault to one’s freedom when one is forced to do or cooperate
on a particular act or procedure against one’s moral conviction as it
does not dwell in harmony with one’s moral sensitivity.
Conscientious objection is a moral right of every person and
must be attended to with care and utmost sensitivity. Breakdown in
human relationship can happen when this is not properly responded
to. We must understand that when an act badly affects one’s dignity
and personhood, it can consequently engender breakdown in
communication and destroy relationship, whether interpersonal or
organizational. Thus, freedom is at the very core of conscientious
objection. Without that element of freedom, people will either
cooperate only for practical convenience or simply drift away and
take back loyalty from the (health) organizations for which they
work. Conscientious objection is prevalent in the military as citizens
may refuse to join an obligatory service in the military since their
participation may send them to war and force them to kill humans.
The usual reason for refusal is religious in character. In health care,
conscientious objection is a reality when health providers may refuse
to do or participate in a medical or surgical act or procedure which for
them is objectionable based on religious and moral grounds. It is a
principle in Bioethics that a person is not obliged to do something or
follow a command when such is onerous to his conscience. This is
true to health practice. To violate one’s own conscience is to violate
oneself, honor or dignity. This will always be viewed to be
untenable.

Case Studies:
A. Accountable or not
Mr. Paulo P., is a Catholic nurse and works for a tertiary
hospital. Although the hospital prohibits abortion procedures, he was
requested by an OB-Gynecologist to assist her in a surgical procedure
he initially did not know. Thinking that the procedure was legitimate,
he agreed to assist her, until he noticed that what was being done in
the operating room was clearly an abortion procedure. Immediately,
Mr. Paulo P. humbly requested for a substitute nurse, as he cannot
accept being involved in the abortion procedure. He told the doctor
that he is going to post for a conscientious objection as the procedure
does not sit well with his religious and moral beliefs. The doctor
vehemently did not agree as they are in the middle of the operation,
and his going out would put the mother to unnecessary risk. Mr.
Paulo P. went ahead without listening to the doctor.
1. Was nurse Paulo P’s conscientious objection morally valid
in the case? Why?
2. Can nurse Paulo P. be morally accountable if something bad
happens to the mother? Why?
3. What could nurse Paulo P. morally do to avoid such
situation?
4. What bioethical concepts or principles are applicable in the
case to give enlightenment to Mr. Paulo P.? Discuss.
5. Mr. Paulo P. contended that he cannot be liable for anything
because “truth can never damage a cause that is just.” What do you
think does he mean by this?
B. The Reluctant but Firm Witness
Sunshine C. is a nurse in a government hospital in Metro-
Manila known for delivering an average of forty-babies a day. It has
been dubbed as the center for baby manufacturing in the country. The
government is serious in curbing the country’s perceived run-away
population. A new internal “unwritten” policy in the hospital was
enforced to help prevent the problem from going out of control. She
was assigned in the delivery room and has been a witness to
thousands of deliveries for the past three years. With the new policy
that has been implemented, Sunshine has seen poor mothers being
inserted with IUD’s without their consent or whose fallopian tubes cut
to contracept further pregnancies. Being a Catholic, this has bothered
her. She wanted to be transferred to other sections and formally
expressed that she does not want to be a party to these procedures.
She too said that if the administration would not do it, she will
divulge such practices in the media. The administration charged her
for insubordination.
1. Was Sunshine’s request to be transferred to another section
an ethically tenable act? Explain.
2. Was it ethically right for Sunshine to threaten to divulge the
unethical practices in the delivery room if the administration does not
transfer her to another section? Justify your answer.
3. Does Sunshine’s exercise of freedom not to be part of the
unethical practice warrant her right to conscientious objection?
4. On what basis in ethics or in law can she be right? Cite an
ethical principle or a commonly-known provision of law?
C. The Reluctant Patient
Mr. Edgardo Arda who is in his 40’s comes to the emergency
room of a tertiary hospital. He is being asked to ascertain about his
symptoms and medical history but would only respond even partly.
He has been showing some symptoms like profuse perspiration,
vomiting, low blood pressure and shortness of breath. The health
team was attending to him to draw blood but he would immediately
refuse them. The staff does not know the reason for his refusal.
Although signs of mental competence showed in many ways, Mr.
Edgardo A. behaved so irrationally, in a manner that could jeopardize
his health or life, if not accurately diagnosed.
1. Is there any circumstance or condition through which health
providers can be permitted to disregard patients’ refusal of an
otherwise medically indicated treatment? What are they if there are?
2. Suppose Mr. Edgardo A. has been pronounced as an
emergency patient, can he be ethically treated against his will, since
emergency situation usually decreases usual informed consent
expectation?
3. Does the reason for irrationality matter? Suppose Mr.
Edgardo A’s refusal does not reflect his decision about wanting to
remain alive, is the health team obligated to treat him? What if he
does not want to remain alive?
4. Is Mr. Edgardo A’s presence in the emergency room a
reason to presume that he wants to be treated and must be understood
as de facto consent? Explain.

pinterest
 Chapter 4
But how can they call on him in whom they have not believed?
And how can they believe in him of whom they have not heard?
And how can they hear without someone to preach?
And how can people preach unless they are sent?
As it is written, “How beautiful are the feet of those who bring the good news!”
(Rom. 10:14-15)

BIOETHICS AND THE HEALTH PROFESSIONS

n today’s
market-driven world, where one has to face tough challenges from
stiff competitors, things may lead to a real “dog-eat-dog” mentality to
survive. Many business outfits resort to various marketing paradigms
and practices to survive the onslaughts of the highly-competitive
market. Sometimes when the going gets tough, the real face of
business shows its ugly head, where everyone becomes a wolf to
another. Of course, the corporate world is not totally like this. There
are a significant number of them who would choose to engage their
competitors fairly and justly. Rather than licking the competitors no
end, they forge partnerships or mergers that can capture and
eventually monopolize the market and earn profits on every single
peso they invest. Mergers and partnerships are nothing but
strategizing the market forces. It is a simple professionalization of
business opportunities. They professionalize monopoly, trade secrets,
market advantage, efficiency of services, manufacture of quality
goods, and do just about everything we can think of to have
advantage over others. This certainly is how most of the market-
driven world of business behave, especially among big corporations.
Medical care no matter how one sees it, is viewed as an item
of consumption or commodity, therefore a marketing good. Be it a
service, a product or a consultation, it is mostly market-driven. For
doctors to stay in the market of medical practice, they must
demonstrate an image of credible market value. Like the corporate
world, they should professionalize their brand of care – that is to
make their work relevant to those whom they pledge their service.
One has to understand that more and more people are becoming
conscious of their rights, and demand for better professional services,
because satisfaction is at the helm of their health decisions and get the
most value of their money. Gone were the days when we were
satisfied with the less than the minimum standards. “Puede na” is
taken as alright but it actually means vaguely alright. As a matter of
fact, patients would choose something better if such is available. In
medical service or care, “puede na” cannot be right because it is
somewhere between the vague and the mediocre, and we would not
want to avail ourselves of medical service that sits uncomfortably
between these two poles. Anything that is between the vague and the
mediocre is a bad and distressing compromise. We want a care that is
complete and satisfactory and nothing less. Life and health cannot be
compromised. And to avoid this compromise, the answer lies in
professionalization of medical practice. Professionalization will
provide an enduring answer that will outlive all notions framed
around skepticism, distrust and contempt about the profession of
medicine. This will earn medical practice its self-respect amidst the
increasing commercialization of medicine. We are afraid that with
the society’s obsession for commercialization, profits or other gains,
without professionalism of the medical practitioners, medicine would
become an anonymous functionary and lose much of its nobility.
And what is professionalism in medical practice? The following
below will shed a good stand of understanding.
 Professionalism in
Medical Practice: What is it? There is not a single definition of the
term, “professional” or “professionalism” that one could find as
acceptable in that as it is unarguable. The word, “professional” is
applied practically to everyone doing some services or fulfilling jobs
that need some skills and knowledge. A housekeeper in a hotel or a
hospital can do his job well and may do it as professionally as one
sees it, though he may not have gone to college that offers a
housekeeping degree. A technician can do well an automotive work,
even if he only learned the trade without going to a technical school.
An amateur athlete can well show an athletic prowess, even if we
know that he is not professional. Likewise, a professional player can
well demonstrate an amateurish capability even if he is in the
professional rank.
1. Etymology of the term, “profession.” The term
profession or professional comes from the Latin word “professio” or
“profiteor” which means “a public declaration with a commitment or
force or a promise.” As a public declaration, it has a social
dimension. That social dimension is anchored on a commitment or
promise to help or to assist those in need. That is why, the term does
not come from the word “to profit” (Latin, profitere), which is the
very opposite of that declaration to help the society. A profession is
usually practiced with a group that shares the same skill, knowledge
and code. They declare in public that they will act in certain ways and
that the group and the society may discipline those who fail to do
according to what they profess. The profession is presented as a
social benefit and the society accepts the profession, expecting it to
serve some important social goals. Thus we have the traditional
professions like medicine, law and divinity (doctors, lawyers and
clerics).
2. The Amateur and the Professional. Traditionally, an
amateur is one who is initiated into the trade or craft. He is expected
to be more erratic, more panicky, even more clumsy and inelegant
compared to the professional. Nothing can be more evident than this
in the world of sports. The same can be said when it comes to medical
care. The student of medicine, the residents or the fellows are of the
caliber of the amateur compared to their counterpart in the
professional ranks. What makes the professional behave like one is
the fact that they have more skill, knowledge and experience and they
are at the high end of the craft or trade. They do things with supreme
confidence, style, ease, with flair for the dramatic, and with the so-
called finesse and touch. They are equipped with more techniques, so
that when difficult cases present their way into the procedures, they
can be entrusted and relied upon. They can even put their work under
time pressure and end it accordingly. And the result is at the high end
of it. He works even when he is sick and is told how marvelous he
looks. He gives high energy performance up to the final curtain call,
whether it is drawn above a legitimate stage or around a bed.
Sometimes, he delights in doing home visit, rather than just accepting
a patient’s visit. Unfortunately, in the Philippines, a professional
driver, for instance, is no different from a non-professional.
3. Difference between a Profession and Business. The
difference that distinguishes a business and a profession may not be
as distinct as we may want to know it to be, since professionals may
engage in business and make a living by it. Nevertheless, one crucial
distinction between them is that professionals, like doctors or priests,
have by their essence a fiduciary duty toward those they serve. This
means that professionals have particular stringent obligations to
assure that their actions serve the best interest of their patients or
clients, even at the cost of themselves. No wonder, a doctor or a priest
will have to wake up at one in the morning in order to respond to a
call of need. The road may be rough and tough, they may be placing
themselves in danger, but they consider serving their clients or
attending to patients above their own safety. They have a code of
ethics to follow as part of these fiduciary duties, and ethical conflicts
appear almost always, when there is a clash between their duty and
their personal goals. In this modern era, a sacrificing attitude is
observably found wanting. This is the reason why there are more
medical practitioners in the urban area than in suburban or remote
communities.
More concretely, it is observed for instance that a grocery man
who refuses free food to the hungry is normally not denounced. The
builder does not deserve scorn by failing to give shelter to the
homeless. The tailor is not normally expected to give away winter
clothes to those who have none and he is not detested for it. A car
manufacturer does not earn derision for not offering a ride to the
commuters. But if a doctor turns away a sick person for any reason,
especially if he has no money, he is highly repulsed and denounced.
It should stand to reason, that when he sees someone in pain or in
suffering on the road, he does not walk away from him but stands by
him, be he unknown or an enemy.
4. Who is a/the Professional Doctor? From the concepts we
have delineated above, one can now glean some ideas, in order to
determine what the term “profession” or “professional” may stand
for. From the root of the term, to its distinction with the meaning of
the term amateur and its difference from the concept of business, we
shall find that. Any definition of profession implies essentially the
distinct possession of skills, knowledge and conduct of a person
exercising it. But these concepts do not simply a professional make.
One has to go beyond the trappings of these requirements. The
concept must include what these skills, knowledge and conduct can
do to the society to whom they pledge and eventually commit to
serve. Thus, the professionals are those who possess knowledge,
skills and conduct and utilize them to enhance, ennoble and promote
people’s and society’s lives and dignity and goals. Further, as
professionals, they are guided necessarily by some code of conduct or
ethics for clarity of purpose. This code of conduct is not meant to
restrain their practice nor control the inevitable advances in medicine,
but for them to enjoy freedom and creativity although with attendant
responsibility. It serves as guide to make them vigilant but
encourages them to explore vast possibilities that medicine has to
offer, where efficiency and effectiveness are premium. The code is a
guide to action where the primacy of least harm and maximum
benefits are integral to good professional and medical practice.

Going back to
the definition, the skills, knowledge and conduct are those that have
been acquired through long years of studies and practice, most
especially those that have been acquired through formal training and
education. They embody as they should, a spectrum of the ideal and
the admirable. They are meant to serve the society even at the cost of
some personal interests. Classically, medicine, law and divinity fall
under this concept. A terrorist or prostitute cannot be professional.
Neither are squatters, pickpockets or criminals, in spite of their being
something erroneously dubbed as professionals. This appellation is
myopic in that “professional” here may only mean being skillful or
stylish in how things are done. If they have any code of conduct for
that matter, they are usually unwritten for some sinister motive with
the idea of ensuring personal, illegal or selfish interests. Over and
above the skills, knowledge and conduct and the idea of promoting
human lives and dignity, the professional must embody core values
that will positively impact on his professional image. Below are the
values.
Core Values of a Medical Professional. There are commonly
accepted core values that are attributed to health professionals and are
a must. The following below necessarily expected of them to possess,
namely:
1. Commitment to Competence and Commitment to
Excellence. Competence and excellence in the profession refer to a
specialized body of knowledge and skills necessary to practice the
profession. It is central to it. It is what makes the professional doctor
speculative and practical in dealing with the ailment. It is necessary to
tackle the technical aspect of the disease. It is the reason why doctors
and other health professionals go through long years of studies and
research.
Competence is the result of continuing education and research,
where scientific knowledge is acquired and advances are realized.
Skills associated with knowledge are designed to utilize effectively
the knowledge proper to the profession of medicine. But while
knowledge and skills are necessary to professionalism, they are not
everything about it. They are only integral to the profession.
It is a cliché to nag that much of medical knowledge quickly
becomes obsolete, and that clinical skills will rust out with time.
Lifelong learning in order to keep medicine’s cutting edge is expected
of all doctors without exception. For commitment to excellence is the
crowning glory to one’s pursuit of a healthy and wholesome world.
And a doctor who does not study today is courting ignorance
tomorrow. Further, one must also seek to learn from error, perform
self-evaluation and submit to the critique of others. Specifically, in
medicine, “excellence is the result of caring more than what others
think is wise, risking more than what others think is safe, dreaming
more than what others think is practical, and expecting more than
what others think is possible.”
It is everyone’s wish to see more doctors or health
professionals defer a round of golf, with free green fees, courtesy of
pharmaceutical companies in order to go to a post-graduate course to
update themselves in their specialization. Proper perspective is
certainly an important professional attribute. It is a good
development that the PRC re-introduced the application of the CME
units as requirements for renewal of license, and made it conveniently
as requirement for collection of doctors’ fees. It is laudable that the
monetary aspect has not replaced the scientific aspect. Now doctors
attend scientific meetings to learn, not to learn how to collect.
2. Commitment to a Code of Conduct. The code of conduct
characterizes all professional bodies including the medical or allied
profession. It includes even the personal conduct and dealing in the
professional practice of a doctor. The code of conduct of the medical
profession is fundamentally ethical in nature because it promotes
notions of duty, honor and integrity that are part and parcel of the
professional formula. It also delineates provisions that bind the
doctors in the promotion of beneficence, non-maleficence, fidelity,
patient autonomy and justice. Added to these are ethics of working in
a managed care environment, interactions with the pharmaceutical
industry, the disciplinary measures, human experimentation and
research, the brave new world of genetics or eugenics, etc. The code
is a moral compass that keeps them on the straight and narrow way. It
is the code of ethics that sets apart the good doctors from the bad. A
doctor without ethics is a mere technician. With ethics, he is a real
physician.
3. Commitment to Altruism. It is an old-fashioned word,
but has always been acknowledged by many physicians as a core
value in the health profession. It is simply doing good for others, and
putting their interests above that of the physician, sometimes at great
personal sacrifice. It is an unselfish regard for and devotion to the
welfare of others and is a key element of professionalism. It is almost
a heroic and noble act for doctors to give up their weekend and sleep,
to care for those with hepatitis and AIDS infections, or to be in the
front line in the event of pandemic, like the horrible Corona Virus
Disease – 19, that has plagued and turned the whole world upside
down. Moreover, the professional doctors are exhorted to treat all
irrespective of their ability to pay. One does not expect that from
other professionals that do not deal with health. Sir William Osler,
unarguably the most famous of modern-day physicians, said it best in
these simple words. “The profession of medicine is distinguished
from all others by its singular beneficence.” It is wished that all
medical professionals will always remember that time when they
were interviewed just before they were accepted in the medical
school, and how they promised before heaven and earth, that they will
serve mankind, how money mattered so little, how they were attracted
to the challenge of mastering a fascinating and exciting field. These
are by all angles and norms correct responses. They are what
everyone wishes to see from all of the health professionals. It is real
adherence to the proverbial value that makes medicine a vocation
rather than a trade. It must always be remembered, “We do well for
ourselves when we do well for others.”
4. The “Imprimatur” of the Society. The avowed
recognition and acceptance by the society to the profession is of high
import to the practice of any profession both ethically and legally.
This recognition and acceptance is the society’s marked “imprimatur”
to the benefits and advantages the profession is expected to deliver to
the society. The society gives prior articulation of policies and rules
governing the practice of the profession, so that those who want to
practice it follow (at least) the minimum requirements and
qualifications as any prudent practitioner would to legally and
ethically exercise it. This is important in order to curb abuses and
misuses in the exercise of human skills, knowledge and attitudes.
This is also meant to protect the society from unscrupulous people
who promise to deliver the said professional service and in the end
deliver only bogus and substandard outcomes. Hence, in the exercise
of any profession, the society has authority on who should practice it,
what to practice and how it should be practiced. The “imprimatur” of
the society confidently tells the medical professional, “Go ahead. You
are cleared. You are safe.” Literally, “imprimatur” means “Let it be
printed,” as when the book that must see print is clear for printing
because it contains no danger but only benefits to the readers.
Other Professional Values of the Medical Profession. These
values refer to attributes which physicians should ascribe to as
important cognates because they too serve as barometers to
professionalism namely:
1. Accountability (Kamalayan sa Pananagutan). It must be
instilled among medical practitioners that since medicine has a social
dimension, it has therefore social responsibility and accountability.
For the health needs of the public and the advancement of science,
they are accountable to their patients, colleagues and society. They
are answerable to their profession for adhering to medicine’s time-
honored ethical practices. They should be rewarded for their service
to the society, whether in terms of money or honor, and should
likewise be responsible for whatever mistakes they commit. This is to
ensure that the ethical precepts are upheld.
Medical care and medical errors do not mix. Their mixture is
very expensive and burdensome, and puts medicine in question and
encourages people to redress grievances through legal remedies. As
accountable professionals, they must trust audit and not begrudge the
principle of external review. Furthermore, there must be willingness
to accept responsibility for errors.
2. Honesty/Integrity (Kaganapan ng Pag-uugali). It is the
consistent regard for the highest standards of behavior and the refusal
to violate one’s personal and professional codes. Honesty and
integrity imply being fair, being truthful, keeping one’s word, meeting
commitments, and being forthright in interaction with patients, peers,
and all professional works, whether through documentations, personal
communications, presentations, researches or other aspects of
interactions. They require awareness of situations that may result in
conflict of interest or that result in personal gain at the expense of the
best interest of the patient. (ACGME and the ABP).
Leopold in the movie, “Kate and Leopold” castigates Kate
(played by Meg Ryan) for being concerned only with profit from
advertisement and the convenience it will give the businessmen and
her, no matter how deceitful the product she endorses. He confronts
her by asking, “You have time for comfort and convenience, but you
do not have time for integrity?”
3. Respect for Others (Pagiging Maka-tao). It is the essence
of humanism, and humanism is central to professionalism. This
respect extends to all spheres of contact, including but not limited to
patient, families, other physicians and colleagues. It includes
recognition and treating all persons with dignity and worth. He must
not be discriminatory and should accord everyone what is due
him/her, including patients’ rights, cultural differences or patient
confidentiality. Rumors should never be a favorite menu among
doctors during meal times. They should be fascinated discussing
about the science of medicine and how to help patients in every way
possible.
4. Compassion/Empathy (Pagmamalasakit). One must listen
attentively and respond humanely to the concerns of patients and
family members. Empathy for and relief from pain, discomfort and
anxiety should be a part of one’s professional undertaking. A
tradesman or artisan, a plumber or electrician, can perform his service
even if he knows nothing about the person who requested the service.
Their duty is to ensure that a building will have water and electricity.
While the people who utilize the building may benefit from the ready
supply of electricity and water, the person installing or repairing the
equipment need not personally contact the persons living there.
Doctors, as professionals, on the other hand, must know their clients
intimately in order to accomplish their goals. And these goals are
goods that bespeak of our humanity. This is what makes a medical
professional distinct from others. To be compassionate is to embody
in ourselves suffering souls of others and feel with them how it is to
be in pain. Doctors feeling the pain even if they are not in physical
pain lighten the burden of patients and so patients don’t suffer
unnecessarily. Further, it makes healing fast. It must be remembered
that compassion is a conspiracy a healer forms with the patient in
order to combat the inhumanity of hospitalization and the horror of
disease.
5. Collaboration (Pakikipagugnayan). It is communicating
(by words and actions) clearly and effectively with patients and their
families and all health care providers. It is an effective means of
carrying out whatever is necessary in the treatment of patients. A
patient would always appreciate a doctor who engages him in any
interaction. Many doubts are cast aside and questions are answered.
A patient who goes out of the hospital cured, will not go satisfied if
his questions are not answered. Every word of the doctor is deeply
meaningful to a patient who is struggling in an emotionally-charged
condition. It gives him comfort to know that a doctor has real time for
verbal engagement. It is not wise nor fair therefore to charge any
professional fee without having talked to the patient or his family.
More so too, should a surgeon charge the same when he is not present
during the operation. Ghosts do not have any right to exist in
operating rooms, much less charge a fee.
In the same fashion, doctors should coordinate efforts with
other health carers especially when co-management is necessary.
There must be no “prima donna” in health care nor should anyone
enjoy “de campanilla” mentality. These should be things of the past.
No one is indispensable in this world. If they believe they are, then
they have to check their appointment book a week after they dropped
dead. We should remember that the most important person in health
care is the patient himself. He must be given the best “shot,” and
doctors should never have any aversion to seeing them. It is a virtue
to honor especially the aged, for such act is a tribute to wisdom. If by
any unfortunate event, a patient leaves a doctor, he has to rejoice and
should not blame himself or someone else.
 6.
Appearance (Disyenteng Panglabas). This value may appear to be
the least important, because it is something which every doctor is
expected to project at every moment of his professional practice. To
many, it is still one of the significant exterior indicators of the
professional and committed physician. This refers to the physical
appearance or his external bearing. Hippocrates (460-370 AD) the
great forerunner of professionalism in medicine, has underlined this
when he said: “The physician must have a worthy appearance; he
should look healthy and be well-nourished, appropriate to his
physique; for most people are of the opinion that those physicians
who are not tidy in their own persons cannot look after others well.
Furthermore, he must look to the cleanliness of his person; he must
wear decent clothes and use perfumes with harmless smells.”
“Doctors,” according to Dr. Silva (2003), “do not have to look
expensive, just clean and well groomed – no matter how harassed
with work they might be. This includes gowns and blazers that are
supposed to be white, and most appropriately not smelling of
cigarette smoke.” Yes, it should normally be white and should never
be of other colors, least so, of bright and abhorrent colors.
 According to an unknown author, appearance should include
one’s workplace or clinic because it is reflective of one’s personality.
Therefore, one must have a lovely office with a nice receptionist
(whether or not she bends like a ballerina). But one should not hang
mirrors in the waiting room unless a 2 o’clock patient enjoys
watching herself age visibly by 4 or 5 PM. It is alright for doctors to
drink, but if they do, they should not drive. However, if they smoke,
they should not even bother wearing seatbelts. They are killing
themselves anyway.
Professional Fees. The most obvious question which patients usually
ask when it comes to the topic of professional fees is “How much is
an appropriate professional fee?” What can be said here is not of
course an absolute proposition but only a suggestion as to what
constitutes a fair professional fee. Dr. Patrick Moral suggested that
“an appropriate professional fee is that which allows the physician to
practice his profession and permit him to live a life without
distractions or interruptions from other concerns and endeavors to
earn a living.” The prevailing rate in the locale is a good proposition.
Fees may vary according to certain factors like experience, training,
specialization, technical considerations or use of devices and the
community served. Specialty societies should help peg professional
fees. Contemptible fees are those which are too low, with the
intention of undercutting other physicians and those that are too high.
Ethics committees can help decide on this. Splitting of referral fees is
usually frowned upon. Thus, when it comes to charging professional
fees, Dr. Moral (2008) declares: “A doctor should always watch his
integrity. Without it, he is worthless. With it, he is priceless.”
Challenges to Professionalism of Health Professionals.
Observably, as many would attest, doctors get through the
stringencies and rigors of long years of training and education
focused not only on acquiring knowledge but also on developing
attitudes. When they are trained in wholesome attitudes, the
resulting professionalism is not too far behind. Sadly, in spite of
these stringencies and rigors, many still lapse into the same old error
of unprofessional conduct. The following are some challenges which
every doctor should be aware of lest they fall into their trap.
 1. Abuse of Power. An unknown writer said that the respect
enjoyed by scientists and physicians results in significant influence to
the world of medicine. When used well, this authority and power, can
accomplish enormous goods to the humanity. When abused, this
power can go berserk, and can develop into deviant behaviors that can
affect patients and other health care givers horribly. But this power is
supposed to be cherished, not abused. Many consultants have been so
intoxicated with power that they even use it to threaten junior
residents, interns and clerks and as potent weapons during oral
examinations against them (University of Kansas Medical School), or
insult them in front of patients and their families.

Doctors
have been graciously entrusted with power, but society wants them
only to be its trustee. They should not take advantage therefore of
those who may be under their authority and mercy and always treat
them with respect. Unfortunately, there had been reports recorded
that some doctors who are supposed to be honored as noble
professionals have not totally lived up to these expectations. We can
think about for instance of the lowly medical representatives who try
to eke out a living by promoting medicines and medical supplies with
medical doctors. It is sad to note that some of them have been taken
advantage of by the very honorable doctors. Nevertheless, if we have
to listen to this bunch of well-groomed medical representatives, for
instance, it is encouraged to let them propagandize. We can listen to
them rhapsodize to high heavens about the merits of their latest
wonder drugs. However, it is unconscionable to prey on their
weaknesses and take advantage of their vulnerabilities.
Professionalism dictates that they, too, are not to be manipulated but,
respected as members of the health professional team.

2.
Discrimination, Bias and Harassment. The medical profession has
a particular responsibility to ensure an environment in which all
colleagues enjoy equal respect and where they can advance to their
full potential, irrespective of their disability, ethnicity, race or
religion. The person of the patient is humanity in progress and must
be seen as a bundle of infinite treasures and possibilities. He must
therefore be esteemed with awe. Each one must be called by his
name and never by demonstrative impersonal pronouns like “ito” or
“nito”. We are treating here the most important character in health
care, and not an object of technicians’ expertise. Any form of
discrimination, bias or harassment must be avoided. It is encouraged
that doctors should always bring back the gentle touch of healing.
Healing is an art with a heart.
3. Breach of Confidentiality. Patients trust that conversation
and information obtained through the course of patient and doctor
relationship must be held in strictest confidentiality. Casual
comments or discussions of patients in public (not in scientific
discussion, but in crowded elevators) are breaches of confidentiality
and are unacceptable. Confidential communication should not be
used for personal gain or publicity. Filipino culture seems to thrive
on spreading rumors and secret information through the grapevine.
Patients love to be cared, not bared in public. For medical
procedures, they can be disrobed, but not robbed of their honor.
4. Arrogance. This is an offensive display of superiority and
self-importance. Unfortunately, by their nature, medicine and science
can foster arrogance in the medical profession. Probably, since the
training of doctors has been long and arduous, to survive means a
great achievement. But arrogance destroys professionalism and
reduces individual’s ability to think and remove the checks and
balances of self-doubt.
5. Greed. This is an inappropriate aspiration to fame, power
or money. Greed impairs altruism, caring, generosity and integrity
and therefore negates professionalism. Professionalism demands
evaluation of one’s motives to ensure that no actions are made solely
for personal gain.
6. Misrepresentation. This consists of lying and fraud. It is a
conscious effort to stall the amazing revelation of truth. Lying about
statistics in research, assignments and experiments is a serious breach
to professionalism which raises the specter of overall dishonesty of
the individual. Fraud is conscious misrepresentation of information
with the intent to mislead. Lying about services performed to obtain
reimbursement and professional fees from the Philippine Health
Insurance Corporation (PHIC), and other HMO’s for instance, is
evidently an example of fraud.
 7. Impairment.
Doctors who are handicapped in their ability to carry out their
professional obligations must relinquish their responsibilities,
particularly when caring for patients. Impaired cognitive abilities and
judgments due to illness are no less common among doctors than
among the public at large. Reluctance to draw attention to an impaired
or potentially impaired colleague is a significant problem associated
with medical professionalism. Rationalizations that inhibit prompt
and appropriate action are common, but such inaction in dealing with
an impaired colleague is a failure of professional obligation. (Univ. of
Kansas School of Medicine, 2000).
8. Lack of Conscientiousness. Failure to fulfill
demands of duties is incompatible with the essence of
professionalism. Doing only the minimum, being “too busy” to
commit the time and effort required for teaching or service
commitments, delegating the care of patients to unsupervised trainees,
not participating or contributing to committee meetings exemplify a
lack of conscientiousness and a deviation from expected standards of
professionalism. (in Univ. of Kansas School of Medicine, 2000).
9. Conflict of Interest. Issues are inevitable in medical
practice. But if we can help it, we must avoid situations in which the
interest of the physician is placed over and above that of the patients,
or where the scientific process is affected by other interests.
Avoidance of potential conflicts of interest is a welcome idea in
professionalism in medicine and science. Conflicts of interest may
refer to self-referral, interpretation of data, based on influence from
pharmaceutical companies and the acceptance of gifts. In this regard,
it is suggested that policy statements must be explicitated to the effect
that personal acceptance of gifts subsides for travel from drugs and
equipment companies must be scandal free. It is wise to be very
careful about this matter to avoid distrust by the public.
The Inherent Ethical Nature of the Profession of Healing.
Medical professional practice, including the allied health profession,
is considered a moral enterprise. Since medical procedures entail
decision-making by weighing the risks and benefits accruing to it,
then it is a matter of ethical choice. Since there is an act of choice, it
is therefore, presumably a choice to do good (beneficence) and
prevent evil (non-maleficence, primum non-nocere). Or when there
are bad consequences, but the good far outweighs the bad
consequences, then such choice is within the ambit of ethical choice.
This happens in fact in the myriad of medical activities. And since
many of these choices have to take into consideration the dignity and
worth of the human person, particularly the patient him/herself, more
so that the choices that are made must be carefully thought of or
reflected upon as any error committed can have the harmful
consequences of the impairment of limbs or loss of lives.
Moreover, as has been pointed out in the introduction, Chapter
1, medical practice is ethical practice because it entails choice from
among alternatives, like a choice for the culture of life or the culture
of death, for the good of humanity or the good of science itself, for
the good of the patient or of the medical practitioner, for the sake of
honesty or deceit, for the noble values of life or the lure of money,
etc. Many times, values clash and the art of medicine and other life
sciences are not spared. That is why there is reason to pursue the
construct that as a human enterprise, medical practice is ethical
practice. The radical separation of the two creates a wide chasm
between the technical and ethical aspect of medicine, and
consequently makes it a technical and economic enterprise bereft of
nobility, rather than a humane art replete with character. The bond
(nexus) that should necessarily link the technical and the ethical
dimension of medicine is the attribute the integrally perfects the
practice into being a noble profession.
Let us see what the experts in the field say about this, to wit:
“Medicine (or health care) is a moral enterprise.”
Leon R. Kass, MD,
Bioethicist, (1985)
“The ought or ethical dimension is an integral part of the
medical decision.
Healthcare professionals have the knowledge and skill to make
technical decisions, but every healthcare decision involves human
needs & human values that are subject to choice. Therefore, health
caring is also an ethical decision and is loaded with deontology (duty)
towards his fellows.”
Kevin O’Rourke, OP, Prof.-
Bioethicist (1987)
“Without a correct moral line, the best professional is
always bad. Without the moral source, the very technical efficiency
of the profession fades away and disappears. Bioethics springs forth
from the medical profession like a spontaneous flower.”
Gregorio Maranon, MD, Spanish Doctor
(1985)
“Ethics is a damned bloody affair, & if it cannot give me
direction on how I ought to be and to live in this social and historical
contest----well what meaning does it have then?”
Max Scheler, German
Axiologist (1974)
“Physicians must have to imbue their clinical &
professional activity with an ethical aspect; not only because they can
relieve the pain & suffering but turn them into a value that gives them
a true meaning.”
Oscar J. Martinez-Gonzalez, MD, Mexican Doctor
(n.d.)
Case Studies:
A. Advertising for Pay
Dr. V. V. Illa works in a government hospital. As a civil
servant, he receives salary based on his grade in the hierarchy of the
civil service. He has six children and they are of school age. Dr. Illa
needs badly an economic boost to be able to meet the educational
needs of the children. When he was approached to appear in a TV
advertisement to endorse a whitening product, glutathione, he readily
agreed as this will help him in his financial needs. He knew
beforehand that doing advertisement to endorse a product is against
the Medical Code of the Philippines. He knew well that there are
only four things that a doctor can advertise as provided in the code,
namely: the name of the doctor, his specialization, his clinic hours
and the address where he practices his trade. As a consequence, he
was warned by the Philippine Medical Association that doing an
advertisement is a violation of the code and that if he does not end his
association with the product, he can be suspended and repeated
violation would result to expulsion from practice. Dr. Illa justified his
action that as a government doctor his salary is not even enough to
send his children to school. An added income was what he was
looking for when he agreed to endorse the product.
1. Is it ethically wrong for Dr. Illa to endorse a product in a
TV advertisement? On what basis should this be considered ethical
or unethical.
2. Was the Philippine Medical Association right in warning
him about the violation he committed? Why?
3. Should not Dr. Illa be justified in his action as the added
income will surely help him in the financial and educational needs of
his children? How?
 4. Is meeting the educational needs of his children a grave
reason to contravene the provisions of the medical code?
B. A Lesson in Compassion in the Medical School?
The Vice-Dean of the Medical School summoned the faculty
members of the Department of OB-Gynecology to consult and seek
their opinion about the failure of 10 third year students in the subject
Neonatal Neurology. She was told by the faculty members that these
students deserved the failing grade because they got very low marks
in three exams and that no matter how they tried to “doctor” the
grades, they could not meet the minimum requirements for a passing
grade. The Vice-Dean told them that the students, especially, the one
who is close to her deserves a second chance as passing her is a sign
of a compassionate faculty and this would teach her a lesson in
compassion which is an essential characteristic of a good doctor in the
future. This generated a strong reaction among the faculty members
concerned. When the Vice-Dean was insistent, they pointed to the
possible violation of the present policy about student promotion.
Further, if they have to pass the student mentioned, they might as well
pass all the failing students as this would also be a lesson in justice
and not only compassion.
1. What can you say about the Dean’s conduct of insisting to
pass the student? Explain.
2. What can you say about the faculty members’ disagreement
with the Vice-Dean? Explain.
3. What can you say about the student, a future doctor,
asking for a passing grade? Explain.
4. What do you say about the professionalism of the major
characters in the case?
C. Drama in Professional Rural Medicine
The practice of medicine in rural areas has never been more
intense and competitive than medical practitioners fighting for
patients’ patronage. Since it is a usual observation that doctors in the
provinces are faced with a limited number of patients, they try to
attract them with every means or gimmickry possible. When the
infighting becomes intense, they would even resort to solicitation of
patients and make derogatory stories against other doctors. Some
would establish pharmacies and X-rays of their own to get captive
patients. Some would practice medical specializations different from
their own. Pediatricians, for instance, practice geriatrics. Some
would sell sample medicines for added income and give for free the
expired with the justification that even when the expiry date has
lapsed, these medicines would not lose their potency until six months
later. Some work as part timers moonlighting in the municipal health
centers due to lack of medical personnel. When there are medical
missions scheduled in their places, they do not participate saying they
are too tired to do it since they serve the same people everyday.
1. What can you say about the practice of medicine in the rural
areas?
2. Is there unethical and unprofessional conduct that you can
identify in their practice?
3. What principles of professionalism have been violated?
How?
4. What actions can be done to make such practice a
collaborative effort of all and engender win-win solutions?
D. Nurse vs. Doctor
In some states in the USA and some countries around the
world, laws have recognized some advanced practices permitted to
perform responsibilities reserved exclusively for physicians. For
instance, for a long time, insertion of IV can only be done by the
physicians, but nurses can do it now. Before, anesthesiology
procedures could only be done by anesthesiologists. Now many
nurses have master’s degree in special areas (like anesthesiology) and
have acquired a level of competence and eventually passed
certification examinations as nurse-midwives.
Ms. J. Garcia, a pregnant 22-year-old, considers having a
baby with the help of a nurse-midwife in a government hospital other
than an OB-Gyn. The OB-Gyn already expressed her intention to
attend to Ms. J. Garcia. Ms. Garcia feels more comfortable though
with her nurse-midwife.
1. How should a patient such as Ms. J. Garcia decide on who
among professionals would take care of her?
2. To what extent can Ms. J. Garcia insist on her choice
without hurting the feelings of the OB-Gyn?
3. What happens if complications arise during the delivery
and she will need a physician to consult? Should this not be taken into
consideration? How?

Chapter 5
What is man that you should keep him in mind,
mortal man that you care for him?
Yet you have made him little less than a god;
with glory and honor you crowned him. . .
Ps. 8:5-6

HUMAN DIGNITY: THE GOAL OF BIOETHICS

good understanding of the concept of human dignity
A will pave the way to a good understanding of what the
nature of the discipline of Bioethics is all about and vice-
versa. Bioethics, as we know, is a relatively new discipline. Up until
now, there is a vague understanding of what the goal of Bioethics is.
Below is a discussion on why human dignity is the specific goal of
Bioethics.
The Concept of Human Dignity. Etymologically, the term dignity
comes from the Latin term dignitas or dignus, -a, -um which means
“worth” or “worthy”. Accordingly, anything that has worth has
value. And such value can be understood in monetary as well as, in
ethical terms. Obviously, human dignity can only be understood in an
ethical way, as the value of humans cannot be reduced monetarily, but
only in terms that are intrinsic to its nature as a moral being and
therefore with a sense of right and wrong. When the term is applied
to human persons, dignity refers to human worth and value. And
since human persons have the highest rank in the hierarchy of
creation, it follows that human dignity is the highest worth and value.
What makes human dignity even more significant is the fact that its
concept is not only limited to earthly appreciation, but even beyond
it. That is why, any decision or act made in favor of human dignity is
one that merits heavenly rewards. On the contrary, any decision or
act that conflicts with or hurts human dignity defies heavenly merits.
This should be one reason why Bioethics holds human dignity as its
distinct and foremost goal. For this reason, all bioethical concepts
and principles are meant for the pursuit, promotion, protection and
defense of the value of human dignity.

Essentially, human dignity is “the state of being worthy of respect and

honor.” (in Oxford Encyclopedic English Dictionary, 1991). Thus,
the term is not only an accident of quality but is essentially and
substantially inherent in the nature of a human being. Where a human
person exists, there, too, is his dignity. When this concept therefore is
predicated with the adjective of “human”, it is used to signify that all
human beings possess inherent worth and deserve unconditional
respect, regardless of social and demographic categorizations like age,
sex, health, economic status, social or ethnic origin, political
persuasion or religion. In other words, this respect is owed to every
individual by the mere fact that he is a “member of the human
family”. The Universal Declaration of Human Rights of 1948 in its
Preamble is very emphatic about this. This intrinsic worthiness is
widely recognized by international law as the source of all human
rights. Many international covenants recognize and affirm that any
recognized human rights are “derived from the inherent dignity of the
human person.” Even natural law implicitly but directly recognizes
it.
Moreover, at the philosophical level, following the great
theologian and philosopher, St. Thomas Aquinas and modern thinker,
Emmanuel Kant, the expression, “human dignity” is used to indicate
that persons should always be treated as ends in themselves and never
merely as means. Kant presents “dignity” as exactly the opposite of
“price”, since “price” is the kind of value for which there can be an
equivalent monetary appraisal. But “dignity” makes the person
irreplaceable and inviolable. Therefore, dignity can be explained as a
requirement of non-instrumentalization or non-utility of persons.
According to this anti-utilitarian approach, there is nothing, neither
pleasure nor common interest of society or science, nor other good
consequences, through which it is morally acceptable to treat persons
merely as means or as utilities even if an act will lead to some good
end. Philosophically, the end is always greater than the means. Since
humans are ends, others are subordinate to it.
Human dignity extends therefore to all human beings whether
in the ontological level, as in the case of human embryos or fetus, or
in its functional level, as in the case of those who have already
developed mental functions or who have reached the age of reason, in
whatever condition or circumstances they may find themselves in.
Human dignity therefore prohibits any unjust discrimination of
human beings especially in their pursuit for the actualization of their
human potentials through education, contemplation, spirituality or
any other human pursuits.
It is in this view that patients can reasonably demand quality
service from health care professionals and institutions. They can
demand swift attention because they bear a dignity which they are
duty bound to protect and defend. They should feel obligated that the
dignity they possess brings with it the obligation to stewardship
which they are accountable. It should be understood that patient
rights are claims to fundamental needs to promote and protect human
life with its attendant dignity when such is in danger of ruin or faces a
prospect of undue death. And those to whom patient rights are
entrusted must feel the same obligation to uphold the same right to
their person. As a consequence of the respect due to their dignity,
freedom is enjoyed. Freedom after all is the enjoyment of human
rights.
The Theological Bases of Human Dignity. Salvation history
presents a rather clear and deep understanding of the bases of human
dignity. This should not pose any difficulty as this can be seen in the
theological and scriptural concepts of the creation of man, his
eventual redemption and his ultimate end. Moreover, it can be seen in
his intrinsic nature as a moral being. The following are the bases of
human dignity:

1. Man is
Created in the Image and Likeness of God. The crowning glory of
God’s creation is the human person. When He created man, He gave
him the greatest and highest gift He could ever accord to any
creature. God gifted him with unearned sanctifying grace, thus,
making him a very special child (or friend) of God. It pleased the
Creator to see that man was immune from moral defect, to be as
perfect as God wanted him to be, such that among creatures, man is of
the highest order and worth. The book of Genesis is crystal clear in
declaring that “man was created in the image and likeness of God.”
Analogically, when one faces a mirror, it gives him a picture of his
image and likeness. The image and likeness are almost a perfect copy
of his features, including his shape, form, color, beauty, etc. When
we talk about our being an “image and likeness of God,” it simply
tells us that we reflect in us the attributes and qualities of God. Thus
even as creatures, we inherently reflect goodness, truth and beauty.
Thus every person possesses these attributes, making him good,
beautiful and truth-bearing. Thus, these attributes carry with them the
attendant obligation from others to give due respect, precisely because
in man are God’s attributes.

2. Christ
Redeemed Man from His Sin. The indignant Psalmist David asks
God, “What is man that You should care for him, mortal man that
You should keep him in mind,” (Ps. 8:5). For God to shed away His
dignity and majesty and consequently assume a human flesh is a
mystery. For God to die a shameful death to redeem man from evil
and its consequences is even an act of “foolishness” as St. Paul says.
And lastly, for God to act like a “fool” for the sake of man, seems to
defy divine logic. But the fact is that, God did so and such has been
consigned to the depths of the divine wisdom. It is like saying that
God was willing to do anything for man. Be that as it may, this act
of God in the person of Christ attests in absolute terms to the worth
and value that is in every human person. God would not have done
all these “foolishness” if the human person was not worth redeeming.
It is in this view that we attribute to man his privileged dignity. Of all
creatures, one finds that it was to man that God bestowed his
divinity. “Though He was in the form of God, Jesus did not deem
equality with God. Rather, He emptied Himself and took the form of
a slave, being born in the likeness of men.” (Phil. 2:6-7). Any
dignitary would not sacrifice himself in favor of anyone, if he does
not see any worth in the latter. It is for this reason why the second
basis of human dignity is man’s being redeemed by Christ. This is
also the answer to the indignant Psalmist’s query above.
3. Man Possesses an Ultimate Destiny. Among creatures,
man stands out to be distinct from the rest. Not only is he gifted with
the power to think and love, but also with a prized privilege to
possess a destiny beyond earth. Plants and animals come and go.
The Psalmist attests to this when he says, they grow in the morning
and wither away in the afternoon. “Like grass they wither quickly;
like green plants they wilt away. (Ps. 37:2). Man was not only given
the privilege to behold the beauty of visible things, but even the
power to possess those that are beyond it. God, in his generosity, has
gifted man with the highest and greatest destiny that no other
creatures could achieve and experience. That destiny is his ultimate
union with his Creator where every tear will be wiped away, every
defect is perfected and shortage filled to the brim, even and flowing
over. This destiny is what we fondly call Heaven. Therefore, any act
that stalls or is contrary to man from achieving his ultimate destiny is
a violation of his human dignity. Any act that stymies him from
pursuing his ultimate end is repulsive to human dignity. Any
structure or system, whether political, economic, religious that works
to negate his ultimate goal is against human dignity. When a patient
who needs help is not being attended to by his doctor, nurse or any
other health care giver for any reason, be it financial, social or racial,
constitutes a great violation against human dignity, and therefore
against God. Every person must have a moral imperative to remove
obstacles that contravene human dignity even if sometimes, one has
to pay for it with his very life. The saints, and especially the martyrs,
have exhibited this moral courage many times as can be gleaned from
the history of Christianity.
4. Man is a Moral Being. Man’s moral nature is the
philosophical basis in the understanding of the intrinsic nature of man
deserving a human dignity. Any creature that has a sense of right and
wrong possesses free will and has reason to be treated with respect
and honor. In the depths of his heart, man knows what these right and
wrong are all about. Human reason dictates that there are acts that are
worth doing and acts that are prohibited. Natural moral law is very
clear in this regard. As a moral being, man knows what to decide on
even imperfectly, sometimes. He knows how to choose which path to
take as he deems fit. This power to choose is brought about by his
freewill thus making him responsible for his actions and their
consequences. For possessing that attribute, he deserves to be
respected. It is through this attribute that he is able to determine what
he likes or dislikes or what is good or not good for him. This makes
him a moral being, an agent that knows how to choose what is right
and wrong, and foresees the consequences of his choice. He,
therefore, is responsible for the choice he makes. Any good thing he
does merits reward and must be acknowledged. He cannot demand
respect however when he himself does not know how to respect other
moral beings.
In summary, it is well to note and aver that if we wish to talk
about human dignity, we necessarily have to talk about man as a
being with created in the image and likeness of God, having been
redeemed by Christ, possessing ultimate destiny, and finally, as a
moral being. When these bases are not present, then we cannot talk
about man’s worth and value. Without these bases, man is reduced to
the level of beasts, plants and animals and other lowly creatures. We
cannot also talk about respect for others. Consequently, the proverbial
law of the jungle, not natural moral law, will determine and dictate
the behaviors of man.
5. Man is a Rational Being. No creature can compare with
man because he is gifted with reason. Being gifted with reason he is
able to think, reflect, analyze, decide, love and act the way he wants
according to how his thoughts operate. His rationality includes the
exercise of his free will and therefore decides what he wishes to
accomplish. He crafts his destiny according to how he things about
his future based on how he knows and understand his actions and
things. He is able to educate himself and mold his character. He does
not act only on instincts but out of deliberate action, unlike the
animals. Because of this, man is placed in the high pedestal of
hierarchy, the hierarchy of creation’s dignity.
From the above, one is able to understand where man’s dignity
comes from and how it is known by reason or natural law. In effect,
it is to this human dignity that all actions or decision of man, whether
by any ordinary or professional person must be to promote and
uphold human dignity. Without this, all actions or decisions do not
have meaning nor sense. What makes actions meaningful and filled
with sense is when everything is done and decided towards the
safeguarding and preservation of human dignity.

Case Studies:
A. A Laudable Collective Act
Jojo is 6-years-old. He was brought to the hospital
by his mother due to an on-and-off fever. He and his mother came
from the squatters’ area where they have a “home along the riles”
(home along the rail track). Further examination revealed that he had
dengue. Due to poverty, Jojo’s mother could not buy the medicines
necessary to treat the illness and according to the hospital, could only
be bought on cash basis. The mother could only afford a small
amount and no matter how she tried she could not produce the
money. She was able to get a discount from the hospital but this was
not enough. The medical residents and nurses contributed whatever
amount they could to help little Jojo. The attending doctor did not
charge little Jojo’s mother any professional fee. Luckily, everything
turned out fine with him. He was discharged after seven days and
recovered well.
1. What can you say about the actuations of the residents and
nurses and the attending doctor of the hospital?
2. What virtues can be learned from them?
3. What can you say about the policy of the hospital with
regard to the payments “on cash basis”?
4. Emergency situations to save life must be addressed with
swift medical attention in order to save life. Hospital payments must
be deferred if only to hasten the procedures that need to be done.
What can you say about these statements? Elaborate.
B. A Medico-Legal Case
Richard Grande is 18-years-old and is out-of-school and
resides in a squatter area. He and his friends figured in a rumble with
another gang which left him with a gaping wound. If not immediately
treated this could leave him dead. He was brought to the hospital by
some bystanders. The hospital has a policy that all medico-legal
patients seeking treatment must as much as possible be identified and
reported to the proper police agency. Richard Grande could not be
identified as he did not bring any ID or any paper for identification
that delayed delivery of medical attention. Richard was gasping for
breath and was losing blood. The emergency director immediately
dispatched a surgeon to do the operation on him. Richard
unfortunately did not survive.
1. Was there negligence on the part of the hospital that caused
the delay of Richard’s operation which led to his death?
2. What can you say about the hospital policy of requiring
identification of medico-legal patients before doing any procedure?
3. Do you believe in the treatment of emergency patients even
if they are too poor to pay the hospital bills? What ethical principles
can be applied here?
C. A Day in an Anencephalic Baby’s Life
Baby Angel is born as an anencephalic baby. She was born
with only one fourth of her brain present. According to medical
experience, those born with such physical condition do not live longer
than three days. Meanwhile, she was left in the delivery room to die
while struggling to cry. The doctors ruled out feeding her as they
believe this would not help her survive and it would only be a waste
of resources. Baby Angel is born to poor parents and the mother does
not produce enough milk to feed her baby. Eventually, Baby Angel
died.
1. What can you say about the actuation of the doctors as
regards non-feeding of Baby Angel?
2. Is feeding really a waste of resources since anencephalic
babies cannot survive more than three days? Explain.
3. Was it still ethically worth feeding the baby? How? Was it
still ethically worth saving the baby’s life?
D. To Restrain or not
Mrs. Grace M. is seventy-six years old and has dementia.
Although she functions at normal levels, at other times the nurses in
Catherine Nursing Home where she resides for the past 10 months
would find her wandering aimlessly along the corridors and unable to
recognize them or know where she is. She is unsteady and frail when
walking alone. She has already fallen out of bed two times. She
might then endanger herself if she continues to wander around. The
nurses did not want to sedate her with tranquilizers because they are
chemical means of controlling her.
The nurses sometimes restrain her onto a chair or
bed as the case may be. Mrs. Grace M. objected and tried to fight it
out with the nurses, then cried, struggled and finally gave up in
frustration. She lost all vibrancy and became very passive.
1. Is restraint on Mrs. Grace against her human dignity?
2. Are chemical restraints more unacceptable ethically than
physical restraints?
3. Sometimes nurses use restraints to simplify their work, how
might the staff be acting in favor of the patient?
4. If Mrs. Grace M. were your mother, would you want to see
her just cry when restrained to her chair or bed? Explain.
E. No Money, No Body
B. Extraordinario, a 60-year-old male, single, was brought to
the Emergency Room brought by unknown persons. He complained
of low back pain. He was eventually confined and was treated at the
Orthopedic Services for Low Back Pain Syndrome. He underwent
various procedures until his hospital bills had accumulated. No
relatives and visitors came to see him nor settled the hospital charges.
Later, Mr. Extraordinario had a CVA stroke and was transferred to
the ICU, and was later intubated. Unfortunately, there was no one to
sign the consent for further medical treatment and procedures. His
case was referred to the Bioethics Committee which decided later that
the treatment be continued. The hospital bills this time reached to
more than three hundred thousand pesos. The committee ordered
search of his relatives, but efforts have been in vain. When Mr.
Extraordinario died, no one even claimed his body. Accordingly,
since no one claimed him, the administrator, Mr. B. Halfoso, decided
to sell his unclaimed remains to a medical training institution. He
justified it by saying that it was done to compensate for the patient’s
unpaid hospital bills.
1. What are the ethical issues that can be raised in the case
above?
2 Was it right for the Bioethics Committee to decide on the
continuance of treatment even without signature of consent from
anyone, for further treatment? Explain.
3. What can you say about the relatives who did not show up
to claim Mr. Extraordinario’s remains? Explain.
4. What can you say about the administrator’s decision to sell
the patient’s body to a medical training institution? Explain.
 Chapter 6
Beloved, I hope you are prospering in every respect
and are in good health,
just as your soul is prospering.
3 Jn. 2

LIFE, HEALTH AND DISEASE

clarification of the understanding of the concepts of human
A life, health and disease is dealt with in this chapter since we
talk about Bioethics, the ethics of life and of life sciences.
We cannot really make ethically sound decisions about human life,
health and disease unless we are able to understand the nature of these
concepts. Essentially, all legal and moral acts are related to them and
their values. Be that as it may, we have to understand that all ethical
decisions must consider what promotes life, what enhances health and
what mitigates disease.
The Concept of Human Life. Life, as in human life, is “that
which consists in self-motion or operation.” This is how
philosophers generally understand it, although very abstractly. Yet, if
we try to understand it under the light of biological science, this
definition is full of relevance. For indeed, life must have self-motion
that is either generated by its interior principle, or as a responsive
reaction to some stimulus. Because it has self-motion generated from
within, it has the capacity for change through locomotion, growth or
sensation. Both plants and animals are endowed with life. Now, for
life to effect change, there must be a principle that is responsible for
it. For philosophers, this principle is called the soul. St. Thomas
Aquinas has claimed that all living beings possess that soul, be they
humans, plants or animals. The only difference of the soul of man is
that it is spiritual while that of plants and animals is material. Since
man’s soul is spiritual, it is immortal and thus cannot die. Since plant
and animal soul is material, it is mortal, and thus can die. The death
of pants and animals is the death of their soul.

Accordingly, human
life begins at conception, a.k.a., fertilization. It is when the male
sperm and female egg fuse together and produce another entity,
different from the mother or father. This uniqueness is well proven
scientifically, as has been declared by geneticists or embryologists
through the presence of the chemical basis for heredity, called
deoxyribonucleic acid or DNA. It is a biological fact that there had
been no known similar DNA’s for even two different persons. It is
for this reason that even the newly formed fertilized ovum or zygote
possesses an entirely new entity that is human in nature because when
given the chance to develop its potentials, it becomes a truly perfect
human form and will never become something else. It will never
become a plant or animal, nor will it be a totally different creature
from the parents where it came from. As it develops, more and more
features and characteristics that are distinctly human will become
evident, like the capacity to think, reason (out) and exercise free
choice. Later, this human becomes more and more educated to
morality and will make ethical choices befitting a human being. The
capacity for morality is therefore an essential part of humanity. And
when such capacity becomes even deeper, such leads to spirituality.
Thus, spirituality is also a very essential part of one’s humanity
because indeed, man is a composite being, with body and spirit. Here
we see that humans are embodied spirits.
Now, human life consists of various dimensions, namely:
physical, mental, social, moral and spiritual that develop in stages
through time. To have life is to have these dimensions function as
they should. The absence of anyone of them makes life incomplete
and makes a person “less human”. Being human gives one some
natural claims, called human rights. The highest of these rights is
the right to life. Hence, even at the earliest stages of the development
of a fetus, it is endowed with a right – the right
 to life. In this
case, a human being is a person and therefore has rights. Thus, human
life consists in those attributes that are inherently human in character.
Basic among which are the capacity to think, reason, pursue a goal or
exercise freedom. And this capacity is fulfilled when the right age of
the development of the person arrives as all humans do.
Woefully, the pro-choice, a.k.a., pro-abortion advocates
cannot comprehend, whether by design or ignorance, a fetus or
unborn baby to be truly human because of their advocacy in favor of
abortion procedures aside from other reasons ranging from economic,
morally guilty conscience, or purely on ideological basis. The very
strong lobbying of these advocates before their government has paved
the way and penetrated into the political arena where eventually, the
politicians acquiesce into making legislations in favor of abortion, the
killing of unborn fetus. These legislations have been skewed sadly, to
the disadvantage of the most vulnerable members of the society, the
unborn babies. Here is where the significance of Bioethics becomes
even more relevant, even as it is direly needed in order to save babies
from getting slaughtered and avoid the replay of Herod ordering
innocent babies getting killed unconscionably.
The Beginning of Life, What Scientists Say. Some bare
scientific facts must be borne in mind to understand clearly what this
so-called beginning of life is in more technical terms.
To reiterate, according to geneticists and embryologists around
the world say that human life begins when male sperm and a female
ovum unite to form a new organism. An embryonic genome or
fertilized ovum is the result of the union. This process is called
fertilization. Sometimes it is referred to as conception, taking
shape, quickening or ensoulment (but not nidation because this
refers to implantation). This new organism initially is one-celled,
then two-celled, four-celled, until it completes the 23 pairs of
chromosomes. This genome is a genetic unity and remains to be one
organism (unless it is a multi-pregnancy). It becomes activated until
after two to eight cells are present in about two to three days. The
development of this embryo is rapid and continues to grow to other
fetal stages.
There are some peculiarities that must be well grasped in this
so-called fertilization, as understood as a beginning of life, namely:
1. It should be a clear and well defined event that can actually
be pinpointed as the beginning of life. Hence, when a being starts to
exist where before there was nothing, then that is called a beginning.
2. It should exhibit the cardinal feature of the beginning of
life, i.e., growth. Hence, movement must be present for any
beginning to happen.
3. If this growth is not interrupted, it will naturally lead to the
subsequent stages of life as we know them, namely: fetus, neonate,
adolescent, adult, old . . . until death.
4. It contains the genetic code (DNA, as mentioned above) that
is characteristic of the human race at large, and also of a unique
particular individual of whom no other human being is a perfect copy,
from eternity . . . until eternity.
5. It is not preceded by another phase, which combines all of
the characteristics from 1-4 above.
It is unfortunate that the definition by World Health
Organization (WHO) (and Pro-choice advocates) of the “beginning
of life” is not the “moment of conception” but the “moment of
implantation” of the fertilized ovum into the uterus. For whatever
reasons, the Philippine Department of Health does not make definite
declaration about the moment of conception. But WHO is flagrantly
and grossly erroneous in its pronouncement bereft of any biological
basis and only pander with the pro-abortion movement. This is so
because WHO, especially the United Nations Development Program
(UNDP) has been promoting among the developing nations the use of
various morning after pills, deflecting the idea that killing the fetus
while still in the fallopian tube or when implanted in the uterus will
not be considered abortion. Granting without admitting that life
begins in implantation, it is proven that morning after pills and IUD
function to destroy fetus in the uterus. This is a brazen display of
arrogance that mocks the view of authentic and disinterested
biologists. It is hard to understand why an institution like WHO (and
even DOH) misinforms people with a doctrine based on a very bad
biology. When pronouncement is based on bad biology, it leads to a
very poor and even egregious thinking and practice. We can only
think how bad biology is when life is understood as to begin only
with implantation of the fetus in the womb of the mother. It is ironic
that the mother who is bearing an ectopic pregnancy is considered
pregnant. This is so because she carries a baby in such a pregnancy,
no matter how such pregnancy may not reach her uterus.
The Sacred Character of Life. The expressions “sacred character of
life” and “sanctity of life” have always been perceived as religious in
modality. And yet, it has always been understood under a secular
interpretation. It is a “non sequitur” though that when a something
is primarily religious, it is religious through and through. As a matter
or fact, whether someone is religious or profane, human life has
always been deeply understood as sacred because it comes from a
holy Creator. As many philosophers and bioethicists ask, “If life is
not sacred, what is therefore sacred?”
 Now,
attitudes about the appreciation for life among peoples and societies
constitute some fundamental concepts of their behavior. Among
physicians and theologians, this principle of the sanctity of life is
most relevant and meaningful as they always deal with life in their job
and in the practice of their profession. Now the basic attitude of
respect and honor for human life is served depending on how people
and societies valuate it in their mind and in their conduct.
Of course, the sacred character of life is very much rooted in
one’s religious view. However, it can also be based on some
humanistic or rational stand.
The Judeo-Christian tradition based on the Sacred Scriptures
gives a very deep respect for human life. First, by order or origin,
God is the Author of life and that by virtue of its nature, human life
has a dimension of spirituality and a destiny that is beyond time and
far-reaching grasp until eternity, the domain of an eternal Creator
God. Hence, man is not the absolute master of life, but God. Thus,
the sanctity of human is both extrinsic and intrinsic, from God and is
destined to God, and from the nature of man himself, as an embodied
spirit. The advantage of this position is that, no human authority can
tamper or tinker with life unless it takes into account and receives
countenance from God Himself and the inherently moral nature of
man. Life therefore, is something to be affirmed, cherished, respected,
enhanced and promoted as God’s will and gift. And this has bases on
the doctrine of creation, of the presence of God of History in the
affairs of humanity, their redemption in Christ and their eventual
eternal destiny.
Moreover, the humanistic view that life is sacred can only be
gleaned from natural law, since right reason can discover what the
provisions this law demands. For an honest and sane person, this
view leads him to the admission that life is meant for something noble
and admirable beyond the world, beyond “eating and drinking, for
tomorrow we die.” Life therefore always looks at its highest
perfection and would not stop until it finds what St, Augustine of
Hippo said, “rest in God.”
From the religious and humanistic points of view, we can
deduce some natural consequences of what life demands to be a
sacred obligation. These include among others the obligation to
promote and work for the survival and integrity of the human species
and the created world as these contribute to the recognition of the
sanctity of life. Added to this is the sacred duty to work for the
survival and integrity of family lineage, to perpetuate the human
community and of the world in general. It certainly also includes the
integrity of personal bodily and psychic individuality of persons.
That is why doctors and their allied professional health carers should
be solicitous of the health of humanity and should always be ready
and willing to help the sick and the ill even without financial gain.
Lastly, since human life is not only a bodily organism but also a
spiritual being, everyone must work for that which will lead him to
the highest destiny that is supernatural where he will achieve his
greatest satisfaction and actualization.
Health and Disease. Human values can never be understood well
unless we have a good knowledge of the nature of health and illness.
The term, “health” is etymologically derived from the Anglo-Saxon
and French word, “hal” from which other terms are derived like,
“healing”, “wholeness”, and “holiness”. One who is healthy is
(w)holistically well, that is, he is harmoniously functioning as a
complete being in all his physical, psychological and spiritual
dimensions. When a system is functioning well and is properly
ordered and all components are harmoniously coordinated, then the
system is in good health. Take the case of a bridge. If all its
structures and functions are well in order, each part contributes to the
whole, then it will never collapse and no accident can happen that
would harm people and motorists. The same can be said to the health
of human life. When a part or the components of the bridge cannot
serve the purpose for which it has been erected, that is, when they are
deficient, it breaks and collapses. It becomes useless. The same can
be said of humans, when their health is whole, they function well, but
when it breaks, they become unproductive. And the consequences
may not only take its toll on them, but on the general community, as
in the case of the dreadful COVID-19 pandemic that shut down the
whole world in 2020 (or epidemic as the case may be.)
Now, the WHO defines health as “the state of complete
physical, mental, and social well-being and not merely the absence
of disease or infirmity.” This state of well-being is an ideal concept
which involves maintenance of proper latitude for human functioning
in terms of physical, social and mental order. Any deficiency in any
of these latitudes may render illness or disease to a person. Thus, for
instance, when it comes to mental state like happiness and we find
someone who seems to be unhappy, this could be an indication of a
state of being unhealthy. A good understanding of the definition of
health, as here above underscored, brings to the fore the idea of how
we exercise our human values. This is especially important to health
care professionals, and as such will lead them to the understanding of
the goals of medicine, public health and even public policies on
health. If the goal of health is preservation of life, then medicine
becomes preventive (like, immunization, and a heavy focus on
nutrition and vitamins). If it is on cure, then medicine becomes
curative and restorative in character (like restoration through immune
system boosting or antibiotics-based cure). And when its focus is
improving the quality of life of those that cannot be otherwise cured,
then medicine becomes convalescent (like hospice care and comfort
care). Unfortunately, when medicine becomes defensive, then, such
medicine is legally-loaded due to the threat of civil, criminal and
administrative liabilities. What can be most scary is when medicine
becomes unreasonably aggressive and assaultive, and then medicine
is abortive or murderous. In this case, while medicine must bring
about goods to the people or society, it becomes its own enemy. This
kind of medicine is sick!
Both Ashley and O’Rourke (2002) have crafted a very
splendid definition of the term, health. Accordingly, “health is the
state of being in which an individual does the best with the
capacities he has, and acts in ways that maximize his capacities.”
This definition dismisses the idea of medicine as defined in terms of
standard of physiological parameters – the vital organs, the presence
of various chemicals in the blood, electro-neurological readings, gross
anatomy and histological condition, etc. In part, this may be correct,
but if the above indicators are the only parameters used to define
health, then no one can really be healthy. The consequent inference is
that health is arbitrary and that the healthy are not really completely
healthy.
 The definition of health by both Ashley and O’Rourke is not
based on organ or organ system but on the functioning well and
together to form a single harmonious life process. In other words,
health is orderly and harmonious functioning of the various
components of the body, and although different, it is characteristically
whole.
The setback however of this definition is that, now everybody
is healthy for as long as he does best the capacities he has, and acts
optimally with these capacities. The best acts may be very relative
and optimal act may be very subjective. There are no standards or
averages here. One may be limited in his physical movements due to
high uric levels in the joints, but for as long as he acts best and
optimally with whatever capacities that is left in him, he is healthy.
The above definitions have of course their own merits.
Although they have limitations, both in the understanding of the
concept and in real experience, they are no doubt very helpful. This
should lead us now to the concept of disease and/or illness.
Disease and Illness. A better understanding of the nature of health
should contribute to a deeper grasp of the nature of disease and
illness. This is due to the fact that the understanding of health is
intrinsically connected with the understanding of disease or illness,
and vice-versa. Where in the age of yore, the concept of disease was
understood as a separate entity from health, as if it were some kind of
strange devil infesting the person or some bad contagions that can be
classified as either micro plants and animals, it was seen as
unwelcome entity that constantly destroys homeostasis. They should
be faced head on through some specific remedies like drugs or
surgery. In the interpretation of oriental or alternative medicine,
health is seen as a harmony and a balance within the organism.
Disease therefore is an imbalance. The concept of Yin and Yang,
accordingly, can only view the presence of health if there is harmony
and balance in the organism. When there is imbalance in the
organism, then there is disease. To restore that healthy status, the
imbalance or fluctuation or disturbance brought about by various
factors in and out of the organism, must be corrected.
From the above, we can define disease as a “state of deficiency
caused by the imbalance of the system of the organism either in
its nature or functions due to biological, mechanical or mental
factors.” This definition falls short though with those who may not
have any deficiencies or imbalance, but who are personally or socially
unproductive, like the lazy persons who do not want to look for a job
to make them productive. The society can easily brand them as sick.
While we attempt to look for a definition of disease or illness,
we should never be ambitious in looking for one that is universal, for
there is none, nor there will ever be. To have one is to do a lot of
semantics and mental calisthenics just as we have seen in our struggle
to have good definition of health. The same struggle can also be said
if we are to distinguish disease, sickness, illness, ailments or
impairments. Usually the use of these concepts must be understood
in context and in the proper use of language. It is difficult to use each
of these concepts in an exclusive manner.
Now, it must be said that life, health and disease are so
intricately intertwined that one cannot be without the rest. Their
relationship can well be seen in this way. Health sustains life and life
disintegrates without health. And this can only happen when disease
overwhelms health. So, health is to life, like a glass is to a drinking
water. When the glass breaks, water is spilled. This happens when
an agent from outside or inside breaks it. And even when the glass is
fixed whole, the water can be in constant risk of getting spilled
because of previous breakage. Life becomes also more fragile even
after breakage in health. Constant watchfulness of one’s lifestyle is
necessary to maintain health and life. Maintenance here includes
physical, mental and even spiritual health. Health is like a container
that sustains life, its attributes and quality. Elements in the
environment can destroy that container.

Case Studies:
A. My Pets’ Interests or my Househelp’s
Mrs. Ma. Cue Nat is well-to-do and lives in a mansion. She
has several househelps and one of whom, Cory C, who has been
serving her for nine years has been designated to just take care of her
pet dogs and cats. Mrs. Nat spends around P50,000.00 for her pets’
food and nutrition and another P20,000.00 for their hospitalization
every month. One day, Cory asked for a cash advance and promised
to pay through monthly salary deduction for three months. She
needed P5,000.00 to pay for her 12-year-old-daughter’s CT Scan
procedure as suggested by the doctor. The daughter complained of
headache due probably to the fall she had five days ago. Mrs. Nat
gave her P500.00 for free and suggested that she rather look for the
rest of the amount from other sources. She further explained that the
money that she had was earmarked for the expenses of her pets and
their eventual burial in a specialized cemetery. Cory C. is a poor
woman who does not know anyone who could lend her money. Non-
procurement of enough money forced her to forego the CT scan
procedure. The daughter was subsequently brought home. Six days
later she died due to blood clot in the brain.
1. Was Mrs. Ma. Cue Nat’s actuation of favoring her pets’
expenses rather than another human being who needs emergency
health care ethically acceptable?
2. Should Cory C. insist that Mrs. Cue Nat prioritize helping
humans first than pets especially when human life is at stake?
3. Should the doctrine of Samaritanism be obligatory upon
Mrs. Cue Nat, and since she did not respond to a cry of help, must she
be ethically accountable for the death of the daughter? Why?
B. Humane Care for Dogs and Cats
In many western countries, people have given so much value
to pets, like dogs and cats. Dogs and cats are given expensive pet
food and usually sent for veterinary check-ups. They undergo
vaccination against rabies. They are given a bath every day and
shampooed. When they die, they are buried in cemeteries for pets.
Flowers are offered to them as if they were humans. They are
considered members of the family. When they are harmed, the person
who does it may be charged with cruelty in the courts of law and may
even go to jail. Pets therefore live as if they were humans with all the
care (and even privileges) given them.
1. What can you say about those who take care of pets like
human beings or consider them like family members? Explain.
2. Do you really think there is such thing as animal rights?
Elaborate.
3. What can you say about cemeteries for pet dogs and cats?
Explain.
4. Do you think it is ethically right to spend for the life of the
cats and dogs more than that of human beings? Justify.
C. Life or Love
Katrina Hermosa, a 19-year-old pretty girl, is a nursing
student. She suddenly stopped her studies when her father resigned
from work due to weakening health brought by a diagnosis of first
stage prostate cancer. Her mother, a plain housewife, told her to look
for a job and help in the needs at home and of her father. She had a
boyfriend, also a nursing student, whom she loved very much. But
she has another persistent suitor who was well-to-do. The suitor
promised to help her in her studies and health needs of her father, if
she would break up with her present boyfriend and accept his
proposal. Katrina was confused. She was torn between deciding for
her father’s health or for the love of her present boyfriend.
1. While the health of her father is very important, was it
ethically acceptable to break up with her boyfriend and accept the
other suitor who can help in the health needs of her father?
2. Was it also ethically alright for the suitor to help her father
in exchange for her love?
3. Does love require conditions?
4. What if the mother advised her to go for the suitor? Was
the mother correct in this case? Why? Why not?

D. Houses for the Squatters or Cemetery for the Dead Pets

The City Council made an ordinance to build
cemeteries for dead pets like dogs, cats, etc. This was in consonance
with the provisions of law about animal rights. “Just as humans have
rights,” the council says, “animals too have rights and deserve to have
decent burial.” But some of the council members posed objection
since this was unconscionable. Many of its constituents wallow in
misery under the bridge and unoccupied spaces as squatters, since
they do not own any lot where they can build their own houses, much
less have decent burial grounds in the public cemetery due to their
poverty.
1. What can you say about the plan to build cemetery for dead
pets? Is this ethically acceptable?
2. What can you say about the objection of the other council
members?
3. Should dead pets deserve a cemetery funded by public
money? Is there any objection if payments would be drawn out from
private funds? Justify.
E. SSS and GSIS to Benefit all Senior Citizens
As they say, “Life is what we make it.” Now, we know that
GSIS and SSS pension funds belong to the private individuals that
have accumulated them through time during their employment. But
the government is tasked to administer them and make sound policies
so that pensioners can benefit from them in a way that their retirement
life would be relatively comfortable for them. Now the government
wants to use these funds help as ayuda to all senior citizens during the
COVID-19 pandemic. But this plan was not without criticism from
the pensioners since the funds may be diluted to benefit also those
who did not contribute to them. The pensioners contented that these
monies are funds they made and contributed during their employment
and that they should only be for their benefit.
1. Is there anything morally wrong with helping all senior
citizens with pension funds from SSS and GSIS as proposed by the
government? Why?
2. Should money from these funds not benefit all senior
citizens since if they are all healthy, the rest of the official senior
citizens will also enjoy health since they will not catch the contagion
of deadly virus as the COVOD-19? Would that be ethically
unsound? Why?
3. What good proposals can be made to benefit all senior
citizens in the use of SSS and GSIS in this case? Justify.
 Chapter 7
All scripture is inspired by God and is useful for teaching,
for refutation, for correction, and for training in righteousness,
so that one who belongs to God may be competent,
equipped for every good work.
2Tim. 3:16-17

THE PRINCIPLES OF BIOETHICS

he term principle is used in all sciences, be they profane or
T sacred. This is so because no science can thrive without principles
that have been truly and scientifically proven through observation,
research, reason and logic. Scientists use principles as guides to
determine patterns of behavior of things and other phenomena. The
same can be used in human activities. People are also called
principled men and women because they follow or abide by some
philosophies or values they believe and live in their life. Which can
withstand the test of time and argument. Principles here are also
used as guides to human actions essentially based on strict mental
analysis and scrutiny. Consequently, this concept agrees well with
what philosophers commonly understand the term “principle” as “that
from which something proceeds.”
The Concept of a Principle. The term principle, as in principles in
Bioethics, refers to the intellectual guide meant for ethical actions. It
is a philosophically and theologically accepted basis or foundation
that can be used to establish directions for ethically tenable actions.
For a medical decision to be sound and justified, a decision must have
a basis that is ethically defensible in theory and practice and must be
able to stand the assault of contrary ethical opinions. Without such
basis, health care professionals will make medical decisions that are
only imitations of what others do or what others believe to be true.
Most of the time, this is what happens to secular ethics. It has loose
foundation as it is loosely based on current or ephemeral flow of
thoughts but not really based on permanent and solid foundations in
Philosophy and Theology and sources from solid foundations. In
view of the above, when decisions become an accepted practice even
when they are flawed, they are passed from one generation to another
only to be discovered later that they actually are wrong and devoid of
reason. Unfortunately, such practice becomes the accepted norms
and are dangerous bases from which to make

ethical decisions, no matter how

indubitable and unsound. When this happens, every decision
involving ethics can be characterized with instability or volatility that
cannot stand the scrutiny of an intelligent debate. This is what
ensues in many of the medical and ethical issues that lead to legal
problems. The cases of Roe vs. Wade, Karen Quinlan, Nancy
Cruzan, the Willowbrook Research, Tuskegee Syphilis Research,
Terri Schiavo, Baby M., etc., have been classic examples that saw
decision-makers struggling over what appropriate ethical principles to
invoke regarding some particular ethical problems. Many try to make
shortcuts by making the courts of law decide on problems that are in
the first place only ethically-intensive. When that happens, we waive
our own freedom and autonomy to decide over health issues and leave
to judges the task of presiding over our health and life issues.
“Legality does not always mean morality” is a doctrine that needs to
be emphasized in our decision making processes. Sadly, when the
courts of law decide and preside over our life and health, the
consequences are shattering.
These principles are guiding instructions on moral or ethical
conduct, as they express what individuals and society expect humans
ought or ought not to do based on their deep personal and social
importance measured by the way they affect human interests and
concerns. They are thus properly called ethical or moral principles.
We have learned, for instance, those maxims, “Respect others’
rights.” “Do not harm.” “It is better to give than to receive.” “It is
always good to honor and respect the elders and parents.” It is of
course taking into account the interests of others. It is through these
elementary maxims that we are led to understand and get deeper
knowledge about the ethical directives and human relational
behaviors. This way of behaving has been integrated, articulated and
expressed into the so-called principles of Bioethics. Thus, these
principles are not the products of mental speculations only but have
bases in human behavior. Consequently, they have bases in natural
law.

It must be noted that without these principles, we run the risk

of falling into inconsistencies and instabilities of ethical judgment in
resolving issues and dilemmas in health care. And any inconsistency
or instability of judgment can lead to some legal complications that
can put health care in question. This will lessen substantively or even
totally erase whatever credence or positive strides earned by this
discipline of Bioethics. As a consequence, Bioethics will be like
sailing against the current and it will be extremely difficult to pursue
the stability of ethical truth in health care.
Categories of the Principles of Bioethics. While the Principles of
Bioethics can stand as principles by themselves, that is, they can be
applied to cases involving ethical issues and dilemmas, according to
Ashley and O’Rourke (2002) they can be categorized under the three
headings, namely:

1. Principles of
Faith. They direct us to form a prudent conscience as fundamentally
a process of knowing and the strengthening and deepening of human
insight and reason that should result in wise and prudent decisions,
(e.g., Well-Formed Conscience, Free and Informed Consent, Moral
Discernment, Double-effect, Legitimate Cooperation, Truth-telling
and Professional Communication).
2. Principles of Christian Love. They motivate the person
to direct his will to be concerned about another and his needs (e.g.,
Principle of Human Dignity, Justice and Solidarity and Totality).
3. Principles of Christian Hope. They are the
eschatologically-charged aspect of ethics. The principles look into
the final coming of Jesus Christ (Parousia) in the fully realized
kingdom of God, where every tear shall be wiped away and dream
realized and where the just shall be like angels praising God in all his
glory, (e.g., Principles of Growth Through Human Suffering, Human
Sexuality and Stewardship and Creativity).
It is under this purview why health professionals, and even
ordinary people, must be trained in Ethics or Bioethics so that in their
life and practice, they shall be found justified as morally-anchored
that should lead them to the possession of the ultimate goal, the
eternal happiness, that the Creator has in store for them.
Further, the Principles of Bioethics are part and parcel of the
notion of the three theological virtues referred to above. Hence, it
should give one comfort to know that the practice of these principles
expectedly can lead to the development of virtues necessary for living
the life of Christ, particularly as health professionals.
The Interrelatedness of the Principles of Bioethics. The Principles
of Bioethics are essentially interrelated. One principle cannot claim
exclusivity by itself since a bioethical case can present its way to
plurality of views and understanding. A single principle will not be
enough to resolve the issues under which cases are being scrutinized.
Philosophically, man and his health needs cannot just be viewed
under a single category but under a plurality of categories. Hence,
any ethical case can involve a plurality of principles, because man has
to be seen in his medical, personal, social, cultural and economic
condition. No single principle can claim monopoly over a particular
case. While some principles are extensive and broad in their
coverage over cases, there are also principles that can specifically
answer particular cases as distinctly as possible. But it should not
altogether exclude other principles as if they are irrelevant to the case
in point. These Principles of Bioethics are also complementary in
function and application, that is, each principle strengthens other
principles when they are concurrently utilized on a particular ethical
case.
The Principles of Bioethics are ethical constructs that may
ethically govern the patients, the health professionals, the health
profession and life sciences themselves, the researchers in life
sciences, the public policy-makers and the general public. While we
recognize that people have their own religious and moral paradigms,
one thing that stands out as basis for ethical pursuits is the inherent
attribute of human dignity and freedom that must be respected at all
times and places.

In specific
terms, the principles of Human Dignity and Stewardship and
Creativity subsume all other principles since one cannot talk about
other principles without touching the former. The principle of
Totality is closely related with the principle of Double-effect.
Autonomy is closely related with freedom and voluntariness. The
ethical and legitimate use of all bioethical principles is related to the
principle of (well-formed) conscience and natural law since both
principles are norms of ethics. One can go on and on regarding the
interrelatedness of all bioethical principles and find that no single and
distinct bioethical principles can stand isolated or independent from
the rest. This is the beauty and wonder of knowing Bioethics. One
cannot be a real Bioethicist by just knowing a part or some principles
and disregard the rest. It is the unfortunate lot of those who may only
know some and be ignorant of others.
Hierarchy and Conflicts among the Principles of Bioethics. The
Principles of Bioethics are utilized according to a certain hierarchy
and precedence. There are principles that are superior principles or
inferior to others. When conflict arises the superior principles have
precedence over others. For example, the principle of dignity or right
to life has precedence over the right to privacy. When life is at stake,
as in abortion procedures, the right to privacy cannot take precedence
over the right to life. This was the problem that has become the bone
of contention in the celebrated case of Roe vs. Wade. The US
Supreme Court decided in favor of right to privacy over the right to
life of the unborn, and since then millions and millions of human lives
from 1973 onwards have been destroyed. Many of the conflicts that
have compromised the Principles of Bioethics are those that have
been mishandled in the courts of law.
The Principles of Bioethics: Bases for Codes of Conduct for
Health Professionals. The principles of Bioethics are the ethical
bases of various codes of health professions like the medical, nursing,
and other professional societies. Without these principles, codes are
mere agreements for professional behavior that can easily break when
members do not act for the interest of the association. But as codes
based on the principles of Bioethics, they include fiduciary duties to
the society it wants to serve. That is why, members are not only
accountable in their misconduct to the association they belong to but
more so to the society they serve. Herein lies the meaning of the
principles of Bioethics as rather far-reaching than limiting in
application.

Case Studies:
A. A Beer and an Accident
Dr. L. A. Singh is a physician on vacation. He had more than
a couple of Red Horse beer and was intoxicated. He witnessed a
traffic accident in which several people appeared to be hurt and
needed emergency medical attention. He felt divided between a duty
to help and running away to evade the humanitarian call as the police
might later discover that he intervened in spite of his alcohol
inebriation. By doing so, he can be apprehended. The police might
also charge him for jeopardizing the life of those who have been hurt
if he helped them.
1. Should he intervene in the accident even if he was
intoxicated? Explain.
2. How strong should a moral obligation be in helping the
victim?
3. Would intervention be morally wrong or obligatory?
Explain.
4. Is intervention morally required while intoxicated? Justify
if yes or no.
B. Med Reps Treats Med Residents to Dinner
A medical representative of a major pharmaceutical company
offers to treat the medical residents to dinner at an expensive
restaurant downtown. The meal is offered, the representative says in
order to provide a location and a comfortable environment to inform
the residents about a new product, an erection drug called Erecta.
1. Should the meal be viewed as a bribe, and thus morally
unacceptable, or is its purpose more benign?
2. Suppose it is a moderate-priced restaurant or inexpensive
one, would either of this alter the situation?
3. Suppose the residents already know about the Erecta, would
there be any morally acceptable reason for the dinner in this case?
4. Suppose the residents could get the same product
information by means of a two-page flier, will it alter the moral
dimension of the case?

C. To Intervene or not to Intervene

 The Nursing Code of Ethics states, among others, the
following regarding patients who are dying: “Nursing care is directed
towards the palliative care of the suffering commonly associated with
the dying process. The nurse may provide interventions to relive pain
and other symptoms in the dying patient even when the interventions
entail substantial risks of hastening death.” It had two paragraphs
earlier that said: “The nurse does not act deliberately to terminate the
life of any person. Death is an indirect consequence of a benefit
enjoyed from the use of pain relievers.”
1. Does the fact that the primary intent in the provision is the
relief of suffering eliminate any apparent or potential contradictions?
Explain.
2. Should there be special concerns in nursing that should be
emphasized by a code of ethics for that profession? What should that
be if there is?
3. The nurse participates in the profession’s efforts to
implement and improve standards of nursing. Does this place burdens
on nurses beyond those of caring for patients at the workplace?
Discuss.
D. Right to Life or Right to Privacy
Gina L. wanted to get rid of her 6-week-pregnancy since it
was a result of incest. She wanted to seek legal relief by invoking her
right to privacy. “This right,” according to her, “is protected by the
Constitutions.” As a matter of fact, there had already been cases of
jurisprudence that have been decided on it. The court, after four
weeks of litigation, decided in her favor. Thereafter, she submitted
for the termination of pregnancy.
1. When principles of Bioethics clash, which one has
priority?
2. Is the right of privacy of Gina more important than the
right to life of the unborn baby?
3. Was the court of law right in favoring Gina what she sought
for in the case?
4. Do you believe that the principles of law be in equal footing
with the principles of ethics? Explain.

Hippocrates

Chapter 8
What father among you would hand his son a snake
when he asks for a fish?
Or hand him a scorpion when he asks for an egg?
Lk. 11:11-12

THE PRINCIPLE OF HUMAN DIGNITY

T

he first
principle that we must consider in Bioethics is the Principle of
Human Dignity, since the goal and soul of the said discipline resides
in human dignity. Without this consideration, bioethics is empty of
meaning and direction. It is this patently distinct human dignity
which all the rest of bioethical principles primarily pursue and expect
to achieve. It is the reason why doctors and health care givers should
first and foremost think of this value without regard for the patients’
economic status, race, color, political affiliations or religious beliefs
especially so when the life of an individual is threatened with disease
or death. Even an enemy is included in the health providers'
functions. This is why even in wars, a doctor has the duty to treat the
wounded enemy combatants regardless of who he/she is. It therefore
behooves them that their role transcends beyond borders and enemy
lines. This is where the giga allocation of health care resources
(which will be discussed later) to population in disaster or catastrophe
areas and of refugee camps has been an expedient international
obligation heaped upon multinationals. “Above all, the value of
humans!” is a valid cry of need. When human dignity is not
respected, all unjust discrimination becomes the source of evils dealt
to humans. As a consequence, “homo homini lupus” i.e., man
becomes wolf to man and man’s inhumanity to man becomes the
order of the day. Jesus commanded his disciples, “to treat others the
way you would have them do to you; this sums up the law and the
prophets.” (Mt. 7:12). Or as the golden rule would say, “do not do
unto others what others would not want done unto you.”
 It is worth noting that the patient is the most important person
in health care. The patient is not an interruption of our work – he is
the purpose of it. He gives meaning and nobility to the profession of
health caring. The patient is not an outsider of our day to day
operations. He is our concern. Health carers should thank him
because he serves as an instrument by which we also save ourselves.
As Ecclesiastes would declare, “Our good works cancel many of our
sins.”
The Principle of Human Dignity. The Principle of Human
Dignity (cf. Ashley and O’Rourke, 2002) is formulated in the
following:
“All decisions in health care must aim at human
dignity, that is, the maximum integrated satisfaction of
the innate needs of the human persons, as individual
and members sharing common humanity.”
This principle demands that all those in health care, especially
those who hold some power or authority, be they doctors or nurses,
must protect, defend, enhance and enable the person and his worth.
They have to be patient advocates who will protect patients from
abuse or misuse of the power given by medical science to health
professionals. Pope Benedict XVI says it all when he stated, “Power
should not be used as weapon to oppress.”
Depending on who our favorite author is, whether ancient or
modern, the concept of needs or goods come into the fore and may be
understood in various ways. St. Thomas Aquinas spoke of the need
to preserve life, to procreate, to know the truth, and live in a society
as fundamental needs or goods that anyone is naturally inclined to
pursue. All of these can be classified as the ontological bases by
which humans can pursue human rights as their rightful claims.
Maslow’s Hierarchy of Needs, a Re-visit. In 1947, the famous
psycho-sociologist, Abraham H. Maslow, illustrated above,
mentioned in a rather detailed and hierarchical fashion the human
goods or needs specified by Aquinas. Up to these days, these have
been commonly referred to as standard paradigm. They are:
1. Physiological Goods or Needs. These refer to anything a
physical organism needs to survive. And since a human person is
also a physical organism, and an embodied nature for that matter,
these needs are innate in him. They are more concretely detailed as
food (nutrition), water (hydration), oxygen (respiration). Further,
since humans are sexual beings, they have also natural sexual needs
not only to serve him personally, but also the social needs in which all
societies must multiply.
2. Safety or Security Goods or Needs. These refer to the set
of needs that may rightly be categorized as those that contribute to the
protection or preservation of one’s well-being. These goods or needs
include: security; stability; dependency; freedom from fear and terror,
anxiety and chaos; need for structure, law and order; protection from
cruelty, etc. These goods contribute substantially to one’s physical
and psychological well-being. This may well be the reason why in
spite of the cruelty of war, nations would rather choose peace than see
its citizens live forever in the grip of fear and terror by unjust
aggressors.
 3. Belongingness Goods and Needs. These goods or needs
are borne out of man’s relational nature. It involves giving and
receiving affection or empathy, and the need to be identified with
someone or something, with relatives, friends, mates or any groupings
or institutions. It refers to one’s desire for meaningful relationship
with people by blood or choice. To some, attaining such
belongingness matters more than anything else in the world. A
person may even forget that hunger is foremost, inasmuch as love is
favored to be necessary for survival more than one’s own life. One
realizes that when pangs of loneliness, ostracism, rejection,
friendlessness and rootlessness predominate in one’s life, the need for
belongingness and love is highly preeminent as it ennobles and
strengthens one’s well-being.
Moreover, belongingness includes the expression of his
relationship with his fellows. Protracted separation is devastating to a
person who is unable to show ones’ connectivity with his relatives,
loved ones, acquaintances, neighbors, or in general, with his own
kind. The reason why people have been very uneasy, uncomfortable,
stressed and some have been mentally affected to being at home
during lockdown imposed by the threat of COVID-19 pandemic of
2020 is because there is something essentially lacking in his nature as
someone who belongs to a bigger human society and that he must
express it as naturally as he should.
4. Esteem Goods or Needs. Accordingly, everyone in the
society (with few abnormal exceptions) has a need or desire for a
stable, firmly based, usually high valuation of themselves to develop
and ensure self-esteem. These needs according to Maslow maybe
categorized into two subsidiary sets, namely: first, the desire for
strength, achievement, adequacy, mastery and competence,
confidence in the face of the world and independence and freedom;
and secondly, the desire for honor, reputation or prestige (defining it
as respect or esteem from other people), status, fame and glory,
dominance, recognition, attention, importance, dignity and
appreciation.
The satisfaction of these needs leads to feelings of self-
confidence, worth, strength, capability and self-adequacy or being
recognized to be important in the world. It promotes one’s worth and
the confidence of being somebody and not nobody. Thwarting these
needs results to feelings of inferiority, helplessness, hopelessness or
uselessness that could lead to bitterness.
5. Self-actualization Goods or Needs. These refer to those
which relate to one’s desire for perfection or actualization of his
capacities or capabilities. These are goods or needs that satisfy one’s
potentials, as a fitting human being as they should as humans called to
his/her highest calling or destiny. Musicians, for example, must make
music, artists must paint, poets must compose, or athletes must
deliver – if they are to be at peace with themselves. In other words,
what humans can be, must be.
In view of the above, a human being will never experience
tranquility and serenity with himself/herself and with the outside
world, unless he achieves his natural (and supernatural) aspirations.
While these are true to human begins in general, truer are they
specifically to patients in health care. That is why the principle of
human dignity talks about decisions in medicine that should promote
his dignity. Whether a patient is rich or poor, influential, powerful or
the like, restoring him to his dignity is foremost, and this can be
concretized by helping him in his needs and leading him back to be
integrated to the human society. Any or all acts of antipathy, cruelty,
negligence or malpractice contravene the very idea and nature of
human needs.

The Case of
the Dignity of the Unborn. It is a perennial issue that familiarly
comes out whenever we talk about the concept of dignity applied to
unborn babies (blastocyst, embryo, fertilized ovum or any biological
name applicable to it). At times, many liberal thinkers believe that
unborn babies to not have dignity because accordingly, they are not
human persons. For them, only a human person can be human and
therefore bearer of human rights. This is inaccurate since these liberal
thinkers cannot even define in simple terms what the meaning of
person is, more so the meaning of human rights or when life begins.
It gives comfort in knowing that Emanuel Levinas (1906-1995), a
Lithuanian-born French Jewish philosopher and Talmudic
commentator incisively said,
The problem of course is recognizing the
unborn as ‘Other’ because its Other-ness is concealed
in the fetal form. And that is precisely the challenge:
to recognize the ‘Other’ where the ‘Other’ does not
meet our expectations, requirements or demands. This
is true not only of the fetus. It was true of slaves who
their masters thought to be unfit for humane treatment
and to be engaged in human discourse. It is certainly
true of other peoples, like the indigenous ones, whose
rights are routinely trespassed because they do not
meet the ‘like’ mainstream society.
What lies at the heart of all ethical thinking is
the issue of our capacity and our willingness to
recognize others and their uniqueness. But, it cannot
be denied that there is a moment when the mind makes
summons of this so-called ‘Other.’ This is the
fertilized ovum in its primitive state.
Again, the statement above resonates so profoundly to those
who otherwise do not have the mind to think deeper into the status of
the unborn fetus. Those who possess this profound truth also have
some obligation to spread this very important pronouncement as a
teaching moment as it is remarkable.

Case Studies:
 A. Refrigerated for Seven Years
In many medical and scientific laboratories in England,
close to twenty thousand fertilized ova have been frozen in a
depository similar to a sperm bank. These ova have been officially
declared excess and are collected from the In Vitro Fertilization
(IVF) procedure left in fertilization centers. The process of
cryogenization (the process of refrigeration to preserve the normal
condition of specimens) was done with a view to using these fertilized
ova for future experiments for the prevention and better
understanding of human diseases and human reproduction.
Meanwhile, these ova have been frozen for more than seven years
now, and could be utilized any time by whoever wants or needs
them.
1. Name the ethical issues involved here?
2. What is the ethical dimension of cryogenically preserving
the fertilized ova?
3. What ethical action can you do to make something right in
the case?
B. Ashley, the Pillow Angel
Ashley is a severely brain-damaged girl whose parents feared
that as she got bigger, it would be much harder to care for her the way
they wanted to. So they (1) gave her high doses of estrogen to reduce
her bone growth in order to keep her small, make it more possible to
include her in typical family life activities and give her needed
comfort, closeness, security and love: meal time, car trips, touch,
snuggles, etc.; (2) had her uterus removed to prevent menstrual
cramps and pregnancy in the event of rape; (3) had her breast buds
removed because of family history of cancer and fibro-cystic disease
since she will not breast feed, to prevent discomfort since harness
strap that hold her upright go across her chest. (TIME, Jan., 22, 2007)
1. What are the ethical issues involved in the case?
2. What is the ethical dimension of the parents’ actions?
 3. What ethical act can you do to make Ashley’s dignity
preserved?
C. Nobody and Somebody
A 12-year-old girl was brought to a charity hospital by her
parents who are poor and marginalized farmers. She complained of
severe pain in her stomach. After some examination and laboratory
tests, the doctors initially diagnosed her as having a very rare cancer
of the intestines. The parents were advised to subject the girl for
more examinations and tests. After a couple of days, more tests and
examinations have been done to the patient. The parents could not
afford the financial requirements of the diagnostic and therapeutic
management, but were advised and assured of continuous tests and
treatment as the patient was a charity case and under the social service
of the hospital. Unknown to the parents though, the girl had been
included as a subject to a research being conducted for rare case of
cancer. After getting the needed data for the research, the doctors
informed the parents that the girl’s case was beyond therapy and she
was advised later to go home.
1. What are the ethical implications of the behavior of doctors
in the case?
2. What is the ethical dimension of treating the patient and
including her in the research being conducted?
3. What ethical demands can parents do to rectify the apparent
unethical conduct of the doctors?
D. A Hospital Discount for Wrong Medication
Hospital patient, R. Lacson had been given a prescription for
an oral medication. Said medication had to be compounded in the
pharmacy for the parenteral route. Pharmacist Alyssia prepared the
medication in a way that was customized for enteral route. Nurse
Levina administered it through the enteral route as the preparation so
indicated. The patient went into convulsion until emergency
measures were done. The patient’s family wanted to press charges if
they would not be given 100% discount on hospital bills which had
already reached P110,000.00.
1. Who must answer for the error in medication? Pharmacist
Alyssia or Nurse Levina? Were they remiss in their duty as either
nurse or pharmacist?
2. Should the hospital be obliged to give discount to the
patient for the harm done to him?
3. Was it right to oblige either of the two health personnel to
pay for the discounted amount?
4. What should they do to prevent similar incident?
E. The Multi-patient Examination
It has been the practice of Dr. X. Toda to keep all of his
patients waiting in the ante room of his clinic for an average of one
hour and a half after their scheduled appointment. He later would let
three or four patients come in for consultations and examinations at
the same time, by way of multi-patient diagnostic practice. When
asked about the practice, Dr. Toda justified himself by saying that this
would hasten examination and lessen patient’s waiting time. Further,
he stated that he had other patients to take care of who also were
important.
1. Suppose Dr. Toda claims that he is not blameworthy since
the receptionist does the scheduling, would this be a good excuse?
2. Is it ethically right to practice multi-patient diagnostic
examination? Elaborate.
3. Many professionals charge patients based on the length of
time of the examination. Might patients be entitled to a discount for
multi-patient examinations? Defend your view.
 4. Do you
think Dr. Toda was after the interest of the patients or a larger
revenue? Explain.

Chapter 9
Notice how the flowers grow. They do not toil nor spin.
But I tell you, not even Solomon in all his splendor
was dressed like one of them.
If God so clothes the grass in the field that grows today
and is thrown into the oven tomorrow,
will he not much more provide for you, O you of little faith?
Lk. 12:27-28

THE PRINCIPLE OF STEWARDSHIP

AND CREATIVITY
T

he bioethical
Principle of Stewardship and Creativity immediately brings to the
fore the idea about care for the integrity of creation, applicable to both
the natural resources and human creativity. It is an important
bioethical principle since it touches on the fiduciary ethical
obligations humans have towards those which sustain and enhance
their life or survival. Inclusive of this principle are certainly concerns
on environment and ecology, their protection, preservation and
sustainability for the sake not only of the present generation but of the
future as well. This principle reflects our own essential connectivity
with the natural environment since we humans are part and parcel of
it.
In a more specific view, the principle of stewardship and
creativity is an attendant principle that necessarily supports the
principle of human dignity. It is like a moral leg that sustains the
former principle to stand solidly on ground to make it compellingly a
goal to pursue. Without the principle of stewardship and creativity,
human dignity cannot be ethically pursued nor promoted.
The Principle of Stewardship and Creativity. Health care science
normally realizes and understands the importance of the environment
and ecological balance in nature, as their natural attributes are so
inherently important to health care needs. They can respond to
humanity’s predicaments and insure its own continued existence. The
plants and animals, minerals, chemicals and their by-products are
essential to creating and compounding medicines and engineering
bio-procedures that help contribute to humanity’s life preservation
and survival. Their destruction will not only lead to and bring havoc
to the integrity of creation but also preclude and endanger humanity’s
health care needs. It is therefore imperative to care, protect and
sustain their viability, as they are of supreme importance to the whole
health care function and development. Serious researches are also
needed so that new knowledge can be gained and that the raw
materials needed to sustain human, plant and animal life can be made
readily available. Destruction for example of the forest, rivers,
vegetation, mountains and many other natural resources may erase
whatever opportunities and gains that could be harnessed as necessary
ingredients needed to treat cancer or HIV infections and other virulent
and untreatable diseases. Humanity’s present and future are solely
based on whatever can be usefully done to sustain the integrity of
creation and especially of humanity. Although science is very
essential in preserving creation, human creativity must certainly be
appropriately and ethically used appropriately so that it can positively
contribute to the preservation and not to its eventual destruction or
devastation. Thus, human knowledge and creativity must build, not
tear down; create, not destroy; harmonize, not divide the integral
totality of creation. This is the serious role of those who are gifted
with stewardship and human creativity. And medical science is in
integral part of it. The following Principle of Stewardship and
Creativity (Ashley and O’Rourke, 2002) runs thus:
The gifts of multidimensional nature and its
natural environment should be used with profound
respect for their intrinsic teleology, and especially the
gift of human creativity should be to cultivate nature
and environment with a care set by the limits of actual
 knowledge and the risk of destroying these gifts.
In sum, it must be noted that this principle truly recognizes the
gifts of nature and the attendant obligation of everyone to respect the
intrinsic purpose for which this gifts have been created and given and
should recognize the imperative to work within that framework.
Lastly, it also recognizes that human creativity (human knowledge,
set of skills and talents) is also a gift that must be used to cultivate
and enhance nature and its environment and that people should also
be conscious of the actual knowledge that so that they do not go to
excesses or be doomed to destroy nature. Doing so, will respect
creation, its creator and humanity that must benefit from it.
Stewardship, not Absolute but Shared. Stewardship is taking care
or administering goods or services according to the will of the owner
of the goods and services. This means that a person who is a
caretaker or an administrator functions as having power to play his
role not as an owner but as a manager of said goods or services, and
he has to account how he played that administrative role in favor of
the rightful owner. He is not therefore the owner, neither can he
administer with absolute dominion, for only the owner possesses such
power. Obviously, only the Creator has that absolute dominion over
creation, concretely understood as either goods or services. Humans
are simply stewards of creation, and therefore, not the owner. Thus
he cannot exercise absolute dominion but only a shared one. They
have to know the will and the intent of the Creator, under whose plan
they have been given the right to manage. Deserting the will of the
Creator, they run the risk of losing their stewardship role and
destroying them. Thus, they need norms that are basically ethical
which are used in partnership with the technical norms. Stewardship
is the Creator’s gift to humanity and the world, which is a great sign
of His generosity and graciousness. Thus, creation must
 also be used
intentio dantis, i.e. in view of the intention of the donor or owner.
Nowhere is mandated to thwart or divert such intention. Doing so,
the consequences may be fatal or catastrophic. The great calamities
or pandemics, like, the impending global warming, or AIDS
infections around the world, the COVI-19 contagion that may or have
wreaked havoc on humans are sufficient proofs of how this
stewardship is being misused and abused with impunity. Awareness
and application of ethical standards of behavior are needed to combat
the aforementioned evils under physical and moral categories. This
should also be true in health care. That is why, human creativity,
provided by human talents, knowledge and skills must be properly
used so that they do not go berserk or out of control. When they do
not conform to nature’s end, they become destructive.
It was said in Genesis: “Go and multiply. Have dominion over
the birds of the air, the fishes of the sea, and . . .” This command
must be calculative and should not be understood without a
corresponding norm on how to follow and apply it. To go and
multiply means to be productive, but one has to be responsible for
what he produces or makes. It is not within the mind of the Scriptures
for man to just beget children uncontrollably more than he can take
care of. Good family planning is needed so that one is able to
produce children according to plan, through spacing and managing
the number he wants to produce with responsibility and in accordance
with some moral norms.
 To have dominion means to have stewardship over creation
and that no one has a right to use earth’s wealth without the attendant
responsibility and even accountability. This means that people are
accountable to the Creator inasmuch as they are representatives of
God’s reign on earth. It does not follow that when one exercises such
power, he can do anything he wants more so when they lead to human
greed and destruction. There must be norms and guides to follow so
that no one unnecessarily gets the raw end of it, as when pain and
suffering are inflicted on humanity due to the excessive and
unrestrained behavior. In health care, one should be very conscious
of the use of the gifts of nature and always consider their teleology in
order to develop, benefit and guide humanity to healthy behaviours.
Those with human and scientific creativity must educate and train
people to live healthy lifestyles and use natural and human resources
to advance people’s time-honored dignity. Medical knowledge or
skill can not and should never be used to downgrade and denigrate
human worth nor destroy them as they are contradictory to the idea of
stewardship and creativity. Neither should one use them to advance
selfish interests or impose authority. Since stewardship is a shared
dominion, between Creator and man, and not an absolute one
according human whims or caprices, the society’s common good
must be one of the norms that must always be taken into
consideration.
Again, the Principle of Stewardship and Creativity
according to Ashley and O’Rourke (2002) requires us to appreciate
the two great gifts that a wise and loving God has given: (1) the earth
with all its natural resources, and (2) our human nature (embodied
intelligent freedom) with its biological, psychological, social, and
spiritual capacities. Recently, we have come to recognize that our
earthly environment is a marvelously balanced ecological system
without which our human nature would never have evolved. We
must take utmost care to conserve our ecological system, to keep it
unpolluted and unravished and to recycle raw materials and energy
supplies. Similarly, our own bodies and minds are wonderfully
constructed. We must work to prevent defects in our bodies through
medical innovations but with greatest respect for what we already are
as human beings. Hence, persons, even as patients, have a right to
demand appropriate and fast medical care. This will contribute to the
building of a community in the sense that healthy people bring about
healthy community. A healthy community brings forth a healthy
earth and thus, secures its survival. Securing survival engenders
happiness.

Ashley and O’Rourke

(2002) continue by saying that “a technology intensive world is
counter- productive as its principle is grounded on a wrong basis.”
“If it can be done, it should be done,” is therefore a misuse of
creative intelligence. Rather, we should ask first, “Should it be
done?” and bring the effects that any new innovation, as in the
community and health care, would have upon the environment and
upon human nature into consideration. Our creativity should be a co-
responsibility with the Creator and not a reckless wasting of gifts.
Thus, we have the principle of shared dominion of creation with the
Creator. When Alfred Nobel, from whose name the Nobel Peace
Prize was attributed, invented the dynamite (the forerunner of the
modern bombs and missiles), he only wanted it to be used within a
limited and distinct purpose. Yet scientists who never considered any
respect for the limits of human creativity used its physics’ principles
and made an atomic bomb out of them. What happened to Hiroshima
and Nagasaki and the hundreds of thousands who perished from their
bombing is a grim proof and reminder of the misuse and abuse of
human creativity. If only medical and surgical technologies are used
to promote health, alleviate pain and suffering, no single unborn
would have been aborted or killed without compunction. With the
improper use of technology, more than a million and a half unborn
babies (and three million around the world) every year until now are
murdered since 1973 in USA with the US Supreme Court making it
uncomfortably legal. If doctors only bring to heart the Principle of
Stewardship and Creativity, they would always be a friend to their
patients and to creation. Now, this paradigm has changed
dramatically since. If patients do not give a hundred percent trust to
doctors, it could only be inferred that the latter have been willing
accomplices in the misuse and abuse of technologies and creativity.
The uncontrolled use of the technologies of contraceptives and
abortifacients has taken its toll on the negative population rate in
Europe, and has led it to an aging continent or countries even as the
average labor force of Japan is now pegged at 47 years. Needless to
say, this has also happened to Singapore.

Case Studies:
A. To Procreate or not
Jessa C. is an 18-year-old girl who has been diagnosed of
having a bone marrow deficiency. In three years, her chances of
survival may be slim if not treated. The only therapy that may be
feasible and available is through a bone marrow transplantation.
Jessa is the only child of her parents and no one in her relatives
matches her bone marrow constitution. The last chance that she had
was to have a sibling. Her parents, being still of a reproductive age,
decided to have another child with the view of harvesting from the
latter the needed bone marrow for transplantation. Within a year a
child was born to them. When the baby was a year old, a bone
marrow was extracted from her and transplanted to her elder sister.
According to doctors, Jessa is now healthy and has become a happy
young adult.
1. What are the ethical issues that can be raised here? Briefly
explain each.
2. Was the extraction of bone morrow from the younger sister
and transplanted to the elder Jessa C. an ethically tenable procedure?
Why?
3. What ethical consequence/s can be drawn if the baby’s
bone marrow would not subsequently match with that of the elder
sister Jessa? Will there be psychological setbacks in case this
happens?
B. Abortion or Adoption
Medical and technological advances today in imaging
procedures have made it interestingly easier to determine pre-natal
gender, genetic make-up and health prospects. There are times when
physical and psychological defects are known while the baby is still
in the womb even at an AOG of four weeks.
Unborn baby Ruffa Mae is in her 18th week AOG. Through an
advanced ultrasound imaging procedure, Ruffa Mae was diagnosed to
have Down ’s syndrome. Her mother Lily, 35, a laundry woman has
had already 7 children who seldom get even the needed nutrition.
“Another baby,” according to Lily, “would be a serious additional
burden in her family’s already poor condition, more so that the new
baby will require a lot of ambulatory care.” Lily is thinking of
terminating the pregnancy unless someone adopts the child.
1. What are the ethical issues in the case?
2. Does the disease and unavailability of adopting parents
warrant the termination of pregnancy on ethical grounds?
3. What can be ethically done if in fact the mother were
determined to dispose of the unborn baby through an abortion
procedure?
C. Training Procedures on the Newly Dead
Mrs. Salve Alajar has been rushed to a training hospital due to
cardiac arrest and could not be resuscitated in spite of the many
technologies used to revive her. Consequently, she was pronounced
dead. Medical and nursing students were immediately summoned to
do practice procedures in CPR, proper use of defibrillator, including
intubation on her. Neither the patient nor the family had prior
information of this educational practice.
1. Do practice procedures constitute ordinary practice in the
said hospital and obtaining consent a presumed permission? How
might it be justified? Should this include autopsies?
2. It is argued that practice procedures on those who have just
died are perfectly acceptable for education. It is harmless and avoids
the inconvenience of informing people to protect their sensibilities.
Do you agree with the reasoning?
3. Some would not mind telling relatives because rarely do
they give consent. Was this a good reason to proceed with the
practice? Explain.

D. Solicitousness of the Parents

A ten-year old boy, Ricky R. was playing on the street with his
skateboard with two other playmates. Suddenly a speeding car passed
and sideswiped him and he was badly bruised and bloodied. He was
brought to the hospital’s emergency room. The boy’s solicitous
parents insisted on being present during all procedures, even though
this obstructed the efficiency of the work of the ER team. Ricky’s
parents persisted in asking questions and began to recommend
treatments about which they had virtually no knowledge. They
became hysterical when asked to leave the room and threaten to press
charges if they would be forced to leave.
1. Is it ethically sound to remove the parents from the ER by
force, if necessary? Should their presence in the ER considered
nuisance?
2. Suppose the mother of the boy is a nurse, should she be
permitted to remain with her son while in the ER? Explain.
3. Might the parents’ presence make the team more self-
conscious about what they are doing?
4. Suppose the child calls for his mother, would her presence
be an advantage to the treatment procedures? Why?

Chapter 10
What man among you having a hundred sheep
and losing one of them would not leave the ninety-nine in the desert
and go after the lost one until he finds it?
Lk. 15:4

THE PRINCIPLE OF THE TOTALITY AND INTEGRITY

OF THE HUMAN PERSON
T he Principle of the Totality and Integrity of the Human Person is one principle that
is properly applied to the individuality of the human person who is an embodied spirit with
all the functions and capacities he naturally possesses. Experience teaches us that every
natural part is essential to the existence of the whole being, but is always less in degree than
the whole itself. Even elementary math tells us about the truism of this axiom and that in
fact, the whole is always greater than any of its parts. Such axiom is also true in the
valuation of the totality of the whole human person compared to any of his bodily and
psychic dimensions.
St. Thomas Aquinas (1225-1274) developed the Principle of Totality
that has become an integral part of the moral methodology and which is so useful and central
in Catholic bioethics. Simply put, this principle, as echoed by Pope Pius XII in 1952, holds
that the part exists for the whole and certainly the whole is greater than any of its parts.
“Consequently, it follows that the good of the part remains subordinated to the overall good
of the whole. Therefore, the whole may be seen as a determining factor for the part, able to
dispose of it in its own interest,” says J. Kleinsman (2008).

Accordingly, the
The Principle of Totality and Integrity of the Human Person.
Principle of Totality and Integrity of the Human Person
(O’Rourke and Ashley, 2002) states that:
To promote human dignity in communities,
every person must develop, use, care for, and
preserve all of his or her natural physical and psychic
functions in such a way that:
First, bodily and psychic lower functions are
never sacrificed except for the better
functioning of the whole person, and even then with an
effort to compensate for this sacrifice.
Second, the basic capacities that define
personhood are not sacrificed unless it is necessary to
preserve life.

Immediately, this principle brings

to the fore the moral dictates that requires self-respect as well as,
respect for another human being. Thus the human integrity of
oneself or of another is imperative and is inclusive of all the
components of the human person, both the bodily and the spiritual.
These components are first, the bodily and psychical functions, like
hair, hands, feet, ears and even eyes. Second, are the basic capacities
that define personhood without which there is something lacking in
our humanity, or we are simply not anymore alive, like the absence of
brain, heart, emotional, reproductive or speech capacity/function.
When medical condition indicates the removal of our lower
function/s, like limbs, it must be such that the planned removal must
lead to a better functioning of the whole person. Whatever is the
consequent loss after surgery must be satisfactorily compensated. A
classic instance would be the amputation of a diabetic foot. It is
better to lose that foot and be able to function as a normal and
productive person rather than have the same foot that makes one
unable to function as a normal and productive person. Excision of
some limbs or tissues that are more of a liability to us than being an
asset, like the removal of an excess finger, is ethically tenable and
should not be frowned upon as if it is defying the work of nature or of
the Creator. Humans have the duty to develop themselves for as long
as acts intended for such are not contrary to standards of behaviors.
Thus, the loss of a function through a surgical amputation or
excision must be such that some means be made subsequently
available as compensation for that loss. This is in keeping with the
end to preserve our human integrity in spite of the lack of some
natural functions. This principle also prohibits the sinister act of
mutilation which is both a crime and a moral turpitude against oneself
or another.
It must be noted that when it comes to sacrificing of basic
capacities, it must be such that the sacrifice must have for its sole
purpose the preservation of life. The basic capacities of our
personhood are closely intertwined with our dignity as human beings.
That is why, it is greatly difficult to ethically defend the sacrifice of
such basic capacities unless it is for the save life. Life has more
value because it embodies the totality of the human person. Thus, it
is indeed ethically tenable that even if we lose our reproductive
capacities or a basic capacity lost as when one kidney is left, as long
as human life is preserved, then any procedure done is ethically
sound. Life is the highest value that we can possess. When life is at
stake, measures must be put in place to subordinate to that value.
This is in keeping with our avowed duty to protect and defend life to
the fullest. We therefore can only sacrifice something for the sake of
a higher or nobler end. This can be applied to our bodily and psychic
functions that may be sacrificed to be able to function better or to
preserve life. All surgical excisions or operations therefore can be
morally tenable for as long as the two ends are considered.
The Case of Cosmetic Surgery: Boon or Bane, Necessity or Vanity
or Insanity. Modern cosmetic surgery seems to have been a blessing
come from heaven especially for those whose physical appearance
does not seem any blessing at all, as far as, secular standard is
concerned. This scientific breakthrough has been a boon especially to
affluent men and women who can avail themselves of the procedure
even tagged with skyrocketing prices. Unfortunately, cosmetic
surgery is more complex than it appears. Many still believe that it is
like going into a movie theater and going out of it satisfied with the
movie program after two hours. One has to realize the various
possible ill-effects the operation had on the patient. Some ill-effects
are temporary, but some may result into botched procedures and
could be beyond repair. Many lawsuits on botched surgical
procedures have reached the courts of law for litigation due to
dissatisfaction of the patients with the outcome. As a result, it
becomes even more expensive. Observably, while it is a boon to
some, it could also be a bane to others. While others go for the
surgery because of necessity, some go for it for vanity, (and some
unconsciously, insanity) although no one would admit it. The “vague
gratitude” that sometimes beneficiaries express like, “Salamat po,
Doctor”, (Thank you, Doctor), has sometimes become an expression
of joke or ridicule because the once low valued physical figure has
now appreciated to a higher market assessment.

Regrettably, there are some who pursue plastic

surgery which from all angles are simply out of insanity (or inanity).
And surgeons do not have qualms doing it for obvious reasons. The
case of the pop star Michael Jackson can be mentioned here as an
example. The multi-billionaire Jocelyn Wildenstein is another
example. She had her face operated so that she will look like a tiger
in order to get the attention of her husband who was constantly
fascinated with tigers. He even had a mini zoo of tigers at the back of
his home. But after the surgery, Wildenstein’s husband
unfortunately, divorced her.
There have been a variety of cosmetic procedures and services
in the health care market (see R. B. Pascual, 2004). The following
may help us understand some of their technical aspects:
Hair Transplant. It is a procedure in which hair is
transplanted to bald scalp through surgery by transferring a part of the
hairy scalp into bald areas. It is a tedious process that requires real
expertise.
Facial Enhancement. Several procedures can be done to
enhance one’s the appearance of men and women, who are concerned
with the wrinkles in their faces The Collagen Replacement
Therapy is safe and non-invasive. It involves the injection of natural
collagen in the layer beneath the skin to smoothen and stretch aging
surfaces afflicted with scars and lines. The so-called Paris Lip
Enhancement uses also natural collagen to distinctly define the lips’
border, especially the heart shaped portion of the upper lip to make it
youthful looking and well defined.
Dermabrasion is a procedure that smoothens the areas around
the eyes, brow and mouth by a skin planing instrument. The
procedure or effect lasts only for some 40 to 50 minutes. Botox
procedure is injection of the botox substance beneath the eyes to
remove sagging and making it look fresh and firm. It also removes
dark surfaces, but its effect lasts only for 6 months and must be
redone to retain the same youthful look. The Laser Skin
Resurfacing uses laser compact beams or light to minimize the
development of acne and facial lines. The Chemical Peel or
Cosmetic Peel is a procedure that utilizes carbolic acid. First, a layer
of the skin is burned resulting in the formation of a skin scab. After a
week or so, the scabs peel away to reveal a new layer of the skin free
from the old blemishes and wrinkles brought about by hyper-
pigmentation, or irregularities in the skin due to aging, sun exposures
and genetic factors. The Photo Derm VL is a procedure to remove
skin discolorations which sometimes cause inferiority complex and
embarrassment. This procedure removes spider veins on the face as
well as those in the legs. The Chin Augmentation or Mentoplasty is
done through a cosmetic rhytidectomy. The cosmetic surgeon
implants a soft or firm prosthesis through some incision under the
chin or mouth. The effect is alteration of the contours of the face that
temporarily solves receding chins.
Arms Enhancement. Arm lipolectomy entails the removal of
the excess or sagging skin and fat from the upper inner arms
especially from fat patients. The procedure here is familiarly called
the liposuction.
Breast Enhancement. The cosmetic procedures for breast
enhancement are done to women who feel that their breasts are too
small and who want to have bigger bosoms through Breast
Augmentation. This involves the invasive implantation of breast
prostheses like silicon shell filled with saline solution beneath (and
sometimes above) the breast. Breast Reduction is done to those who
have unusually large bosoms. This procedure helps reduce weight
bearing pain in the upper portion of the neck and shoulders brought
about by the strained brassiere straps.
Body Contouring. Liposuction is properly termed lipolysis.
This involves the temporary or permanent removal of fatty tissues,
particularly in the abdomen, hips, saddle bag areas, buttocks, skin,
neck arms knees, calves, ankles, etc.
Abdominal Tummy Tuck is surgically called Abdominal
Lipectomy. It is a surgical procedure that removes excess sagging
skin and fat, tightening the muscles and the lower abdominal region.
It has been medically prescribed that for these surgeries to
work more effectively, the skin should be elastic enough to result in
attractive shrinkage over the operated areas. This makes women over
the age of 30 not ideal candidates although, there have been cases
that, even at the age of 50, these procedures can still be effectively
done.
It is however an ethical duty for those planning to have these
procedures done to consult a technically competent cosmetic surgeon
because a good and ethical cosmetic surgeon will not immediately
agree to the surgery, and will check patients thoroughly to see if they
are good candidates for the operation. It must be remembered that
these surgeries are very expensive, for good and beautiful looks
command a high price. But the risks are grave enough to be
concerned that any distortion or disfiguration is against stewardship
of the sacred human body, a violation of the greatest gift the Creator
has given.
The Case of Genital Mutilation. There have been several reported
cases around the world about genital mutilation either procured or in
compliance with cultural precepts. The ones who procure are those
who want to have tighter vaginas to increase sexual pleasure, but also
for aesthetic reasons or for some particular purpose like young
women who are expected to be virgins when they marry. They want
to have their hymens reconstructed, otherwise they will bear social
and religious persecution from their partners or community. In some
African countries and backward societies, women are subjected to
obligatory circumcision by having their clitoris removed as a cultural
necessity for growing up. Around 130 million girls and women in 30
countries around the world are reported to have been subjected to this
procedure.
Requesting plastic surgery on one’s genitals does not seem to
sit well ethically, unless surgical necessity calls for it. Vanity is the
excessive obsession to make oneself physically beautiful or attractive
to be admired by others. Ethically, this is never a good reason to
subject oneself under the knife of the cosmetic procedure.
Finally, insanity as a basis for submitting to cosmetic or
plastic surgery raises a lot of ethical question. Readily, because there
is no medical or surgical indication, insanity is usually pursued by
rich and powerful men and women whose mental conditions is
commonly in question. The case of Wildenstein and Jackson
mentioned above is one for the books. Another example that can be
mentioned here are those who pursue transsexual surgery which will
be discussed in a little bit of detail.
Psychological, Social and Occupational Considerations for
Cosmetic Surgery. While it is ethically sound to consider the
Principle of Totality and Integrity before anyone decides for a
cosmetic surgical procedure, there are conditions that must be
considered on a case to case basis. Certainly, not all cosmetic
surgeries are frowned upon by the principle. People sometimes think
and feel differently considering the situation they are in. It does not
violate the principle when one goes for a liposuction to remove excess
fats in order to keep a job that demands some physical weight
standards. Some airline companies require their stewards or
stewardesses to be lean and slim so that they can move faster and
insure mobility in the plane’s cabin. Probably, a movie actress or a
fashion model is required to keep a minimal weight to keep them on
the job they know. Hence, the use of weight reducing surgical
procedures may be ethically tenable. What may probably be ethically
questionable without being necessarily unethical is for movie
actresses to keep themselves slim so that they can maintain their job
and market value as sexy dancers though not necessarily as strip
teasers. This of course is obviously subject to so much debate. On
the other hand, it may well be that a woman has to increase the size of
one’s belly to be able to do belly dancing as a profitable job.
From the above discussion one can safely stand on ethical
ground for as long as one considers the reverence due to one’s body
as the temple of the Spirit and that nothing in it is used for unethical
acts or that which will subject it to inhumanity, like mutilation. More
so, any act or procedure must acknowledge the dignity that life
possesses. There has to be a serious consideration also about using
these procedures between correcting a defect versus “improving”
certain conditions.
The Case of Transsexual Surgery. There are basically two groups
of medical cases in which sex-changing surgery may be an important
procedure to consider in view of human dignity that must be
promoted, namely:
1. a. Hermaphrodites. They are those who were born with
both the testicular and ovarian tissues and organs.
b. Pseudo-hermaphrodites. They are those who were born
with one sex, but in whom some hormonal imbalances have produced
(some physical or biological) characteristics of the opposite sex.
2. Transsexuals. These are men and women who are
biologically and phenol-typically normal, but who believe themselves
to belong to the opposite sex. The psychologists refer to them as
having “Gender Dysphoria Syndrome” (GDS), because of their
obsessive feeling of being trapped in a wrong body, coupled with a
severe anxiety that sometimes reaches suicidal depression. Because
of this, a man may desire his sex or gender to be transmuted changed
or altered. Believing that he belongs to the opposite sex, most of the
time, he is carried away by or carries himself into fantasy. He reads
and is interested in hearing about medical and scientific propaganda
about sex-changing surgeries. He readily welcomes the idea that
synthetic hormones are or can possibly be manufactured somewhere,
or that scientific breakthroughs that can replicate the natural organs of
the body, and that sex transmutation can accomplish this for him. He
centers his attention on the genitals and the gonads. If a male, on the
breasts, while if a female, on the hairy face and deep voice. And the
elements of transsexual surgery are thought in terms of penis, gonads,
vaginas, breasts and beard. Rarely though is the male specifically
concerned about having a uterus, although his dreams eventually
include that of having a baby. With this severe anxiety and hang-up,
a transsexual is willing to subject himself to such a mutilating and
painful procedure involving amputation of normal external genitalia.
It should not come as a surprise that transsexuals also dream
of seeing themselves romping all the way to the Miss Universe beauty
pageant as in the case of Miss Spain in 2019 and further, getting
married as any woman would wish. What with gay couples now
knocking on the doors of the city hall for legal marriage recognition
and union! The State of California in 2008 and other states and many
countries around the world have legally allowed gay marriages. Asia
is contemplating it.
Sex Reassignment and Requirements. Sex re-assignment, through
surgical procedures, includes a very wide spectrum of medical,
psychological and surgical operations, especially performed on a male
to appear female, at least physically. These may include hormonal
oral medications and injections, the augmentation mammoplasty, the
penile amputation and subsequent reconstruction of a pseudo-vagina.
These have to done aside from other pre-requirements, like living and
acting like a woman, staying in a community of women for at least
one year, as in the USA. Using female dresses, paraphernalia and
other feminine enhancing activities have to be done before the
operation. In the Philippines, these procedures are surreptitiously
done, because these are widely condemned and ridiculed. In
Thailand, the procedure can be done to walk-in patients without
undergoing any activity to psychologically prepare them for the
radical operation.
Transsexual Surgery and its Ethical Dimension. The transsexual
surgery or sex re-assignment touches not only the Principle of
Totality and Integrity of the Human Person but also the
Stewardship and Creativity. Firstly, stewardship and creativity
exhort that the richness of the nature’s resources must be utilized in
view of its intrinsic teleology. As recipients of the nature’s riches,
there is an attendant duty on our part to develop and not to destroy
these riches. And though we have dominions over these gifts, it is
never absolute. As such, we do not have the limitless right or
privilege to do what pleases us, especially when these run counter to
the ends for which they have been given. Secondly, we must realize
that such dominion cannot be unilaterally disposed of by the
recipient. The amputation of a normal penis is nowhere treating this
gift with respect to its teleology. It is against human dignity and
integrity that it involves not only medical impropriety, but more so
ethical repulsiveness.
This should now lead us to the principle under which this
procedure properly falls. We now can say that by any standard, the
mutilation of a normal penis is not in any way near the conditions set
by the principle to warrant the admonition for the amputation of its
normal, physical functions or capacities. The normal penis and other
organs are not in any way a threats or risks to the health of a person,
nor are they diseased as to indicate surgical removal. The procedure
is not meant to preserve life, nor did it bring about a better
functioning of the individual. On the contrary, it may even be
preponderant and fortuitous to cause other psychological, social and
even medical problems, as many of those transsexually operated
intimated and testified. Impending infections must be taken into
account as these pose a lot of medical and hygienic dangers. It was
allegedly reported in the US that 9 out of 10 have regretted
transsexual surgery and would have wished it were not done at all or
at least restored back to its original form. This is so because, the
difficulty that one has to undergo is as cumbersome as it is
burdensome to insure hygiene and ward off infections and bad smell
caused by the permanent open wound. One has to bear the daily and
painstaking hygienic rituals as to sacrifice sometimes his job, social
life, not to mention the anxiety his relationship with a sexual partner
may entail, let alone intimacy. The transsexually reassigned person
will have to cleanse the open wound almost every thirty minutes to
insure asepsis or ward-off infection.
 Corollary to the
ethical argument above, through the said surgery, one has to violate
himself (i.e., the reverence due to his body) in order to achieve what
seemed to be a great promise of his deliverance from a wrong gender.
And he must allow others to violate him or his integrity, if only to
enjoy what has been promised it will do to him. Unfortunately, these
are only empty promises, for the pleasure he had always dreamt of are
false and not forthcoming. Becoming a woman even in a very loose
sense can never be a reality for one who has undergone transsexual
surgery.
Moreover, a psychological illness, as deep as that of
transsexuality, can never be solved by a surgical operation without
psychotherapy. Unfortunately, there are those who believe in the
usually erroneous principle of “last resort”, i.e., if given the last
chance or means to solve a dilemma or issue, one can justifiably
resort to the last practical way to achieve it. The idea behind the
transsexual surgery is the belief that the human mind is a very
complex and mysterious matter to deal with rather than the human
body. Therefore, when there is a dissonance between the human mind
and the human body, it may be easier to change the human body
rather than the human mind. If the solution can be done in the human
frontiers of the body, which is much easier and practical, then why do
it in the frontiers of the mind? Of course, this argument is untenable
because the illness is mental, and the relief of the anxiety can be
corrected not by surgery but through psychotherapy. Scientific and
medical advances have shown time and again, that there is significant
difference between psychotherapy and radical mutilation of the penis.
There is no known solid argument in favor of the “alleged” pr
“promised” benefit sex-changing surgery could give. Changing of the
mind has stronger impact and is more effective than changing of
sexuality based on physical function. John Hopkins University, a
noted research center in the world, has announced the suspension of
its program of transsexual surgery for further reassessment as a result
of evidence showing that surgery of this kind offers no advantage
over psychotherapy.
In many studies on enzymatic and hormonal abnormalities, the
psychologic profiles of transsexuals do not demonstrate significant
correlation between behavior and the variables studied. Physiological
differences therefore cannot also be claimed to determine or even
influence sexual orientation.
Finally, the great clinical Psychologist, Jordan Peterson has
stated that in his tens of years of studies, no one who was born a man
or woman can never become woman or man respectively. This is so
because there is no genetic basis for changing sex. The feeling that
one belongs to an opposite sex does not make one belonging to the
other sex. Feelings remain as feelings and cannot in anyway change a
radical condition as the case of feeling being 30 years old when in
reality he is already 60 years old.
Accordingly, the human body possesses molecules that
distinctly belong to either the male or female sex. These molecules
function in unison when the person acts accordingly as it is
appropriate to his birth sex. When this condition is changed, these
molecules are disrupted and distracted and consequently, can
psychologically confuse the person. This is the reason why the
likelihood of suicide is high among those who have gender issues,
even when they have transsexual re-assignment surgery.
Holy Scriptures and Transsexualism. It cannot be denied that the
Holy Scriptures has very incisive pronouncement about Trans-
genderism or transsexualism. The following below will enlighten
everyone on:
 1. On the Mutilation of the Body. St. Paul, as elsewhere in
the Holy Scriptures, teaches that “The body is the temple of the Holy
Spirit and should be protected. Glorify God in your body.” (Cor.
6:19-20). Thus, the Bible views it that the unnecessary damage to the
body is considered evil and any deliberate mutilation is an insult of
great magnitude against the Holy Spirit.
2. On Propriety. “A woman shall not wear an article proper
to a man, nor shall a man put on a woman’s dress; for anyone who
does such things is an abomination to the Lord, your God.” (Deut.
22:5). Any attempt at blurring the distinction between sexes is
serious and sickening to God. And man’s imaging of God is marred.
(Scipione, 2003).
3. On Gender’s Role. A person must accept his or her God-
given gender and learn its role. “Each one should lead the life the
Lord has assigned him. Everyone ought to continue as he was when
he was called.” (Cor.7:17-20). The reason there are two and only two
sexes is that God created mankind so that to be human means to be
either male or female. (Gen. 1-27). The human body is therefore a
good gift of God and essential to the human person. The (sexual)
gender is part of the basic identity of the individual since his birth and
not a temporary role or function. It has never been found that genders
are physically and biologically based. Even the concept of XX and
XY chromosomes attests to the dual sexuality that is either male or
female. The Book of Genesis is very clear about this. It is interesting
to find out that some cases of monozygotic male twins, one has
become a transsexual, while the other has not. Genes therefore do not
exclusively determine transsexual behavior.
Theologically, it is evident that surgical sex re-assignment
does not in fact solve the problems of the transsexual’s existing
problems, since it does not make him really a woman, for the essence
of a woman is that of giving life. It does not enable him to achieve
normal sexual pleasure and be able to enter a valid marriage from the
ethical point of view or sometimes from the legal point of view. It
may give him relief from the burden of anxiety but this is very
temporary. It is very unfortunate that some countries are amoral
about the procedure and believe in the exaggerated reports of success
usually learned from the cyberspace. These have created an
increasing demand among troubled people although reputable clinics
would not engage in them carelessly. Usually only those fly-by-night
or back yard health centers perform such surgeries which are usually
done surreptitiously.

Case Studies:
A. A Hasty Move for an Unfounded Fear
When Daniel was born, he was found to have the
characteristics of a hermaphrodite. He had both penile and vaginal
physical attributes. As a little kid, he did not have any problem
associating with other kids until he reached three years of age. His
parents could not decide which toilet he should use, especially when
he was in the mall. Worried, they consulted a pediatric doctor about
their predicament. A priest was also consulted and even advised them
to proceed with the surgery. As the story went, a sex determining
surgery was scheduled. The penile part was removed and she was
made to be a girl and guided to act like a girl. This time her name
was changed to Danielle. His birth certificate was legally applied for
record changing process to make her officially a girl. When Danielle
was seven, surprisingly, she did not behave like a girl, rather her acts
and behavior were that of a boy. The parents were in a dilemma
because this time, Danielle was indeed Daniel. The doctor was also
confused.
 1. There is evidently haste in the surgical procedure to remove
the penile attribute. Is there ethical accountability from the parents,
the doctor, the hospital and even the priest who agreed to the
procedure?
2. Was there an ethical principle violated in the surgical
procedure? Why?
3. What ethical considerations should have been taken before
any surgical procedure was performed to Danielle? Is the
psychologist’s role important here? How about the ethics committee?
Explain.
4. Was it ethically sound to advise the parents, doctor and the
rest to postpone the surgical procedure up to a time when Danielle
could distinctly be assigned the sex to which (s)he belongs?
B. Is He/She Lucio or Lily
Lily is a 25-year-old fashion designer. He was formerly called
Lucio. He has been telling everyone that he acts, behaves, feels, love
like a woman. Due to these circumstances, if given a chance and if
his wishes would be followed, he wanted to be a woman. He
therefore wanted to submit to transsexual surgical operation. What
constrained him though were his temporary financial limitations. He
dreamed of doing the sex changing surgery once he got sufficient
money. After five years, he got what he wanted and submitted
himself to transsexual operation. The surgery was successful. Now,
Lily claims that he is happy for at last he can act, behave, feel and
love as a woman. He is also married to a Spanish national. He is
now a she.
1. What are the ethical aspects of the case?
2. Is transsexual surgery ethical or not in this case? Why?
3. Will her being a “woman” now solve her anxiety and her
getting married really make her a woman?
4. If you have a brother or friend in a similar situation would
you agree to the surgical operation, knowing that he will be happy
about it as similarly claimed by Lily?
C. We Want a Girl!
Maria and Juan Vinto got married in their late thirties. After
the birth of a son, named Bobbit, they now wanted to have a daughter
before their productive and biological clock became inoperative.
When the next child was born, he had ambiguous genitalia and the
parents tried to raise the boy as belonging to the other sex which was
comfortable for them as they had always wanted to have a girl. They
even called her Angie, short for Angelo. They bought girlish dresses
and toys for him. It did not take long for the boy to act like a girl.
After finishing high school though, he entered the seminary to
become a priest to follow the footsteps of his older brother who is
also in the seminary. While in the seminary, he courted a seminarian
to the point of even becoming aggressive in his sexual behavior
towards persons of the same sex. He was sent out of the seminary
after the Director knew about his sexual misconduct. While outside
the seminary, he wanted to have sexual re-assignment surgery as he
believed that improving the normal appearance or function in
accordance with the gender in which he had been raised was good for
him. He further reasoned out that a person must “live according to
nature” insofar as this is humanly knowable. Meanwhile Angie has
been looking for advice and was in a dilemma.
1. What are the ethical issues that can be raised about Angie’s
plan to submit himself to a sexual re-assignment surgery?
2. At this point in time, is it ethically correct to do sex
reassignment surgery since his gender is also ambiguous?
3. Should the parents’ obsession to have a daughter be blamed
for the predicament of Angie? Is sexual selection ethical in which
parents could have their subjective preferences operate at the expense
of their children, just as it is when they want their children to be a
doctor or an engineer or a military man?
4. What should be done ethically to resolve Angie’s dilemma?
Suggest.
D. A Necessity or Vanity
Mr. C. Abuda consulted Dr. W. Lalla, a plastic surgeon, in
order to have his penis re-figured even as he requested the latter to do
additional procedure in order to have an optimum sexual orgasm
during the sexual act. The surgeon agreed on doing the planned
surgery as requested. Accordingly, the surgeon claimed success with
the surgery as the procedure did not pose any complication and Mr.
Abuda was able to go home three days after hospital confinement.
Six weeks later, and after having allegedly recuperated, Mr. Abuda
noticed that the surgery did not give the promised result. He claimed
that his penis had become even more deformed than before.
Moreover, he did not feel any additional pleasure during sex. On the
contrary, he even claimed that he had experienced a substantially
reduced sexual pleasure after the surgery. Mr. Abuda went to another
expert to consult if the procedure was in accordance with the accepted
surgical standards. He learned that it was not.
1. What are the ethical issues than can be raised in the case of
Mr. Abuda?
2. Does the operation requested by Mr. Abuda merit necessity
or was it just vanity and or insanity?
3. What are the ethical infractions committed by Mr. Abuda
and Dr. Lallla, the plastic surgeon, if there are any?
4. What is the ethical dimension of a surgical procedure on the
re-figuration of a deformed penis? Justify.
St. Thomas Aquinas, OP, a great Dominican Moral Theologian

Chapter 11
For the Father makes his sun rise on the bad and the good,
and causes rain to fall on the just and the unjust.
Mt. 5:45

THE PRINCIPLE OF DOUBLE-EFFECT

T

hose who engage

in health care profession know very well the many medical
implications their procedures or protocols have when performed upon
patients or any human subjects. As a matter of fact, all medical and
surgical procedures entail risks, like loss of limbs, discomfort, pain
and suffering, discomforts or inconveniences and many others aside
from the primary benefits obtained therefrom. Nevertheless, the
benefits of medicine and its procedures cannot be overemphasized,
and certainly cannot be obtained without some attendant side- or ill-
effects that patients have to necessarily bear. Some of these ill-effects
are physical, mental and even emotional in nature. And since they
always accompany medical procedures in spite of the benefits
obtained from them, does this mean that the procedures cannot be
ethically tenable or performed? Here we draw the importance of the
bioethical Principle of Double-Effect, its usefulness and meaning,
especially to health care professionals as it can guide them in forming
well their conscience before making medical decisions. The same
should guide the patients and their families. This principle is
primarily used when a particular procedure will engender not only
beneficial effects but also (calculated, estimated or foreseen) harmful
effects. Thus, from a single particular act, there are two effects that
emanate, namely: the good or beneficial effect, and the other, the bad
or harmful effect. That is why, this principle is called the double-
effect or twofold-effect principle.
This principle therefore attempts to establish a judgment
and/or argument over an action that is ethically legitimate, even if the
act is followed by an evil effect secondary to the good effect.
Accordingly, this principle must ultimately be to “form a good
conscience when an act is foreseen to have both beneficial (good) and
harmful (evil) effects.”
The Requisite Conditions in the Use the Principle of Double-
effect. For an action to be ethically legitimate or justified, it must
satisfy four conditions as required by the principle (formulated by
O’Rourke and Ashley (2002), with similar formulation by Beauchamp
and Childress (1994) and Basterra (1994) which are formulated in
the following, namely:
1. That the directly intended object of the act must not be
intrinsically contradictory to one’s fundamental commitment to
God, neighbor and self. Simply, this criterion must be such that the
act should be ethically good or at least indifferent. This means that
the directly intended object of the act (see Chapter 2 above) must not
be intrinsically contradictory to one’s individual commitment to God
and neighbor, and even to oneself. We cannot violate anyone or
ourselves, and even God when the object of our action is good or at
least indifferent. An act which is intrinsically or morally evil can
never be morally right. Man therefore, cannot do something which is
in itself evil, nor can he do evil to accomplish something good. The
proverbial “a good purpose can never be justified through an evil
means” is always morally right.
There are some criteria that must be considered to determine
an act to be good and therefore morally good. Ashley and O’Rourke
(2002) spelled them out, namely:
a. An act directed toward the right ultimate end, that is, union
with God and friendship with fellowmen.
 b. Choose an effective means to achieve that goal. Thus, acts
that are intrinsically evil must be rejected. Help in selecting good
actions and in avoiding bad actions is offered in the various codes and
norms of in the Church’s teachings: e.g., Natural Law, the Ten
Commandments, Church’s Encyclical Letters involving moral
actions, Directives for Hospital Workers, etc.

c. If the act chosen is an appropriate means to the ultimate end,

then one must have an honest intention, and all other circumstances
must contribute to the good moral object.
Further, we must remember that that which is good must be
integrally connected to all the phases of the act and that any defect in
them may render them wholly or partially evil.
On a deeper thought, the only and absolute norm of human
conduct is that which leads man to his ultimate good. This absolute
good is the wholehearted love of God and neighbor. “Hear O Israel,
the Lord our God is Lord alone! Therefore, you shall love the Lord
your God with all your heart, with all your soul, with all your mind,
and with all your strength. And you shall love your neighbor as
yourself.” (Mk. 12:29:31, which is the Jewish Shema Ysrael, (Hear O.
Israel)). Thus, an act to be good should never be anything less than
our deepest intention to do the will of God, who is ultimately the
absolute norm. In effect, to do the will of God is simply to do good
and never evil.
2. The agent’s intention is to achieve directly the beneficial
effect and even if there is a resulting harmful effect. Simply, the
good effect must be “primus in intentione” (i.e., first in intention) and
the evil effect is never intended. Thus, the foreseen harmful effect
though necessary is not the direct intention sought but only as a
collateral or side effect of an action. All medical and surgical
procedures normally seek what is good for the patient, and leaves the
bad as a necessary evil. The previous chapter should be borne in
mind about the finis operantis, i.e., intention of the agent. If that
which is directly intended is wrong, then the act is wrong. An evil
effect can and should never be intended. Thus, the surgery on the
cancerous uterus that carries a baby demonstrates this point.
Regrettably, the mother wants the baby who will have to die if
hysterectomy is undergone. This is ethically justified through the
criterion of not being intended by the agent.
In consideration of the case mentioned above, the good effect
is the very reason for the performance of the act. Only the good is
directly intended while evil is tolerated. There is certainly a
distinction between tolerating and permitting/allowing. To tolerate is
letting something happen without actively authorizing it, whereas,
permitting presumes complete authority to allow evil to happen. Evil
is tolerated to happen because it cannot be avoided. If there is in fact
another way to avoid the harmful effect, such must be pursued.
However, in medicine and surgery, that is not the case. In fact, all
ethically allowed procedures do have several effects. The saving
grace here is that the good effect is much more compelling than the
indirect harmful effect. Otherwise, nobody recovers from sickness or
disease due to impermissible necessary effect even when it is indirect.
3. The foreseen beneficial effects must be equal to or
greater than the foreseen harmful effects. An assessment of both
the beneficial and harmful effects must be such that the beneficial
effect must be greater in value or at least equal to the harmful effect to
allow the performance of the act or procedure to be done. In this
way, even with the occurrence of a harmful effect, an act is
considered ethical. Otherwise, the imbalance that is present in both
the good that is sought and the bad that is avoided must be resolved.
Sometimes, philosophers and theologians refer to this as the Principle
of Proportionality and must be observed as a necessary condition.
In this principle, one must consider carefully the balance between
benefits and risks or good and evil effects.
It must be remembered that in our ethical life, there are
various ways to assess goods or values. Thus, a hierarchy of goods is
considered when it comes to making decisions. Conflict of values
may ensue when values are of equal importance or that one is greater
or less than the other. To choose one over the other is sometimes a
very onerous task, especially when various ethical values clash with
one another. However, there are situations in which people have to
make choices no matter how painful these choices are or will be.
Such choice can be ethically justified if there is proportionality
between two values or goods, as in the case of the classic example of
a surgery on a cancerous uterus that in the process will also render the
baby dead. Nevertheless, it will be outrightly unethical to choose
material comfort in lieu of human life. However burdensome and
dolorous, the situation might be, a choice between two values has to
be made because it is a necessity even if ontic or necessary evil may
occur. It is therefore expected that an ethical person should recognize
the concept of hierarchy of goods to be able to make just decisions.
Even when values dwell on the same level of hierarchy, the choice
does not become any easier. One might just as well resort to the
usually controversial age-old principle of a “choice of lesser evil,” or
a “choice of a better good”.
On a deeper note, St. Paul’s words must be well assimilated:
“we should not do evil that good may come.” (Rom. 3:8)
4. The beneficial effect must happen first or at least at the
same time as the harmful effect. This criterion is not only a
corollary to the third, but a necessary requirement that must be
recognized under the element of the order of time. This must be
strictly observed to caution against misinterpretation that the harmful
effect is used as a means to obtain the beneficial effect. There must
therefore be a causal connection between the beneficial effect and the
harmful one, or at least a simultaneous occurrence of the good and the
bad one. It is never a good ethical action when the bad happens first
before the good effect. For nothing should use the bad as means to
achieve the good. Hence, when an act is performed, both the
beneficial effect must be first obtained and then the harmful effect, or
both should happen at the same time (synchronically).
This criterion is both a condition that is concerned with time
sequence and precedence of causality, but more of the latter. Under
no reason therefore is one justified to do evil in order to achieve what
is good, for doing so would be tantamount to doing evil. Surgery on
the spina bifida may be indicated relative to the prognosis of a baby
while still in the womb of the mother. This deformity may disrupt
the natural course of the baby’s growth and the pregnancy itself, but
the operation is done, so that while the baby is in the womb, the
baby’s prospect to have a normal spine is likely to be medically and
surgically addressed.
To underscore the gravity of the issue, one therefore is
inclined to choose the procedure by knowing that the good effect
should never be a result of a bad effect in the order of time or in the
order of causality. This is greatly significant otherwise, if evil
happens first before the good, then it could be understood as using
evil as a means to achieve the good. It is of great ethical value if both
the beneficial and harmful effect should happen simultaneously.

The legitimacy of the use of any medical or surgical procedures must

be such that all the four criteria enumerated above are present. Any
lack of a single one of them makes the procedure ethically
questionable and consequently illegitimate. This is a case of a
package deal – it is all or nothing. Thus, it must be noted that the
four criteria must be present in any medical or surgical procedures
that entail two-fold effects, both beneficial and harmful, if an act has
to hurdle and clear the bar of ethical standards. If one or two is
lacking, the principle cannot be ethically tenable. Lastly, as a caveat
or caution, when it comes to a case in which life may be endangered
or lost, it is always circumspectly good to use the principle of double-
effect a calculated one or as a last resort.
The Classic Case of a Surgery on Ectopic Pregnancy. Ectopic
pregnancy is that which occurs in the fallopian tube. The fetus grows
in size over a predictably calculated time. And since it is not in its
proper environment, it poses danger to the tube and makes it thinner
and thinner while it is getting bigger and bigger. When the fetus is
allowed to grow and nothing is done, many possible effects

can result as the

fallopian tube can burst and emit toxins that can poison the mother
which may even be fatal. The most logical thing to do is operate on
the mother’s fallopian tube. The fetus in the process dies due to the
surgery. The object of the act here is the “repair of the fallopian
tube” which is equivalent to the life of the mother and not the removal
of the fetus. Its removal is just the indirect object of the
surgery. Otherwise, if the object is to remove the fetus, then, it is
considered a violation of the criteria of the principle of double-effect,
since the removal of the fetus constitutes an inherently unethical act
and a direct attack on the fetus. For in ethics, “any direct attack on
the lie of any person is considered immoral.”
Consider another case of surgery on ectopic pregnancy. There
is a gadget called endoscopic cutting and suctioning machine that is
used to remove the growing fetus in the fallopian tube of the mother.
It can be done as an outpatient procedure that can last for only forty-
five minutes, more affordable and even practical. The gadget has a
mechanism that allows a rubber tube enter the vagina and the uterus,
and is manipulated to be able to reach the growing fetus. At the end
of the tube is a cutting and suctioning mechanism that cuts the fetus
into pieces, suctions it and allows the surgeon to dispose of it. With
this procedure, the mother does not get any external scar and may
already go home. And for some hours later she may do normal
chores. It is different from the surgery in which the mother is put
under knife that cuts into her skin, then reaches to the fallopian tube,
cuts on it and removes the growing fetus. It takes the mother one or
two days of stay at the hospital and is a little more expensive. Again,
if we take to heart the requirements of the principle of double-effect,
this endoscopic procedure cannot pass its

moral demands because

there are many conditions/criteria in the double-effect principle that
are violated. Here, we take into account that “technology is not
always morality” although it may be practical
or affordable. In fact, there had been a
lot of medical technologies in the market that have been in use but
their use is ethically questionable. Take for instance the
omnipresence of abortifacients, like the intra uterine device (IUD) and
morning-after-pills that have flooded the local and international
markets and yet cannot really pass the moral gauge due to the
stringent provisions of the principle of double-effect.
Corollary to the above principle, it must be stated that it is
never a good bioethical principle that in our task of preventing the
concomitant evil, we have to abstain from performing a good action.
If this were the underlying principle that must always be done, then
medicine will have no meaning in the lives of individuals and
society. It is absolutely uncomfortable to allow people to suffer or die
rather than do something to prevent them from suffering or dying. It
is true that the application of the Principle of Double-effect is not
without controversy. And the controversy centers on the occurrence
of harmful effects. But again, as has been mentioned, in medical and
surgical procedures, generally, evil effects cannot and will never be
avoided.
Last Note on the Case of the Concept of Harmful or Evil Effects.
It should not be forgotten that the harmful effects understood in the
principle certainly includes not only those which are proximate but
also the remote ones. How does Dr. Artemio Ordinario of the UST
Faculty of Medicine and Surgery (2002), a prominent Filipino
neurologist elaborate on the principle? The following statements by
him are paramount:
“While it has been criticized as a ‘loop hole’ to justify
acts which are questionably moral, it has nonetheless
withstood the test of time and remains valid.
The principle of double-effect is not limited to
medical and surgical problems. We being with the
premise that no deed is ever in isolation. There are
always after effects which may be either good or bad.
Some effects are proximal and some are quite remote;
some can be foreseen whilst other are unpredicted.
We see these in the day to day activity and our options
are often dictated by effects that we perceive to be
good. Our dilemma comes when the effects are not
predicted. Social scientists and economic managers
call these effects as organizational sensitivity (where
the effects are limited to the association) or political
sensitivity (where the effects extend beyond the
association).
Four situations come into vision: pain,
restlessness and delirium, uncontrolled seizures and
depression caused by illness. Some of the treatments
have adverse and untoward effects. Intractable pain is
all too common in such situations as bone pain,
pancreatic pain and pain due to infiltration of a
nerve. The use of the opiates is potentially dangerous
including the possibility of addiction. However, there
are situations when their use is justified. Similar
arguments can be advanced in using marijuana to
control certain pains and wasting. The euphoric
effects are the primary intention even if the undesired
effects are permitted. Sedation of the very restless and
delirious patient (as in rabies and withdrawal states)
may require dangerous drugs or even anesthesia, even
if these will shorten the life of the patient. Seizures in
the patient with end stage liver failure often can only
be controlled by diazepham which certainly will lead
to deep coma and even death. Yet such intervention is
justified as the primary intent, i.e., control of seizures
is urgent and necessary. Depression is but natural in
the severely ill patient. While numerous drugs are
part of our therapeutic armamentarium, let it be said
that the most efficacious mode of treatment is
compassion and expressions of empathy and
sympathy. This is where hospice care is needed, most
especially when immediate family is either unavailable
or lacking in understanding. Borrowing the words of
Rabindranath Tagore, “I long to grasp your hands in
 my moments of sorrow and agony.” Our primary
purpose as health care givers is to provide comfort
and ease suffering. While we would like to prolong
life, this is not to mean that we must also extend
anguish. As Christians, we have to look at the edifying
efficacy when offered for a noble purpose. We are
closest to God in trying times and poignant moments.
Good intentions demand a cold impartiality
and absence of conflict of interests. Humans as we
are, this may not all be possible all the time. There
are many societal pressures and unforeseen
circumstances that often influence decision-making.
In the end, it is the individual conscience that should
guide the prudence of our action. Prudence is,
according to St. Thomas, “right reason in action.”
A most difficult situation is armed conflict. Is it
justifiable to use superior weaponry as nuclear
weapon to shorten the war if numerous non-
combatants will be killed? The story of Hiroshima and
Nagasaki, Dresden and Intramuros is indelibly
imprinted as man’s inhumanity under the guise of
ending the war. Take note that even the best scientist
then did not have the vision to see the many delayed
and adverse effects of nuclear radiation that persists
even to this day.”

Case Studies:
A. “Two” Close for Comfort
Maria and Rosa are twins and are three months old. But their
condition is unusual. They were joined together at birth, and it was
Maria’s heart and lungs that were keeping both girls alive. It was
certain that removing Rosa would cause Rosa’s death. “Were they left
joined,” the doctors said, “there was an 80% expectation that both
girls would die within six months.”
 The parents of the twins had opposed the operation in an
unsuccessful legal action that cited religious objections. They further
intimated that their religious faith, both being Catholics, compelled
them to let nature take its course, with no medical interventions, even
though it could result in the deaths of both their daughters. They said,
“We could not begin to contemplate that one of our children should
die to enable the other one to survive. That is not God’s will.”
Incidentally, the case of Maria and Rosa was elevated to the Court of
Law and thereafter, the Court turned down the parent’s appeal and
decided to separate the baby notwithstanding the consequences.
1. What are the ethical issues that can be raised in the case?
Explain each.
2. Can the parents’ disapproval to have the twins separated be
justified on ethical grounds? Can the religious belief of the parents be
a good ethical basis for disallowing the procedure?
3. What is the ethical justification of the courts to allow the
operation?
4. Is removing little Rosa a case of murder? Can the principle
of double-effect be used to justify the operation? How do you
personally gauge the nature of God’s will in this case?
B. “Two” Close to Say Goodbye
Katrina H., a 25-year-old married woman and a mother of two,
is having her third pregnancy. During her prenatal check-up, her OB-
Gyne doctor discovered a twin pregnancy in which both of the babies
are on the 19th week of gestation. In her 21st week of pregnancy, her
doctor, through an ultrasound procedure discovered that one of the
twins died in utero. Both babies share a single placenta. Accordingly,
termination of pregnancy was indicated since the dead baby may
affect the life of the other baby and of the mother due to some toxins
emitted by it.
1. Will the termination of pregnancy be morally justified in
this situation? Why? Why not? Elaborate.
 2. Is it ethically sound to wait for 7 weeks more to make it 28
and do the intervention since this time, there is medical basis to do
caesarean section?
3. Is it ethical to just proceed with the pregnancy until some
indications of harmful effects are evident?
4. What other ethical procedures can be done in case the dead
baby endangers the live one?
C. “Two” Close to be in Conflict
Mrs. N. Rivera is a mother of three children. She is presently
pregnant with the fourth on 22 weeks AOG. Since her pregnancy, she
has been feeling weak that she could not regularly attend to her job in
her office. After consulting with her cardiologist, she was found to
have a heart condition which is worsened by her pregnancy. She was
told to go to her OB-Gyn who later suggested to have her pregnancy
terminated so that she can be better managed medically.
Accordingly, the OB-Gyn even warned her that if this is not done, she
might also die of complications as hers is a high risk pregnancy.
Currently though, fewer and fewer cases like this happen because of
adequate treatments available.
1. Was termination of pregnancy the ethical thing to do in this
case? Explain?
2. What should therefore be done since the pregnancy worsens
the condition of her heart?
3. Is this a case of choice between the mother and the baby?
Elaborate.
4. Is termination of pregnancy a treatment to the condition of
the heart? How?
D. To Die Early or to Die Later
Ms. Zes D. is 45-years-old, married and with four teenage
children. She has been in the Intensive Care Unity (ICU) of the
hospital and is terminally-ill with cancer. She is weak but minimally
conscious. The family wants that she be administered with a drug to
render her unconscious in order that she might not suffer too much
physical pain and mental anguish. But the treatment will hasten her
death.
1. Is it justified to administer the drug? Justify.
2. Does dying early or dying later have a significant
difference? Explain.
3. Is there any basis to object if the outcome would be to
shorten her life by a month? How?
 planetebooks

Chapter 12
Walk with wise men and you will become wise,
but the companion of fools will fare badly.
Prov. 13:20

THE PRINCIPLE OF LEGITIMATE COOPERATION

T

here are realities that we have to face in life and in the practice of the
health profession that have to be done no matter how bad an act is and
we sometimes have to do it or cooperate in realizing it. Sometimes,
necessity calls for it in order to avoid further scandal or the worsening
of the present situation or greater harm. Experience tells us that
medical and surgical practice is not exempt from the demand for said
necessary actions. Unfortunately, sometimes, to cooperate in an evil
act is the best thing to do at a given moment. Sometimes this is
referred to as the “lesser evil”, although not accurately. The
Principle of Legitimate Cooperation may simply be the principle
that can provide the justification for cooperating in an evil act. A
taxi driver for instance, may have to cooperate with the holdup men
who commandeer his cab and at gunpoint and force him to drive to
the designated bank for the planned heist. The cooperation shown
here by the cabbie may be ethically justified since there is no evident
voluntariness as to why he brought the felons to the bank. This is
acting under duress. The same thing can be said of the security guard
of the bank who was immediately disarmed by the criminals before
they entered the bank and thereafter complete the commission of the
crime. Even the bank manager who is forced to open the vault at
gunpoint may be doing a justified ethical action by cooperating with
the robbers in taking take the loot. Their cooperation in the crime
here is neither reprehensible nor unconscionable.
The Principle of Legitimate Cooperation. The following Principle
of Legitimate Cooperation (Ashley and O’Rourke, 2002) in an evil
act may explain why:
To achieve a well-formed conscience, one
should always judge it unethical to cooperate
formally with an immoral act, (that is, directly to
intend the evil act itself), but one may sometimes
judge it to be an ethical duty to cooperate materially
with an immoral act (that is, only indirectly intend its
harmful consequences) when only in this way can a
greater harm be prevented, provided:
a. that the cooperation is not immediate; and
b. that the degree of cooperation and the danger of
scandal are taken into account.
Health care is essentially a cooperative work. No doctor or
nurse or any health care professional can be an island by himself.
Health care will never be efficient unless the expertise of each one in
the profession works in tandem with others to elicit the best possible
result. All health care professionals contribute collectively in favor of
the health of families, humanity and the environment. This is the
reason why health care professionals are expected to be allies with
one another rather than fighting each other since the enemy in health
care is the disease that causes a lot of havoc, pain, discomfort,
inconvenience and suffering to humanity. The International Code
of Medical Ethics (Appendix II) is very clear about this. There, the
role of doctors is generally and clearly spelled out.
Now, it is unfortunate that in many health care facilities, not
all health professionals think in the same way. Some may have
diametrically opposite view of ethics in their practice and this may
involve conduct on their part which can be deemed objectively
wrong. When we are asked to assist for instance in such intrinsically
evil procedures, should we refuse to cooperate immediately?
Oftentimes, this happens when a senior consultant asks a junior
resident surgeon to assist him over a questionable surgery. Should
the resident trainee refuse the former? What can he do? Should he
place his conscientious objection? Ideally, the resident trainee may
inform him of the unethical conduct and try to dissuade him from
doing so. This can be done, but, in reality, the resident just
cooperates with the consultant even if deep within himself, his
conscience rebels against the planned surgery. So, he just cooperates
not because he approves or agrees with it, but because he does not
want to displease the consultant and/or jeopardize his training. This is
considered cooperation under pressure by a superior power. This
cooperation may be considered justified.
From the above, we find the principle meaningful as it will
enlighten those who may resent participating, but could not do so
because of the great pressure exerted over them by those in authority
or those who are in-charge of their training.
In the meantime, let us discuss the following concepts in the
principle. First, in the principle above, there is mention of the term
cooperation that is either formal or material. Distinction of these
two terms is very important. A formal cooperation is one that which
is identified with the purpose of an objectively evil act. The one who
cooperates has a direct intention for the evil object itself and this is
morally equivalent to doing the immoral action himself/herself. A
person can formally cooperate in evil act by doing the evil act
himself, agreeing with, counseling/advising, promoting, provoking,
condoning the evil act (of another) or referring to another an act
that is intrinsically evil. (see below discussion). Some other dynamic
verbs/actions can be included here as formal cooperation, namely:
offering support whether directly or indirectly, endorse, provide
resource, encourage, intend, desire, concur, or freely participate,
be and accessory, and the like.
 However,
by avoiding these actions, one may cooperate in an evil act but can
only commit a kind of material cooperation and may therefore be
ethically justified. It may even be permissible and obligatory if the
refusal to cooperate would result in a lesser evil or eliminating evil.
This kind of cooperation is not immediate and is more remote from
doing the evil involved. Ashley and O’Rourke justified this by saying
that this is all done “to prove that one truly avoids formal
cooperation.”
For example, an OB-Gyn who thinks that abortion is wrong
but performs one because the mother is not married and may be
removed from her job as it is a case of immorality. This is a formal
cooperation. Or say an OB-Gyn who may not perform the abortion
itself but refers the mother to somebody who does it, may formally
cooperate with the evil act of abortion. A nurse who does not agree
with abortion procedure but takes an active part in the said procedure
cooperates formally in the evil act. To avoid such formal
cooperation, she/must do everything to express her/his displeasure
over the procedure. And the best is to express his or her conscientious
objection either verbally or non-verbally.
In effect, formal cooperation in an evil act can never be
ethically justified, but material cooperation can be ethically justified
and can therefore be legitimate. Again, when one is identified with
the purpose of the evil act, it is considered formal cooperation. But
when he is identified with the act but not the purpose of the act, it is
considered material cooperation.
The Case of Referral to Another Provider. There had been
many cases in which patients approach a doctor or any health care
provider in order to undergo procured abortion. There are doctors
who would immediately refuse to do the said intrinsically evil
procedure. However, these doctors who express dislike for the said
procedure sometimes refer patients to other doctors or health provider
who would be willing to do it. A moral question ensues on whether a
doctor himself who refuses to do abortion procedure is not without
moral accountability by not doing it but just the same refers procurers
who do the procedures.
This moral question should find enlightenment in the
following argument: “A conscientious objector as a doctor can excuse
himself from these acts on moral and religious grounds. However, he
cannot on moral grounds refer the abortion procurer to other without
himself accountable for the act of referral. For such referral does not
let the referring doctor off the moral hook. Analogically, if someone
is asked to commit a crime and refuses to do so but agrees to find
someone else who was willing to do it, he would be liable in both law
and ethics as an accessory, if not as a co-conspirator in the crime.
Thus, by passing the buck, one does not necessarily get-off the hook.”
The Case of a General Hospital and an Abortion Clinic. A classic
case of a quarrel between two hospitals can clearly elucidate the
principle of legitimate cooperation in terms of the scandal that is
referred to in the principle. It says that scandal has to be taken
seriously to be able to apply the principle over issues. Thus, in cases
involving ethical decisions or actions, the foreseen or actual scandal
and direct cooperation has to be avoided. The following case may be
of great importance to show:
There are two hospitals, one is a general hospital (GH) and
the other is a special hospital devoted exclusively to abortion, called
abortion clinic (AC). The GH performs abortion procedures like the
AC. Now, AC complains of being accused as an evil hospital worse
than GH because of what it exclusively and singularly performs.
Both hospitals perform 50 abortions monthly. So AC debunks the
accusation that it is worse than GH when both of them perform the
same number of abortions every month.
Of course, it is true that both perform the same number of
abortions every month and this is unfortunately detestable as the
practice of abortion is an unspeakable crime referred to by Pope John
Paul II in his encyclical, Evangelium Vitae. However, AC should
consider the implications the principle entails with regard to the
scandal it creates with the evil procedure of abortion. Certainly, when
people see that a clinic is an abortion clinic exclusively in its mission
and vision, it clearly brings to judgment the exclusively evil work of
abortion they do compared to GH, since it does other services aside
from abortion. This means that such accusations cannot be fairly
attributed to GH compared to AC. The scandal created by AC is such
that whoever works in the clinic are all considered abortionists, be
they doctors, nurses, accountants, electrician, janitors, plumbers,
accountants or even the lowly gardeners. It also includes those who
deal business with them. It must therefore be concluded that AC is
worse compared to GC due to the scandal intrinsic to the lone
procedure it performs. Of course it should not be forgotten that as far
as the practice of abortion by both hospitals is concerned, it is by no
standard morally sound and cannot clearly hurdle past the bar of
ethical demands or behavior.
Case Studies:
A. Pregnancy for Love, Abortion for Frustration
Pinky V., an unmarried woman attempted abortion by drinking
some herbal abortion-inducing concoctions she bought from Quiapo
because her boyfriend did not want to marry her. It was her friend
who introduced her to the herbal tiangge that offers all kinds of herbs
including abortifacients. Her friend said that it was what she did
when she too, did not want to proceed with her pregnancy since she
got impregnated by her boyfriend. In her attempt to use the
abortifacients, she later bled profusely and her relatives rushed her to
a Catholic hospital. The doctors completed the procedure. She later
was given blood transfusion and stabilized after three days in the
hospital.
 1. Who among the following characters engaged in formal
cooperation or material cooperation? Explain.
a. the unmarried woman
b. the boyfriend of the unmarried woman
c. the friend who introduced her to the herbal tiangge
d. the vendor of the abortifacient
e. her relatives who brought her to the hospital
f. the doctor who completed the procedure
g. the anesthesiologist
h. the nurses who assisted with the doctor
i. the hospital who accommodated her
j. the janitor who is in-charge of the cleanliness of the
operating
room
k. the nurse-aide who is in-charge of the aseptic condition
of the operating room
2. Does the unmarried woman deserve to be assisted in the
hospital for attempting to abort her child? Why?
3. Should the Catholic hospital opt not to treat women who
perform abortion in an effort to teach women not to abuse said
practice?
4. Does the Catholic hospital have a duty to educate the
patient about abortion and its evils?
5. Is it ethically or legally advisable to report the woman to
the proper government agency for attempting to perform abortion?
B. Training or Abandon Job
Rosela A., a resident physician in her last year of training, was
requested by her consultant OB-Gyne to assist her in a surgical
procedure to fix some abnormalities upon a pregnant woman who is
in her 16th week AOG. While in the operating room, she noticed that
it was clearly a procured abortion procedure that was being done to
the patient. Rosela protested that she could not continue assisting the
consultant as it was against her morals to do so. The consultant
threatened to reprimand her if she would not continue assisting in the
procedure. She even warned Rosela that she was jeopardizing her
training program for not assisting in a procedure that was part of the
residence training module. Rosela assisted the consultant even if
deep within, her conscience rebelled against her presence in the
operating room.
1. Was it ethically justified for Rosela to continue to assist her
consultant in the abortion procedure?
2. Was it ethically sound that Rosela protested against what
she believes was ethically wrong even if her plan to leave the
operating room may jeopardize the patient’s health?
3. Should Rosela protest against the training module that
includes, if it is true, her assistance in abortion procedures?
4. Can a scandal as great as abortion be resolved by staying
put and quiet and not protesting against it?
C. Nobility of Profession or Director’s Threat
Karen C. is a Catholic public health nurse and a mother of
three assigned in one of the municipal health centers in the province.
As part of the new reproductive health program of the DOH, the
municipal health center distributes family planning
contraceptives/abortifacients for free, like IUD, oral contraceptive
pills, condoms, Norplants, and other gadgets to poor couples in its
areas of responsibility. The municipal health director has informed
all public health personnel that it is a part of their duty to promote the
contraceptives. Now, Karen is in a quandary and asks herself if it is
ethically right for her to follow the directive even if her religious
upbringing does not concur with the health program of the health
center. She thinks that this will put her job at risk since distribution
of artificial contraceptives is a part of the reproductive health program
of the DOH.
1. Is it ethically correct for Karen C. to object to the
obligatory force of the distribution of contraceptives since her
conscience does not allow it?
 2. Is it noble for her and her profession to just leave her work
and look for another since helping in the distribution of contraceptives
is against the very oath she made in the practice of her profession?
How about the children who depend economically from her job – is it
ethically sound that she quits her job rather than violate her
conscience?
3. If she distributes the contraceptives, does she commit
formal or material cooperation in the evil act? Justify.
4. What other prospects can Karen pursue to keep her job
without involving herself in the reproductive health program of the
DOH? Or should she just leave and look for a job somewhere else?
Justify.
5. What can you do to help Karen in her dilemma?
D. Nurses on Strike! What?
Nurses have always been known to be gentle and caring.
When they joined the strike, every one’s eyes bulged in wonder? One
day, the nurses at a large university hospital, after two months of
debate and collective bargaining discussion had decided that the said
bargaining was in a lockout. They decided to strike for better pay,
improved working conditions, and even argued that these would mean
improved patient care. Nurses began to form picket lines outside the
main hospital façade. Tensions increased, and accusations of
irresponsibility and injustice from both sides of management and
labor began to fill the air. Meanwhile, patients started to ask for
transfers to other hospitals as they believed they would not get the
needed care while the nurses were on strike.
1. Would such a strike be acceptable on the basis of the
purpose which the nurses expressed?
2. To what extent do nurses have moral responsibilities to the
current patients? To potential patients? To themselves and their
families?
3. To what extent does their responsibility to maintain levels
of patient care limit their picket lines?
4. Who should be blamed if harm happens to the current
patients of the hospital, the nurses or the management? Is joining the
strike a form of legitimate or illegitimate cooperation? Can the
management be legitimately accused of formal cooperation for the
breakdown of care in the hospital?
E. Mr. C. C.’s Role in Abetting Abortion, ‘Babycide’
(adopted from a national broadsheet)
Too often, it seems, unwanted offspring are condemned to
death by the very persons supposed to be caring for them.
In his column “Conscience best guide in family planning”, Mr.
C. C. (not his real name) reported that a 13-year-old girl, who was
raped by her own father and already three months pregnant, was
brought to him by her mother who asked, “What should I do, Mr. C.
C.?”
This was what transpired according to Mr. C. C.’s narration: “I
consulted a doctor-friend who said the baby would have many
deformities due to the incestuous rape.
“I asked the mother and the girl if they were willing to have
the baby aborted.
“When they said yes, I went back to my doctor-friend who
prescribed a medicine that induced abortion. I sent the girl to the
hospital after the abortion.
“Has my conscience bothered me? Not at all . . . I did the
right thing by helping the girl get on with her life.”
“I beg to disagree,” according to Mr. E. S. “It’s obvious from
Mr. C. C.’s story that his doctor-friend never even examined the girl
prior to prescribing the abortive drug. (How can a conscientious
journalist call a drug that kills babies “a medicine”?) The possibility
of deformities may truly be higher in incest babies, but it is not a
certainty. More incest babies turn out to be normal rather than
deformed or disabled. Even if they turn out deformed or disabled,
don’t they deserve to live?”
Having a child by rape cannot be a stigma if the victim
chooses (or is guided) to carry the experience with due dignity and
courage and to nurture a high regard for the life of her unborn baby.
The latter half of Mr. C. C’s story showed utter cruelty. He
actually offered to have the baby killed! When the mother and the
girl following his lead said yes to the killing of the baby, he got the
prescription for “babycide.” And the poor baby was killed. Mr. C. C.
even provided alibis – stigma for the girl, deformities for the baby.
Mr. C. C. did not help that girl get on with her life. He
lowered her regard for life with premeditated murder of her unborn
baby. In retrospect, his influence could have easily guided the girl
and her mother to value life. He could have been more humane to an
innocent, unborn child and allowed him to see the beautiful light of
day. (italics author’s)
There are and will be other unwanted, unborn children. For
them it is not too late to turn misfortune into a blessing.
1. What is your view of Mr. C. C’s actions?
2. What is your view of Mr. E. S.’s rebuke of Mr. C. C.?
3. What ethical principles have been misused or violated in the
case? Why?
4. Can Mr. C. C. be prosecuted for his actuations based on
existing laws? Which one?

Chapter 13
Without cost you have received,
 Without cost you are to give.
Mt. 10:8

THE PRINCIPLES THAT GUIDE HUMAN ORGAN

DONATION AND TRANSPLANTATION

dvances in
medical and surgical knowledge and technology today have made it
possible to do procedures that were unknown two or three decades
ago. Medical skills, too, have heightened the healthcare
professionals’ learning curves and have contributed significantly to
many breakthroughs in health care. Specifically, new modalities have
made inroads into diagnostic and therapeutic management of patients
like seeing the internal organs of patients in high definition images
through the Ultrasound, CT Scan, MRI, Gamma Knife, PET Scan,
Linear Accelerator and other procedures using laser beams that can
even change image or appearances of faces or whiten the skin.
Added to these record breaking modalities are organ
transplanting procedures done through organ donation programs.
Organ transplantation can be done by surgically transferring tissues or
organs from one part of the body to the same body, from living
donors to living donees, cadaveric donors to living donees, or from
animals to living human donees called xenotransplantation. Some
organ transplants are also classified as related or non-related donors-
initiated transplant (to show who the donors are), with the intent of
monitoring the motives behind the donation of a non-related donor.
Many of the common organ transplantations done today are
skin graft transplantation (either homologous – same person, or
heterogeneous – from another person), hair, cornea or tooth
transplant, face, kidney, uterus, liver and heart. Transplantation of
other organs is still quite infrequent.
A Brief History of Organ Transplantation. Organ transplantation
to treat illnesses and injuries can be traced back to as early as the
genesis or initial attempts of healing. However, the procedure
reached great scientific progress as an accepted treatment only during
the 19th and 20th centuries. Great strides have been noted initially in
the transplantation of bones, soft tissues, as skin and corneas. Data
suggested that a great leap forward that is worth mentioning was the
establishment of the US Navy Tissue Bank in 1949 that gave USA its
first bone and tissue processing and storage facility. This facility even
gave rise to an eye bank, blood bank, sperm bank, etc. By the last
quarter of the 20th century more banks have been established due to
the benefits they can offer to the suffering.
Worldwide, immense progress in organ transplantation began
in the 50’s. The mention of Dr. Joseph E. Murray is significant. He
received a Nobel Prize for medicine in 1990 and achieved the first
successful kidney transplant in Boston, MA, USA in 1954. In 1967, a
young South African rose to worldwide fame in 1967 for having
performed the first human heart transplant in Groote Schur Hospital,
Cape Town. Since then, many transplant procedures were done like
ordinary surgical procedures around the world. In the Philippines, a
prominent kidney surgeon, Dr. Domingo Antonio performed the first
and successful kidney transplant in the 60’s at the University of Sto.
Tomas Hospital, Manila, Philippines.
 It was noted that
the success in organ transplantation was somehow impeded due to
some problems regarding the immune system manifested by way of
organ rejection by the host body due to many factors like infections.
But in 1978, a drug, Cyclosphorin, was introduced and administered
as an immuno-suppressant. Through it, the problem of rejection was
substantially resolved. There has been a marked 70% to 90% survival
rate for organ transplants. Continuous research has been done to
neutralize the side-effects of Cyclosphorin. With the modern medical
equipment that have been invented to support and aid the transplant
procedures in the 1990’s, more and more organ transplants are
performed successfully and the success rate has been steadily rising.
In the Philippines, there had been kidney transplantees who were able
to survive for almost 20 years with good quality of life. Many
foreigners come to the Philippines for such a procedure. The
procedure however is not without controversies from all sides,
beginning with the government, the social service, the general public,
as well as, the patriotically leaning advocates.
Furthermore, with the great improvement in imaging and
ultrasound technology the problem about the determination of death
has become much easier. With the advances that took place in the
60’s, it became possible to diagnose clinical death based on the
cessation of all brain functions including that of the brain stem, a
condition referred to as brain death. This determination is enormously
significant to organ donation which is possible after brain death is
declared.
The Principles Underlying the Organ Donation and
Transplantation. Many of the ethical controversies that arise in
organ transplantation are those done with the kidney. Firstly, kidneys
are scarce, and therefore candidates who wait for the procedure may
die without availing themselves of it. Secondly, applicable laws are
not so clear about the practice of organ transplantation, and so, they
are done surreptitiously and unscrupulous persons circumvent them to
avoid legal complications. This happens on foreigner-patients who
come to the country looking for kidneys from the local residents
especially in the mid-2000s. Fortunately, some laws have been
legislated now to this effect. Thirdly, (and this is usually the reason
that gives a lot of problem), the trading and trafficking of kidney
organs that even cross beyond national borders. Many of those who
sell their kidneys are male and very poor or those who are
institutionalized like the prisoners. This can happen in many
totalitarian governments around the world. The idea of exploitation
comes to mind immediately when trafficking is concerned. Thus,
there are great ethical questions on how these transplantations are
consummated, initially from sourcing the organs, to financial
motivations and to the surgical operations. All these issues can be
abated and resolved if those concerned (the surgeons, the donors and
recipients, and the middle men) know the ethical principles and
implications of the said surgical procedure.
It must be remembered this early that we have an obligation to
give reverence to what is due to the human body because it is sacred.
It should therefore be known that even the human body parts
especially if they belong to the basic capacities that define human
personhood are also sacred. Trafficking these human organs for sale
is detested because of the flagrant disrespect dealt on them. Human
body parts or organs are not to be treated as if they were commodities
for sale on a store. Thus, the indiscriminate importation or
exportation of these as if they were spare parts to be transported and
appended to another body calls for censure and denunciation. The
Supreme Pontiff has delineated on how organs can be donated or
transplanted. Pope Pius XII, for decades now, in his address to the
Eye Specialists on May 24, 1957 exhorted all the stakeholders by
saying:
A person may will to dispose of his body and
to destine it to ends that are useful, morally
irreproachable and even noble, among them the
desire to aid the sick and suffering. One may make a
decision of this nature with respect to his own body
with full realization of the reverence which is due it. .
. .This decision should not be condemned but
positively justified.

The Pope is
distinctly clear about the motive of aiding the sick that should
characterize organ donation and that such is a noble act that should be
seen as an act of universal charity and should not be condemned but
even positively justified and encouraged. This universal charity must
be emphasized since it gives us two welcome implications.
Biologically, organ transplantation is an act borne about through a
human bond that characterizes humans as belonging to the same
specific human affiliation with other humans. Morally and spiritually,
organ donation or transplantation is characterized by the call to
charity in which a donor is seen as overflowing in generosity to aid
the sick and suffering. Trading human organs in exchange for
monetary gain is diametrically opposite to the characteristics referred
to above, and therefore should be frowned upon as an aberration of an
otherwise laudably virtuous act.
Specifically, some ethical guidelines have to be taken into
account if organ donation has to pass the scrutiny of ethical debate.
The ethical appraisal, principles and criteria below (Ashley and
O’Rourke, 2002), are deemed important, namely:
1. There is serious need on the part of the recipient that
cannot be fulfilled in any other way. Superficial and shallow
motives cannot be an overriding reason to effect human organ
transplantation by a donor to a recipient. Indeed, a compelling cause
should be indicated and determined as this medical intervention is
deeply serious that it cannot just be performed at will since two lives
are at risk. Thus, the recipient must claim gravity or seriousness of
his condition and that a bodily function (if absent) cannot be fulfilled
in any other way except through an acquisition of healthy bodily
organ/s from another. Seriousness must be understood as a condition
that can adversely put the person to further severe and debilitating
condition, permanent incapacity or irreversibility or even eventual
death. Care therefore must be taken so that the recipient gets what
was predicted to satisfy and what was prognostically envisaged.
2. The functional integrity of the donor as a human person
will not be impaired, even though anatomical integrity may
suffer. There are two kinds of bodily integrity, namely: anatomical
and functional integrity. The anatomical integrity refers to the
quantitative completeness (or total accounting) of physical attributes
or potentialities of the human person. As human beings, we are
naturally and normally endowed with two (a pair of) kidneys, two
eyes, a liver, a heart, two feet, etc. The presence of these makes us
possess anatomical integrity. However, functional integrity is
different. We may for instance lack some bodily attributes and yet we
may function as normally or as closely like an anatomically complete
person. Thus, functional integrity refers to the systematic efficiency
of the human body. A person may have only one kidney but if it
works just as efficiently as it should, then he has functional integrity,
because he can function normally with one kidney. The same can be
said about a liver in which a part is removed and transplanted to
another. The liver has the power to grow and the donor-person can
live normally as he could before the organ donation. It is different
when we donate an external ear as this will reduce substantially the
acuity of hearing. It will therefore affect not only the anatomical
integrity of the donor but also his/her functional integrity, although in
extreme cases this can ethically be done.

Transplant of cornea is
similarly included in this category.
Ashley and O’Rourke (2002) contend that the distinction of
these two kinds of integrity explains why medically and ethically, it is
sound to administer blood transfusion, skin grafts and even hair
transplants. Further, it is ethically sane for elective appendectomy if
an abdominal cavity is opened for another legitimate reason, as one
can live normally without an appendix. Hence, loss of anatomical
integrity is acceptable since there is no (substantial) loss of functional
integrity.
3. The risk taken by the donor as an act of charity is
proportionate to the good effect in favor of the recipient. Shallow
and ephemeral motives exclude the undertaking of organ transplants.
It must well be determined that whatever risks that the donor will take
must bear proportionately to the good that the recipient will acquire.
If the risk is too high and the good is just relatively and temporarily
short-lived, then such decision must be well thought of, suspended, or
even scrapped totally. It is not rational therefore to do kidney
transplant on an 80-year-old man as the life expectancy of the latter is
just too short and that the quality of life if he is able to live may not
be proportionate to the sacrifice made by the donor. The donation of
organs is a great sacrifice made by the donor. It is therefore
imperative that the good that should result in the donation as a great
act of charity must be so great as to make the donee grateful
throughout his lifetime. This must be said about kidney and liver
donations.
It can be added here that there has to be some limits as to what
kind of bodily organs may be subject to donation or transplantation.
It must be seriously noted that transplanted organs that will
substantially alter the donee’s personality or change his psychological
make-up should be enough reason to totally disallow health care
professionals from performing it. This should be applicable to brain
or even reproductive organ transplants like penis, vagina, uterus or
breast.
4. The donor’s consent is free and informed. This
requirement is very fundamental in any procedure but especially in
organ donation. Organ donation is never obligatory. Pressuring a
would-be donor should be avoided as in the case of relatives who may
pressure or even threaten one to donate his kidney with
accompanying warning that he may be responsible for his relative’s
death if he does not donate his kidney. One should freely decide to
offer or not to offer as recognition of his freedom to act charitably.
For a person to exercise free and informed consent, he must be able to
possess the necessary information, both medical and ethical, so that
his conscience would be informed. An informed conscience is a pre-
requisite relative to the exercise of a free and informed consent. Any
essential lack of this information may render the act of donation
ethically illegitimate. The financial implications (pre- and post-) of
the surgery must be clearly specified in detail to avoid legal and even
ethical repercussions. (See topic on basic information needed before
any medical protocol is done, chapter 15, below).
 5. The recipients for the scarce organs are selected justly.
Justice demands that we treat everyone fairly. The selection of
recipients must be fair so that those who receive the prized organs are
treated equitably. There is therefore a need for (national) policies to
follow so that fair chances by qualified recipients of scarce organs are
not based on irrational or discriminatory selection rooted on
influence, wealth or political position. The practice of triage is very
important and there must be rational policy for inclusion of recipients
queuing on the reception line to determine good prognosis. Once the
recipients have been selected, “a first come, first served policy” must
be enforced, unless a donor picks out a recipient, based on his
exercise of freedom to receive his organ. This is usually true with
related organ donors and donees.
6. The donation is by nature an act of charity for both the
donor and the donee. Organ donation is an act of charity that
should spring forth from the sacrificial generosity of the donor. It
should therefore dismiss outright any idea about purchase or sale,
including the sale of blood – although one should pay for its
maintenance, like electricity and gadgets used to ensure the blood’s
active potency and freshness. The sale of bodily organs is ethically
objectionable since it is contrary to the sanctity of the human body,
even as it is depersonalizing, and those who need the organs should
be recipients of charity rather than act as purchasers because they can
pay. This will strengthen and enhance the natural and virtuous bond
that should characterize human relationships. Since these health
resources are scarce, it is ethically commendable that organ banks be
established and its distribution consolidated to optimize the service it
can offer to needful patients. It should therefore be noted that as
parts of a sacred body, it does not sit well that they be subject to trade
for monetary gain. It is for this reason that it is highly objectionable
for humans to engage in prostitution as flesh trade is degrading and
dehumanizing. Yes, flesh trade is immoral.
Health agencies, health professionals and the national
government must encourage and promote donation of vital organs,
especially kidney and liver, primarily to aid the sick and the
suffering. Establishing a foundation is not only laudable but inspiring
as this will truly help those who are financially constrained and are
still blessed with potentially productive quality of life ahead. The
Philippine Charity Sweepstakes Office (PCSO) and the Philippine
Gaming Corporation (PAGCOR) should coordinate and pool
substantial resources so that kidney transplantation would not be
difficult to obtain. (This is not to condone gambling). After all, one
of the primary objectives of these two government organizations is to
assist the poor and the sick. This will certainly create hope to those
who are consigned to the wheelchair or to a dysfunctional physical
organ until their death.
It should not be forgotten that as an act of charity, both the
donee and donor must well be guided by the virtue of charity. This is
explained below.
7. The organ transplant or donation should not change the
personality of the donee. This is one guideline that is sometimes
taken for granted in the whole gamut of the procedure. It is
noteworthy that the organ donation or transplant should help the
person who is sick and be able to live a normal or close to normal
life. It should not in anyway change the personality of the done. In
case there are procedures that can significantly affect the personality
of the donee, organ transplant is not ethically tenable. This can be
applicable to brain or sex transplants. Hence, strict protocols must be
in place before abuse gets into the equation or only for the
advancement of science but not for helping the sick.
The Altruistic Nature of both the Donor and the Donee. There is
one thing that must always be remembered. While it is universally
known and understood that donors of human organs choose the act of
donating as an act of altruism, inasmuch as the act is a charitable one,
i.e., that of helping the sick and the suffering to recover health and
strength without demanding for recompense, it is equally true that the
donor himself must also be altruistic in terms of helping the donee in
her health needs through the donation of the human organ. It is
unknown to many that as years passed after successful organ
transplants, it became apparent that the ones who suffer even the most
are the donors, though not seen insidiously throughout their life.
According to a prominent Filipino UST internist, Dr. Alberto Daysog
(2008), the usual recipients are mostly wealthy. How else can they
afford the expensive surgical procedures and would be willing to go
around the world looking at every nook and corner for the most
coveted human organs? The recipients can easily afford regular
check-ups, expensive non-rejection drugs and care, and can even ask
for a second transplant in case the first fails. What awaits the donors
is something that can surprise many. It has been found out that
whatever has been told about normalcy of life the donor will
experience after transplant, it showed that the remaining kidney and
increasing workload can have an irreversible and detrimental effect
on the donor him/herself. It has been reported that five to ten years
after donation, the blood pressure of the donor goes up by 5mm of
Mercury and that hypertension develops. This has to be looked up to
when seriousness.
It has been reported also that a “Canadian patient in her mid-
twenties who was undergoing dialysis three times a week did not
consent for a transplant from any of her siblings, neither would she go
abroad to look for one. She would just wait for her turn for a kidney
from a cadaver donor,” Daysog continued.
How altruistic in fact is a donee to his donor? Accordingly,
hardly, since many would rather be anonymous to their donor. This
may be reprehensible since the so-called altruism straddles in the thin
line between charity and danger. That is why, for human organ
transplantation to be ethical, there must be a good balance between
charity and risk. This means that both the donor and the donee must
be mutually altruistic to each other.
The Republic Act 7170 or the Organ Donations Act of the
Philippines of 1991. There is a law called the Republic Act 7170,
otherwise known as the Organ Donations Act of 1991. It was signed
by the former President of the Philippines, Mrs. Cory C. Aquino. The
highlights of this R.A, are important for everyone’s knowledge. The
following are:
1. It encourages donors to donate their kidneys or liver or any
other human organs when opportunity opens up for them.
 2. When the patient is irreversibly brain dead or is pronounced
clinically dead.
3. The hospital can harvest organs for transplantation without
the formal free and informed consent of the donor provided the
following requirements are followed:
a. When the family of the patient, as in the case of those who
have been victims of accidents cannot be traced.
b. In the event that they cannot be traced, the hospital
authorities must have informed the public about the situation and need
of the patient through the tri-media of radio, TV and newspaper for a
timeframe of 48 hours.
c. When no one in the family comes to collect the patient, the
hospital authorities can now harvest the organs for transplantation.
It must be noted that for all those who drive motor vehicles,
they can express their intention or willingness to donate whatever
organs they want to and should write it at the back of their driver’s
license as provided. Or for the general public to sign their intention
or wish in their yellow donation card provided by the National
Kidney Transplant Institute (NKTI) in Quezon City. This will
facilitate early and efficient harvest of important and needed organs.
There is certainly a great charitable act in the said donation. After all,
“heaven does not need human organs; we do need them here on
earth.”
What the Church Teachings Say about Organ Donation. The
following are some of the church teaching on Organ donation and
how the Pope and Bishops view it:
Evangelium Vitae (1995). According to Pope John Paul II,
“one way of nurturing a genuine culture of life is the donation of
organs, performed in an ethically acceptable manner, with a view to
offering a chance of health and even of life itself to the sick that
sometimes have no other hope.” (#86)
Donum Vitae (1987). In this area of medical science too, the
fundamental criterion must be the defense and promotion of the
integral good of the human person, in keeping with the unique dignity
which is ours by virtue of our humanity. Consequently, it is evident
that every medical procedure performed on the human person is
subject to limits determined by respect for human nature itself,
understood in its fullness: “what is technically possible is not for that
reason alone morally admissible.” (#4)
Accordingly, any procedure which tends to commercialize the
human organs or to consider them as items of exchange or trade must
be considered morally unacceptable, because to use the body as an
“object” is to violate the dignity of the human person. Here, the
donation is not just a matter of giving away something that belongs to
us but of giving something of ourselves, for “by virtue of its
substantial union with a spiritual soul, the human body cannot be
considered as mere complex of tissues, organs and functions – rather
it is a constitutive part of the person who manifests and expresses
himself through it. (#3)
Deus Caritas Est (2005). Pope Benedict XVI reminds us in
this encyclical that: “We are dealing with human beings, and human
beings always need something more than technical proper care. They
need humanity. They need heartfelt concern – these charity workers
need a ‘formation of heart’; they need to be led to that encounter with
God in Christ which awakens their love and opens their spirits to
others.” (31 #2)
The Catholic Bishop’s Conference of the Philippines
(CBCP, 2008). The CBCP has some important thing to say about the
allocation of scarce resources as kidney or liver. It says, “A just
allocation of the scarce organ should be safeguarded. Scarce organ
donors should be made available first to the local recipients. A strict
limit on allocation should be set for foreign recipients.”
On Xenotransplants. A xenotransplant procedure is a surgical
procedure that uses animal organs for transplantation to humans. In
the Philippines, a noted cardiac surgeon, Dr. Avenilo Aventura has
done several successful transplantation of pig’s valve to humans and
has lengthened substantially the life of the transplantees.
Xenotransplant surgical procedure has not been condemned as
unethical. On the contrary, it is hailed as a breakthrough in the science
of medicine and has not been found to contravene any ethical norms.
Pope John Paul II however has something to say about its ethical
appropriateness. While it was not his intention to explore the
technical aspect of it, he mentioned Pope Pius XII (1956) regarding
the question of its legitimacy. His response is still very enlightening
to everyone today. Accordingly, for a xenotransplant to be licit, the
transplanted organ must not impair the integrity of the psychological
or genetic identity of the person receiving it; and there must also be a
proven biological possibility that the transplant will be successful and
will not expose the recipient to inordinate risk/s.

Case Studies:
A. Am I my Brother’s Keeper?
Tom Cruz is 28-years-old, single and has been on kidney
dialysis for ten months. He was once a junior executive at an
investment company in Makati and earned a handsome salary, until
he was diagnosed to have an end stage renal failure. The money he
saved has been drained due to his frequent visits to the hospital for
dialysis. The parents have been encouraging, short of pressuring his
25-year-old younger brother, Vito, to donate one of his kidneys as his
is a perfect match for his brother’s. Vito would not agree as he
believes that he is not his brother’s keeper. He is afraid though that
he will be blamed by the whole family in case his brother dies without
receiving the said organ. Aside from this, Vito is planning to wed his
fiancée in six months. And she would not also agree as she thinks
this will put his life in danger. Meanwhile, Tom is just waiting for
Vito to decide in his favor.
1. Is the actuation of the parents to encourage, short of
pressuring the younger brother to donate the latter’s kidney ethically
sensible? Why?
2. Should Vito be obliged to donate his kidney to his elder
brother? Why?
3. Should Vito be blamed in case his elder brother dies of
kidney failure?
4. Is the fiancée’s objection ethically acceptable? Is the
fiancée’s fear for Vito’s life founded?
5. If you were Vito, would you donate your kidney to your
elder brother?
B. To Harvest or not to Harvest?
Edu O. is 29-years-old from the town of Paete, Laguna. It was
his first time to come to Metro-Manila, particularly Cubao. While
crossing the footbridge above EDSA, he became so fascinated with
the speeding cars beneath. He therefore amused himself by watching
them even for a while. So he sat down on the railings of the
footbridge as he enjoyed the new spectacle he was witnessing.
Unfortunately, he fell and laid flat on the pavement of the highway.
Concerned bystanders brought him to the nearest East Avenue
General Hospital. Diagnosis revealed a broken skull and a severely
damaged brain. The next day, he fell into a coma and the doctors
pronounced his condition to be irreversible. Three days later, the
hospital harvested his kidneys and liver to be transplanted to waiting
patients. Accordingly, the doctors believed that there was nothing
wrong with the organ harvest as he was already dead.
1. Was it ethical for the hospital to harvest the organs of
Edu O.?
2. The doctors based their decision to harvest the organs as
provided for in the Philippine Organ Donations Act 7170 of 1991,
what makes it therefore legal or even ethical?
3. Edu O. did not give any permission to tell that he was
donating his organs in case of death since he did not carry any
driver’s license or yellow card that tells about his donation. Did the
harvest of his organs warrant an assumed permission? How?
4. Should informed consent from the comatose patient’s
family be necessary before harvest is done? Can the relatives have an
ethical and legal ground to seek legal remedy?
C. No Love Lost for Her Brother-in-law?
Joe and Vic are brothers and were 30 and 27-years-old
respectively. Joey is married to Lara and Vic to Mia. When Vic
married Mia, Joe and his parents were uneasy as they did not like the
idea of Vic marrying his present wife, since she was an ordinary girl
who came from the province and had not earned any college degree
aside from having come from a poor family. At one time, some of the
family members have even derogatorily said that Mia is like a
salvaged pick-up from garbage. Of course, the couple were furious
but did not push for trouble as this would lead to more problems.
Suddenly, Joey was brought to the hospital complaining of weakness
and pain in the whole body. Diagnosis revealed that he had an almost
end-stage kidney disease. The doctors suggested dialysis three times
a week and encouraged the family to look for a kidney donor. After
more than a year no donor was forthcoming. Vic, the younger brother
was the logical candidate to donate one of his kidneys and in fact was
a perfect tissue match for Joey. The parents therefore pleaded with
Vic if it was possible for him to donate to his brother to save him
from pain and suffering. Vic responded by saying that he would ask
the permission of his wife, Mia, as he believes that the wife has a
substantial part in the decision. Mia initially said “No”. Later
however, she changed her decision with a condition that the whole
family of Vic should first sincerely ask for forgiveness from her for
all the affronts and disparaging comments they dealt her since
marrying Vic.
1. What are the ethical issues that can be raised in the case?
2. Was the collective apology by the family to Mia required to
make her decide in favor of Vic donating her kidney to the elder
brother?
3. Is it ethically defensible if Mia does not decide in favor of
Vic’s donation? On what ethical grounds and why?
4. Do the parents have the ethical authority to force Vic to
donate without the wife’s approval? How about a legal authority?
D. A Sacrifice of the Handicapped Son for Husband’s Sake
Mr. O. Estrada, 56-years-old, has a kidney disease and has
been on dialysis twice a week for two years. The doctor had advised
him that kidney transplant was the most medically and surgically
rational procedure for him if he wanted to live longer. Mrs. Estrada
had asked her three children, all single, ranging from 25 to 30 years-
old, if it was possible for anyone of them to donate one of their
kidneys to save their father’s health, since their tissues were a match
to the father’s. The two older children did not agree. The third did
not have any response. He is 25-years old and suffering from
moderate Down’s syndrome. Mrs. Estrada volunteered him to be the
donor, justifying that the son would be useful after all to his father.
Meanwhile, Mrs. Estrada is preparing for all the necessary documents
and papers for the dispatch of the procedure.
1. What can you say about the attitude of Mrs. Estrada, as well
as, the two other siblings in the case above?
2. Was it ethically right that Mrs. Estrada volunteers her son
with Down’s syndrome to be the donor?
3. Can Mrs. Estrada ethically use the proxy consent reposed on
her as mother of a handicapped child? Justify.
4. Do you believe that the way the family treat the son with
Down syndrome is treating him like a throw-away? Your opinion is
needed.
E. Mother’s Milk for Sale
In the year 2002, many lactating mothers from the Philippines,
from poor families, went to another country in unusual number. This
was during the time when the epidemic, SARS hit said country. It
had been found out that these mothers came from the squatter areas
and were poor. They had been contracted by the host country to
‘donate’ their milk in order to fill the need of the said country’s
babies. These mothers were paid by the inviting country for their
fare, lodging and the milk they ‘donated.’ When they came back, the
mothers said that they were happy for the income they earned.
1. What do you think about the practice of ‘donating’ milk by
lactating mothers?
2. Is there any ethical question/s about the practice? Why?
3. Should this practice be tolerated on the basis of ethics?
Why? Why not?
4. Should being poor justify the ‘donation’ of baby milk by
lactating mothers? Why?
F. At Last a Prospect for Actual Motherhood
Just recently, a breakthrough in medical-surgical procedure
has a uterus transplant done on a woman of productive age who did
not have a uterus. She had struggles in fertility making her impossible
to have a baby. Later, she submitted to a uterus transplant from a
woman donor. In short, the surgery was successful. As a matter of
fact, after a couple of years, she conceived and delivered a healthy
baby. The result was well received by many in the medical world but
not without any criticism.
1. What do you think of the uterus transplant in this case?
2. Does it ethically follow the guidelines on organ donation?
3. What do you think about the woman who was a donor of
the uterus? Suppose she is of productive age? What if she is not of
productive age, would you change your position?

Chapter 14
I say this not by way of command,
but to test the sincerity of your love
by your concern for others.
2Cor. 8:8

THE PRINCIPLE OF AUTONOMY OF PATIENTS

 T

he
term autonomy comes from two Greek words auto (self) and nomous
(law). The role of law to provide governance to ensure peace and
order in the society. And autonomy literally means self-governing or
self-determining. Self-determination is therefore an attribute of a
person who possesses a right to exercise freedom of choice and action
in the pursuit of individual goals, whether at present or in the future.
When applied to patients, it is a right by which a patient can freely
decide by himself as a mature person on matters pertaining to his
health and other consequent acts to promote his well-being. This right
cannot be prejudiced by the health professionals to personally act in
favor or not for the interest of the patients as when a patient does not
want to be treated. The patient is the most important person in health
care and his decisions must be respected as they relate to the exercise
of his freedom and unarguably, as an essential part of his
personhood. Medical professionals and other allied health
professionals have genuine but limited autonomy over those entrusted
to their care as given them by the profession they practice. Patients
may have questions about the surgical operation recommended by his
doctor, but they still have the freedom to ask for second and even
third opinion from other experts. This should not be frowned upon by
the attending physician, but must be welcome as the pursuit for other
better treatment answers may be more persuasive to the patients. This
will reduce misunderstanding between professionals and patients and
they will be able to correct things while they are at the initial stages of
treatment protocols. Furthermore, this will also reduce malpractice
litigations since the decision of the patient is given value. There is no
substitute for collective wisdom and knowledge in the discovery of
solutions to health problems. Thus, the opinion of the patients and
their families, no matter, how cultural, primitive, impertinent or
otherwise are always important in promoting the autonomy of
patients.
This concept of autonomy though has been understood by
some in an extreme way as having the “right to whatever they wish
with their bodies, as long as no one else is harmed.” This is rather a
misuse and abuse of the right. For ethically, one can only exercise
genuine autonomy, as in patient care, for as long as one requests or
chooses the medical care that will fulfill one’s responsibility to God,
fellowmen and self. Thus, the essential functions of the decision
making by patients could not be pursued if the reason for it is more
harm and evil no matter how autonomous one makes of his actions.
Intrinsically evil actions therefore invalidate the autonomous
decisions made by patients since autonomy is only a handmaid of
ethical ends or goods. True, autonomy must be respected for as long
as intrinsically evil decisions or actions are not intrinsically evil.
While it is true that autonomy of patients is not absolute, so
are the decisions made by health professionals. Paternalism is not
always a good paradigm in the practice of health care. It can only be
invoked if such has been proven to bring about more ethical goods
and benefits. Autonomy can best be exercised when decisions are
grounded on evidence-based medicine and on the ethical plausibility
of a procedure. When they are acceptable to patients and are
considered the normal way of doing things, then, acquiescence of
patients can be construed as autonomy.
The Requirements in the Use of the Principle of Autonomy. The
formula on the Principle of Autonomy of Patients (O’Rourke and
Ashley, 2002) is as follows:
Autonomy of Patients is the right of the patients to accept or
refuse the physician’s treatment. His option to choose is based on
respect of his free will. The following elements are essential in the
practice of the principle:

1.
The relationship of a physician and patient is governed by a
moral contract. Every encounter between patients and physicians
creates a relationship. Such relationship has both legal and ethical
implications. As part of the legal implications, physicians are
generally expected to demonstrate a conduct that is characterized by
professionalism. The society through its government agencies has a
right to censure erring physicians and impose penalties, if they are
found to be faulty and/or are found to be substandard in the service
they do. They can even be fined or imprisoned as the case may be, if
found to have done flagrant or gross misconduct to the detriment of
their client-patients. Hence, there must be some self-regulatory
measures within their practice and external commissions or agencies
that must be established in order that they can act as agents that must
police the practice of health care, but not necessarily control their
freedom to practice.
Far from the legal implications, the ethical is even more
important since relationship between patients and physicians cannot
just be simply legislated. More so that such relationship is based on
trust, which is based on the dependence of the patient to the
competence and conscience of his physician, and the physician’s
conviction that the patient can be relied upon in the compliance of the
medical protocols. A trusting relationship is essentially required as
cure would be impossible if patients and doctors are unable to give
trust to each other. When there is no trusting relationship, medicine
becomes very expensive as doctors would have to buy insurance
themselves to anticipate conflicts with their patients and ensuing
litigations. Trust between patients and professionals are like a path
that both tread upon. When that path is broken, patients and
professionals will both lose sight of the benefits of medicine. When
that path is lost, there is no direction where both can journey towards
cure. That is why, cure depends greatly on the strength of the trust
they hold with each other. Therefore, it is expected that both will do
their share and act in ways to achieve the best possible outcome of the
treatment. Ethical and competent services are the backbones of a
trusting relationship.
One important thing that we have to remember is that while
the relationship is based on the mutual trusting relationship between
the patient and the physician that has legal and moral implications, it
is above all a covenant. The consent of the patient is not his sole
prerogative nor is it completely the physician’s. God’s norm must be
a part of that consent, so much so that no decision can ever be moral
unless it is within the purview of God’s countenance expressed
through the divine and natural law. Man’s dominion over health
concerns is always a shared dominion with the Creator, because
essentially, it is not absolute.
2. The doctor promises to treat his patient “according to
his best judgment.” No health professionals will admit substandard
service to their patients. They will always offer the best. Best as it
should, the physicians however can always be limited in terms of their
competence, like their medical specialization. Nurses too have their
own specializations like a surgical nurse, ICU or CCU nurses,
anesthetist nurse, etc. When the health professional promises to care
according to his best judgment, such must be in accordance with a
generally accepted standard of care which medical societies demand
from them. Anything short of this can endanger lives and the
profession itself.
 Now, the term, standard care may change particularly from
one place to another, one institution to another, or from one specialist
to another. A standard care from a far flung province may be
different from that of the city, a secondary hospital may be different
from a tertiary or the same specialists may have different ways of
deciding for the best treatment option/s. Thus, a minimum standard is
imperative for all practitioners so that there could be a meaningful
gauge or bar of professional practice. Subsumed under this is the
beautiful practice of referral as “treatment according to one’s
judgment” is not impeded and destroyed, but enhanced and
promoted. Soliciting patients is always unprofessional and
unethical.
In short, the term “best judgment” may be understood in either
of the following conditions: 1. according to the expertise of the health
provider, as a general practitioner or specialist, 2. according to the
capability of the health facility where the health provider works, and
3. according to the standard of care practiced in the locale where the
health provider practices.
3. The doctor, although he believes he knows best, should
fully inform his patient and defer to the latter’s option to accept
or reject the proposed plans of management. This condition is
very important as the option to reject or refuse treatment is the very
core of the principle of autonomy. Hence, essential pieces of
information must be obtained by the patients. These are the following
and must also be the bases for making decisions for or against any
therapeutic options, namely:
 a. Diagnosis.
Obtaining knowledge of the diagnosis is important before any free
decision is made in favor of a certain therapy. Thus, this element
asks the question, “What ails the patient?” Why is he weak and very
pale? Does his history tell that the illness is genetic or acquired? Is it
curable? If curable, is the cure temporary or permanent? Is treatment
available? Who are the attending doctors? Can they be relied upon
or does the patient have to look for another with whom he is
comfortable with and feel confident about their competence?
b. Therapeutic Management. In medicine, no single disease
is ever known with a single treatment. The patients are fortunately
left with many therapeutic options to choose from. The opinion of the
doctors is very important as to which one is indeed effective.
Different kinds of therapy may effect any improvement or recovery
on a shorter or longer period. Usually patients choose those which are
safe, effective, with minimal ill-effects, available and are acceptable
(be it culturally, religiously or ethically acceptable), without
forgetting financial implications. When it comes to the removal of
kidney stone, for instance, the patients can choose from an array of
modern treatment modalities like the Electro Shock Wave Lithotripsy
(ESWL), the percutaneous procedure or the old reliable surgical
operation, or the traditional means by taking medicine when still
warranted. Under this factor, patients can ask, “Is the treatment
painful or not?”, “Will it cause a lot of

inconvenience or
not?”, “Will the suffering afterwards be protracted or short-lived?”
This shows that the decision of the patient should well be based on
the therapeutic information he receives.
c. Prognosis. This refers to future medical prospects about the
relative expected results of the therapy based on claims by medical
facts. It answers the questions: Will the patient recover after the
treatment? What are the chances of cure? If so, will the patient have
a good quality of life afterwards? If cure is not effective, will he die?
Can the patient still do normal activities in case this treatment is
successful? Will bodily deformities be a necessary outcome of the
treatment? Will he be consigned forever on the wheelchair after the
cure? Questions, such as these, are significant to making free and
informed consent and form part of the decision-making of patients or
families.
d. Financial Implications. This is one important factor, if not
the most important one, that patients consider prior to initiation of any
treatment. In the Philippines, where less than 20% of the population
is enrolled in HMOs in one form or another, monetary concerns are
an important basis for decisions to submit to treatment. Many times
one would hear patients who can still be cured, yet would opt to go
home “against doctor’s advice” due to lack of financial resources,
unlike most in western countries where close to 90% have health
insurance. Thus, initiation and continuance of treatment may not be
much of a problem. In fact, the law can even force hospitals to treat
patients without the necessary financial backup. There are a handful
of cases though when families of patients would do everything to help
the patient financially even to the extent of loaning the house or
selling the working carabao (water buffalo) just to see the loved one
come back home alive. They will go to the extent of asking financial
help from the Philippine Charity Sweepstakes Office (PCSO) or from
relatives abroad or politicians. In sum, the financial implications
form a great bulk in the decision making process of patients and their
families towards option for treatment.
4. When the patient is incompetent, proxy consent should
be sought. The very person who can give consent to medical
management is the patient himself. It is appropriately sensible that
patients should make decisions for their health concerns and not those
who foot the hospital and that of the doctor. When the patient is
incompetent (as in comatose patients, minors or those with mental
disabilities) and therefore cannot exercise decisional capacity, proxy
consent must be sought. It is ethically required though that decisions
made will be for the benefit of the patient and not of anyone else. If
there was a Durable Power of Attorney (DPA) executed, and
someone in legal age has been designated to make decisions for the
patient’s health, it has to be honored as this has legal and moral force,
more so because in the DPA are articulated the advance directives.
In the absence of a DPA, the closest relative has the legal and ethical
right to make decisions, as the spouse or children of major age and
down the line of blood affiliations. When the patient is of minor age,
the parents naturally make the decisions. When the patient is of
major age, it must naturally be the spouse or in his absence, the
children of major age, then the parents, or the grand children of major
age. Of course, when there are none, then the grandparents, the great
grandparents. In others words, the acceptable sequence to follow for
those who can exercise proxy consent must be that the vertical
relationship must first be exhausted before the lateral relationship,
like the uncles or siblings.
There are some patients who can exercise autonomy even if
they are still of minor age. These are the emancipated minors. They
are below 18 years of age and yet they are economically stable and
capable. In western countries, there are a substantial number who
exercise emancipated decisions. In the Philippines, this practice is
seldom or rarely done. Even if they may be economically
independent, the influence of parents over them cannot just be taken
for granted nor over-emphasized.
5. The right of the patient to decide is called autonomy
and this should be respected unless his actions constitute an
intrinsically evil act. Autonomy is never absolute just as the exercise
of freedom is not absolute. While we may leave people alone to do
what they want with their bodies, as in the case of those who want to
wear rings on the nose, nipple or tongue, for as long as they do not
harm others, there is danger however that such cannot ethically be
plausible. Harming oneself entails ethical responsibility as we are
duty bound to respect our body with the reverence due it. Our duty is
not only to others but also to ourselves. Any intrinsically evil action
that is done even to just ourselves, is still unethical and therefore
erroneous. Autonomy must always be calculated and its boundaries
cannot be beyond the parameters of what is ethically good.
Corollary to the above principles, it must always be borne in
mind that when there is a conflict between cultural belief and dignity
of life, religious belief and dignity of life, or legalities and dignity of
life, it is always the dignity of life that prevails as life is of the
greatest value. That is why, even civil or criminal laws (at least in
democratic countries and highly civilized ones) would favor life in all
its jurisprudential decisions.
The Rank of the Value of Autonomy among Western
Countries. It must be noted well that the value of autonomy
among the western countries is ranked so high that it is almost
considered absolute. Even civil laws consider it as a very important
value that any other value that may stand to be in conflict with it, is
disfavored in the resolution of legal cases. Freedom to express or do
anything, for as long as it is not in conflict with the rights of anyone,
especially if there is no harm inflicted on another, is usually allowed
of anyone who wishes to express it. WE can observe these health
realities in the USA and UK. Curtailment of such value is equivalent
to curtailing one’s human right. Autonomy almost subsumes many
other rights, like right to privacy or confidentiality, the so-called
LGBTQ rights, gay marriage, etc. This puts the values of law to be
perennially in conflict with the values of ethics. And nowhere is
reconciliation in sight. That is why, it must be understood that
autonomy is like an anchor on which all other values are connected.
It should not therefore come as a surprise that many will fight for
autonomy even if it would mean danger to others, as in the case of
abortion procedures. In health care, autonomy is exercised in many
different and sometimes conflicting ways.

Case Studies:
A. When Doctors Quarrel, the Patients Suffer
It is well said that when carabaos quarrel, the grasses suffer.
The same can be said of the doctors with their patients.
Ms. Gretchen P., 30, has been a patient of Dr. T. V. Juancho,
a family physician for a couple of years who holds clinic in a small
town. Every time she has a health complaint, she goes to Dr.
Juancho. One day, Grethcen complained of stomach pains and
consulted Dr. Juancho. He suspected appendicitis or ovarian cyst, so
he requested her to go for blood examination in the hospital and to a
surgeon in case surgery was indicated. Gretchen consulted a doctor in
the hospital she knew. She consulted Dr. G. Puno, who has mutual
“bad blood” with her previous doctor. Dr. Juancho felt furious when
he knew about it, and threatened that he will charge Gretchen for all
the free consultations she made with him, if she continues with her
consultation with the latter doctor. Gretchen is confused!
1. What are the related ethical issues in the case?
 2. Was it ethically right for Dr. Juancho to prohibit Gretchen
from consulting Dr. Puno?
3. Was it ethically right that Gretchen consults another doctor
other than Dr. Juancho?
4. What do you think can help the brewing conflict between
Gretchen and Dr. Juancho and the old grudge between Dr. Juancho
and Dr. Puno? How do you use the principle of autonomy of patients
in this case?
B. Religious Loyalty or Family Loyalty?
Fr. Francis C. has been a priest of a religious order for three
years. He has been diagnosed to have a second stage cancer of the
bones. The doctors suggested that with his distinct condition, he can
take an experimental drug whose known cure is still in the research
process but is very promising. The family of Fr. Francis was willing
to accept the suggested treatment and said that if it would make him
recover, there should not be a problem for them. But the religious
superior would not want the proposed treatment as it may be harmful
or even fatal to Fr. Francis’ health since it was still at the
experimental stage.
1. Who should have moral authority, the family or the
superior?
2. Suppose Fr. Francis chooses his family’s decision, should
doctors follow him as patient autonomy supersedes all others?
3. What can you say about the principle of autonomy in case
both sides (the family and the religious superior) claim the right to
exercise it?
C. The First and Second Wife
Charles and Charlene, both 35-yearsold are a married couple
but after seven years they separated and have lived different lives.
Charles is now living with another woman, Kristina, 31, for five
years. Charlene however remained ‘single.’ One day, Charles was
rushed to the hospital after a severe stroke and was declared
comatose. It was now one week that he had been unconscious and
that the doctor suggested that he undergo urgently a very delicate
surgery in his brain to remove a blood clot. It was the only procedure
that offered some hope for his recovery. Meanwhile, Charlene
arrived and told the doctor that she was the wife and therefore had the
right to make decisions for his health. She objected to the proposed
surgery as this would only offer some hope but not real hope.
Kristine protested as her decision would not help at all Charles and
even exhorted that if there was hope for recovery, even a slim one,
she would be willing to go for the proposed procedure.
1. In terms of autonomy, who between the two women should
be followed in terms of making decisions for Charles’ health?
2. Was the decision of Charlene to stop the planned procedure
ethically right?
3. Can the protest of Kristina prevail over that of Charlene
since they live as husband and wife? In case she has no legal right,
can she be sustained if she goes to court for legal decision?
4. In your opinion, what could be the best decision to help
Charles in his predicament? Explain.
D. The Jehovah’s Witness Follower
A 12-year-old boy was run over by a car while crossing the
street. Bystanders brought him immediately to a nearby hospital as he
was bleeding profusely. On examination at the ER, he was known to
belong to Jehovah’s Witness through his ID card, it was prohibited
for him to be transfused with blood in case of surgery or any
procedure as this would constitute an abomination to God which the
Jehovah’s believed to be in the book of Deuteronomy. The doctor
indicated that an emergency surgery and blood transfusion were
required. The parents or guardians could not be located. The doctor
was in a dilemma as to what he should do knowing that he had to
respect the boy’s religious belief. But if he would not do the surgery,
he might be charged of negligence, more so if the boy dies.
 1. If you were the doctor, what should your decision be? If
you were a nurse would you assist the doctor knowing that it was
against the religion of the boy? Can you defend your position
ethically? How?
2. Suppose the parents come and they, too, would not agree to
blood transfusion, what can you do as a doctor or a nurse?
3. As a doctor, can you exercise your legal right as a doctor to
seek help from the court of law to help the boy in his predicament?
4. Suppose the parents have not come, can you operate on the
boy without their permission and invoke the doctrine of loco parentis
(in place of parents) as a doctor? How do you defend your position?
5. Since it is an abomination to God to have blood
transfusion, according to the Jehovah’s Witnesses, should the doctors
just wait until a bloodless surgery (as claimed it can be done) can be
performed by an expert on it?
E. Botox for a Job
Camille V., an 18-year-old print ad girl model had complained
of facial wrinkles. She was perfectly healthy, except for some facial
lines especially noted over the glabellar and lateral areas of both
eyes. The patient consulted for the possibility of having Botox
procedure to be able to satisfy some requirements for a print ad
modeling agency. With further inquiry, it was found out that she had
a previous Botox injection done some four weeks ago, but she was
very insistent on having the procedure done so she could immediately
start with the job offer. The patient’s parents, who came along with
her, also demanded for the procedure to be done. With these in mind,
some ethical issues have to be resolved.
1. After knowing the risks and benefits of the Botox
procedure, up to what extent can Camille V. assert her right to
autonomy? Explain.
2. Weighing the risks and benefits of the procedure, can the
physician refuse, and if so, how can he refuse to treat the patient?
 3. Is starting with the job an issue so that that denial of the
benefits of the procedure could be blamed on the physician? Explain.
4. Is Botox intrinsically an unethical procedure? Why?
F. COVID-19 Patients’ Right to Autonomy
The pandemic brought about by the virus (or bacteria as some
claim) called Corona Virus – 19 had extremely disrupted end even
claimed hundreds of thousands of lives worldwide in YR 2020.
Many of those who were infected by the contagion have been
confined in the hospital for treatment or quarantined to avoid
infection to the community. Families or loved ones were prohibited
to visit them. And those who died of the infection were cremated
almost immediately without the families able to grieved over their
loved ones. This, according to the health agencies is the best and
most potent protocol in order to avoid feared transmission.
1. What issue or issues in autonomy can you include in the
protocols done by the government from confining of infected patients
to cremation procedures?
2. Do the government agencies have a right to make decisions
for patients themselves over the patient autonomy? Explain.
3. Can the families have the moral right to claim the deceased
bodies of their patients for as long as they follow the protocols to
avoid infection? What moral ground could you or not to invoke the
right to autonomy? Elaborate.
 Chapter 15
If you remain in my word, you will truly be my disciples,
and you will know the truth, and the truth will set you free.
Jn. 8:31-32

THE PRINCIPLE OF TRUTH-TELLING

AND PROFESSIONAL COMMUNICATION
F

or
trusting relationships to endure, patients and health professionals must
adhere to the principles of truth-telling and professionally-based
communication, as these are the very bases by which diagnosis and
treatment can continue, and remain effective and satisfying. One has
to consider that the first moment a patient and a doctor or any
professional health providers meet, immediately a relationship begins,
and usually does not end until it is directly or indirectly ended. This
relationship is a trusting relationship. It is basically moral in nature
and not necessarily legal because, such encounter is understood as an
encounter of two moral beings who are essentially governed by an
ethical code of conduct and motivated by a moral good. The legal
nature of that relationship is rather a posteriori assumption (an after-
thought), since the encounter is not basically a problem of legal nature
that only a legal forum should resolve. When mistrust gets the better
of the relationship, medical protocols and management are shattered
and no true healing can occur. Indeed, a doctor must be truthful and
the patient must help the doctor ferret out what ails him in his quest
for treatment. Medicine and lying cannot blend or mix. They are
diametrically opposite. Thus, a doctor should continuously and
assiduously pursue truth through precise and accurate diagnostic and
therapeutic processes. Continuing excellence in the physician’s
medical knowledge through study and research or conferring with
colleagues is important as he owes the patient and the community the
highest quality of medical care. Once the doctor stops studying
today, he becomes obsolete tomorrow. As a consequence, he
devastates medical knowledge and the nobility that is characteristic of
his profession. If there is no commitment to a practice of truth-telling
in medical environment, a doctor becomes more of a businessman or
technocrat than a medical practitioner. He would only sell scraps and
junks of the medical knowledge and do repairs of patient parts like an
auto mechanic. This sort of practice will bring about the demise of
his honor and promote arrogance welling forth from his ignorance.
Trust is very important to bind the relationship between the patients
and health care professionals. The patient believes that the doctor
whom he consults can help him in his medical predicament, and the
doctor trusts that the patient is willing to share information that is
necessary in the whole medical management process for the cause of
healing.
Now, communication between the patient and the health care
professional is very important for knowledge is a conditio-sine-qua-
non in the whole process of healing or curing. For knowledge to be
understood, doctors should communicate in a language that patients
can understand. Patients do not need highly technical medical jargons
only the doctors can understand. Such should only be used among the
highly technical men and women. It is enough that the doctors use
any language that is clearly understandable. It is even better, if it is
possible, to use a dialect that is closest to the heart of the patients.
This is also required to get the informed consent of the patients.
When this is done, then trust is solidified, as the doctor can identify
himself with the patient and his/her predicament. Betrayal of this
trust makes a mockery of the profession of medicine and doctor’s
relationship with the patients. When a patient entrusts his life to
someone, he basically surrenders his life to someone’s hands. He
trusts that health care professionals will handle it with utmost care. It
does not sit well with ethics and professionalism that the patient’s
record is abused and misused. This happens when it is used against
the honor of the patient himself, or sinisterly for the physician’s own
personal interest. Once this trust is lost, it is lost forever and the
doctor or health provider would not have anything left with him.
More so, when it is used by others for black-mailing purposes. Life is
the most important and valued gift one has received from God. Just
as the patient wants to give it a steward’s care, so must those to whom
he entrusts it. Needless to say, health is life, and life is health. And
health is wealth and vice-versa. And the doctors and health providers
are given this rare privilege to hold in trust the life of the human
society.
The Goal of the Principle of Truth-telling and Professional
Communication. Truth refers to the adequation or conformity of
the mind with the external object or event that is mentally perceived.
When the object or event that is perceived outside the mind is in
accord with what is in the mind then there is truth. However, when
what is perceived does not correspond to the mind and vice-versa,
then what exists is untruth or non-certitude. That which is untruth
could therefore be a lie, a fraud or fake. Hence, when there is a lie,
there is no conformity of the mind and the object or event perceived.
The purveyor of a lie is dishonest, and the one who fosters truth is
honest. In Bioethics, medicine and lie cannot go together. Hence, in
the practice of medicine, a doctor or health professional must be
honest and candid with those entrusted to his/her care. For a lie
threatens trust between the doctor and patient and can lead to
dangers. Imperatively, one virtue that a doctor or health professional
should develop is truthfulness or honesty.
The following below is the goal of the Principle of Truth-
telling and Professional Communication (Ashley and O’Rourke,
2002):
To fulfill their obligations to serve patients, health care
professionals have the responsibility to do the following:
 1. To
strive to establish and preserve trust at both the emotional and
rational levels. Communication is basically work two-fold, an anti-
thesis to its being just a one-way-traffic. When a patient is sick, he is
emotionally-charged due to the perceived threat against his life, be it
impending or perceived. He may be fearful, apprehensive, feeling
timid and even embarrassed. He may fall into depression and other
psychological or mental disturbances that can lead to behavioral
problems. He can also be angry with himself or others, and even with
God for the sorry lot that he is in. A feeling of abandonment by
people is something he can experience, and that may send him to
suicidal tendencies. That is why, the first of the communication
strategies is one that addresses the emotional needs of the patient. A
doctor or any health care professional must first of all be able to feel
with the patient, or be in the shoes of the patient, be empathetic. This
feeling is characterized by compassion (to feel as the patient feels in
his pain or suffering). Sensing that the doctor identifies himself with
his feelings, the patient will develop a sense of comfort and ease.
This is the communication that is emotion-based, which psychologists
call affective in nature. When the doctor starts to immediately
communicate in the rational level, (which the psychologists refer to
as cerebral in nature) the patient may hear, but not listen to it,
because the first need (emotional need) has not been well addressed.
The doctors must first begin with the lower level of communication
before he can be understood in a level of the intelligent nature. Once
the emotional level is addressed, then the rational communication can
take place. This procedure should not be inversed. Many doctors fail
in professional communication because they think that everything
must be done rationally without regard for the emotional needs of the
patient. But this does not work in health care. Calculated and gradual
entry into the being of the patient is important if treatment has to take
place. Moreover, trust has to pervasively reign until the end of the
healing process.
2. To share such information as they possess which is
legitimately needed by others in order to have an informed
conscience. Information or knowledge is essential in the whole
medical spectrum, for this is the very basis of medical protocol or
management. Such information must be handled and managed well,
to preserve well the dignity and honor of the patients. One important
element by which this dignity and honor can be preserved is to
respect the patient’s conscience by which he can make ethical
decisions. Therefore, complete and necessary information about his
health status must be known by the patient in order to make free and
informed decisions. Any lack of essential information may make the
“free and informed consent” invalid and illegitimate, and can abet
signals for legal remedies. This is unfortunate for medical practice.
There is minimum information that the patient should know as pre-
requisites for “free and informed consent” before any medical
procedure can be done to him. (See minimum information in chapter
15 above).
 3. To refrain from
lying or giving misinformation. Lies and medicine cannot mix
because it is destructive and can bring about loss of limbs or
eventually destroy human life. Truth must always be at the forefront
of medical management. When lies are given, it leads to an invalid
consent. Half-truths are also inappropriate as the patient’s free and
informed consent requires the whole truth and nothing but the truth.
When half-truths are communicated, people possess only the other
half as truth while the rest is a lie. This is tragic. If the whole truth
cannot be divulged to the patient, it can however be given gradually,
but it must eventually be given totally, for truth belongs to the patient
(not to the family, the doctors or the health care team). Since it
belongs to him, he should be able to possess it, even if the truth may
hurt. Eventually, truth will set everyone free and make the patient
wiser when the next time comes. Communicating the truth about a
(bad) diagnosis is better than hiding it. It is unfortunate that because
of over protectiveness of the family, the doctors are prevented from
telling the patients about their health condition. Sometimes they die
without knowing what ailed them. And this is being unfair to them,
not only in life, but also in death. Such is a concrete case of double
jeopardy.
It is well to note that even when the family of the patient does
not want health carers to reveal the patient’s health status for reason
that probably such will aggravate the patient’s health condition,
prudence dictates that postponement is a better alternative. But
keeping the patient ignorant about his health state is being unfair to
him. In the end, we are duty-bound to inform the patient of his
medical condition because truth (again) belongs to him, more so
when the patient demands for it.
3. Not to divulge secret information not legitimately
needed by others and consequently might harm the patient or
others or destroy trust. This element belongs to the Principle of
Confidentiality (and/or secrecy/privacy). Confidential matters
include among others the health records of the patient that must be
well kept and handled, so that the patient would not unnecessarily be
exposed to the prying eyes of the public and ensure his privacy.
Confidential information is part and parcel of the private domain of
the patient. (This element will be discussed more extensively in the
chapter on the Principle of Confidentiality and Privacy).
Truth-telling in Medical Advertising (Physicians in
Advertisements). In 1997, the Pontifical Council for Social
Communication, “Ethics in Advertising” has noticed that advertising
is steadily on the increase in modern society at a rapid pace. Readily,
the council claimed that the media of social communication have
enormous influence everywhere and that advertising, using the media
vehicle, is a pervasive, powerful force for shaping attitudes and
behaviour of people in today’s world. No one therefore can escape
the influence of advertising. While the council however agrees that
there are significant goods that advertising can offer (like economic,
political, cultural, moral and religious), it also acknowledges that
advertising can harm as it can be negatively used by unscrupulous
people whose sole purpose is profit. Communio et Progressio (59, in
AAS, LXIII, 1971) contains a summary of these harms. Consequently,
If harmful or utterly useless goods are touted to
the public, if false assertions are made about goods for
sale, if less than admirable human tendencies are
exploited, those responsible for such advertising does
harm to the society and forfeit their good name and
credibility. More than this, unremitting pressure to
buy articles of luxury (or non-necessities) can arouse
 false wants that hurt both individuals and families by
making them ignore what they really need. And those
forms of advertising which, without shame, exploit the
sexual instincts simply to make money or which seek to
penetrate into the subconscious recesses of the mind in
a way that threatens the freedom of the individual . . .
must be shunned.

Moreover, the same document admonishes that ethical and moral

principles must be seriously taken into consideration so that media
must help human persons to grow in their understanding and practice
of what is true, good and beautiful, otherwise, they will become
destructive forces in conflict with human well-being.
Thereafter, the document delineates that those who engage in
advertising – those who commission, prepare or disseminate
advertising –are morally responsible for what they seek to move
people to do; and this is a responsibility also shared by publishers,
broadcast executives, and others in the communications world, as
well as, by those who give commercial or political endorsements, to
the extent that they are involved in the advertising process. Serious
considerations must be taken regarding advertisement of health
products. Any effect of these can be adversely dangerous to the
integrity of limbs, health and life.
Moreover, it is morally wrong to use manipulative,
exploitative, corrupt and corrupting methods of persuasion and
motivation. In this regard, we note special problems associated with
so-called indirect advertising that attempts to move people to act in
certain ways – for example, purchase of particular products – without
their being fully aware that they are being swayed and hoodwinked.
The techniques involved here include showing certain products or
forms of behaviour in superficially glamorous people, and in extreme
cases, they may even involve the use of subliminal messages. We can
include here the adverse effects of abortifacients regarding their ill-
effects on those who use them.
Thus, the Pontifical Council was firm in pushing for
truthfulness and social responsibility in advertising. And there is no
substitute to truth as it greatly contributes to humans in their health
and well-being.
Lastly, it is good to review what the Medical Code of the
Philippines tells about advertising in medicine. Basically, no doctor
or health professionals are allowed to advertise products and services
except the following, namely: Name of the doctor, his/her specialty,
place of practice and lastly, schedule of his/her practice. Anything
more than this can be perceived as unethical as when a doctor or
health professional would advertise him or her as the number one
practitioner in the field or so. More so, too, when they advertise some
cure/s that have not passed the stringencies of research or study.
Fraudulent cures are strongly disallowed in medicine and frowned
upon by the medical or scientific communities.

Case Studies:
A. To Tell or not to Tell (1)
Marian C. was once a very vibrant teenage girl of 15 until she
was diagnosed to have blood cancer 14 months ago. Marian became
severely depressed that she would not eat unless coaxed by her
mother. She became weak and thin and would just stay in her room
and sleep. She had been undergoing regular chemotherapy for the
past 14 months and had been in pain that she had lost the will to live.
Whenever the idea of her sickness was mentioned, she would have
bouts of depression. Her mother had prohibited the doctors of telling
her of her illness because, as it was in the past, she would fall into
deep depression and would not eat for days. However, Marian
wanted to know why she had to undergo strong radiation therapy
through the modality of the Linear Accelerator. This would certainly
bring forth the thought that her condition was worse than what she
had known. Telling her about it might not only send her to depression
but also to an already serious heart condition that may lead to her
death.
1. Should the doctor tell her about her health condition?
2. If the doctors opt not to but only postpone the information,
when is the best time to tell her?
3. If the patient asks for it, is it right to tell her even if this will
make her condition worse?
4. Does her condition warrant the revelation of her being
currently in bad shape?
B. To Tell or not to Tell (2)
Dr. D. Dante is a surgeon in the Province of Bicol and works
in a tertiary hospital. Mr. C. Veneracion, 34, complained about a
severe pain in the stomach was brought by his relatives to the ER.
Initial examinations revealed a ruptured appendix that needed
immediate appendectomy. Surgery was done and Mr. Veneracion
was brought to his room to recover. But recovery was nowhere at
hand as he had on and off bouts of fever. He had been in the hospital
for three weeks and it seemed his pain and fever would not leave
him. The relatives decided to bring him to a Manila hospital thinking
that he would be well taken care of and eventually recover. On initial
findings in the hospital, X-ray images revealed a foreign material
inside his body specifically on the part where the first surgery had
been done. The surgeon operated on him and a sponge was removed
from him and he later felt substantially relieved. Mr. Veneracion and
his family would like to know what ailed him after the first surgery in
the province and what was removed in the subsequent surgery.
1. Is it morally right to tell Mr. Veneracion or his family about
the finding of the second surgery?
2. Is the second doctor obliged to tell the patient about what
was discovered and removed during the second surgery?
3. Should the second doctor inform the first surgeon about
what he discovered? What should be his purpose in case he does so?
4. What should the first doctor do in case the patient asks
him? Can the patient ethically demand for financial compensation
from the first doctor? Is there a medical negligence in this case?
C. To Tell or not to Tell (3)
Dr. Chris T. was summoned through subpoena by the court to
be a witness in a lawsuit where he was asked to render his opinion
about the botched cosmetic surgery that rendered the patient
comatose. Dr. Chris knew the kind of surgery that was done to the
patient being an expert himself. Dr. Chris was hesitant to be a
witness because he knew that the first surgeon, a friend of his,
committed error in the said operation. Dr. Chris was in a dilemma
knowing that what he was going to tell the court would find his friend
of many years guilty of medical negligence.
1. Should Dr. Chris T. go to court and be a witness and tell the
truth?
2. Should he sacrifice his friendship for the sake of medical
truth?
3. Should all doctors (or all health carers for that matter even
if this may hurt his colleagues) be always patient advocates? Should
they not also be fellow health care advocates? Explain.
4. Is there a win-win solution that can be suggested in this
case? Explain your suggestion.
 D. To Advertise or Not
Dr. P. Fernandez, a OB-Gyne doctor, has been contracted by
an advertising outfit to do commercial on TV, Radio and print media,
since she is blessed with a good personality that can attract would-be
users to patronize condom use. A by-line in the commercial
advertisement has been prominently emphasized that condoms has a
100% protection from pregnancy, as well as, infections from
HIV/AIDS.
Dr. Go Lay is a Chinese herbalist doctor who advertises on
TV, radio and print media about the many good effects of the herbals
he uses for his patients and has reported total cure for many from
hypertension, diabetes and cancer. These herbals have not passed
through scientific research and in fact, in the herbal packages are
written the label: No Approved Therapeutic Claims.
1. As doctors, is it ethical for both Drs. Fernandez and Go Lay
to advertise their products?
2. If there is breach of ethics in advertising medical products,
what did they violate?
3. What ethical truths could be gleaned from the advertisement
of said products by both doctors?
4. What should people ethically know about condoms and
herbal medicines?
E. To Omit or not to Omit
Toni C., a 26-year-old married woman, consulted with a
private dermatologist because of a sagging chin and flabby arms and
thighs. She was admitted to the hospital and eventually underwent
liposuction, and was discharged on the 3rd day. She improved and
was happy about the result. After a week of convalescence, the
patient planned to go back to work. Prior to which though, she
requested from her attending dermatologist to issue a medical
certificate that would not indicate the specific procedure done to her.
 1. Is it ethically acceptable for the dermatologist not to
divulge the specific procedure done to Ms. Toni C’s diagnosis and
treatment in her medical report? Justify.
2. If the dermatologist agrees with the patient’s request and
gives a non-specific report, is it ethically right? Why?
3. If the patient also requests her dermatologist not to divulge
the truth to her husband who is abroad, in case he asks, what do you
think are the responsibilities of the attending dermatologists to the
patient and her husband?
4. What particular bioethical principle/s can be used to
resolve the issue? Explain.
F. “Trabaho Lamang” (Only a Job)
Ms. Nichol E. Hiala is a local radio disc jockey and a
comedienne who anchors a morning program. As part of the
segment, she would give encouraging advice to her radio listeners
seeking enlightenment about problems and dilemmas experienced in
their life and love-life. Her advices are characteristically humorous
but well-balanced with seriousness. Ms. Nichol boasts of having
graduated with honors in college and prides herself in having finished
at an exclusive Catholic school for girls. She has a part-time
advertising job that promotes Frenchee condoms as reliable
prophylactics that can be completely trusted against sexually
transmitted diseases. Hundreds of thousand listeners have been
convinced about the condoms she advertises. Nichol justifies her
promotional activity as trabaho lamang and should not in anyway
compromise her ethical character.
1. What is your ethical evaluation of Ms. Nichol’s activity as
a radio advertiser for Frenchee condom? How about the
manufacturers of the condom?
2. What can you say about Ms. Nichol’s justification that the
promotional activity is only trabaho lamang?
3. What does the 1997 Pontifical Council’s “Ethics in
Advertising” say as regards activities like Ms. Nichol’s activity and
justification, as well as that of the manufacturer? Elaborate.
4. Does Nichol’s action agree with the principle of legitimate
cooperation?
 bmj.com

Chapter 16
Now a word was secretly brought to me,
and my ear caught a whisper of it.
In my thoughts during visions of the night,
when deep sleep falls on men.
Ps. 4:12-13

THE PRINCIPLE OF CONFIDENTIALITY

AND PRIVACY

O
ne of the most important principles in health care is the Principle of
Confidentiality and Privacy. This is so because of the fact that
confidentiality and privacy, be it concerning a medical record or the
person of the patient is essentially attached to the dignity and honor of
the person of the patient. Thus, a breach and violation against the
confidentiality of patient records and privacy of a person is also a
breach against his dignity and person. The medical chart/record and
personal data of the patient are part and parcel of his dignity and must
therefore be protected and defended. These are essentially extensions
of his personal being, and no one has any right to tinker or pry into
them without expressed permission of the patient himself. Unless, it
is for a greater reason or cause, no person or authority can allow
anyone to open a person’s confidential or private records or
information. It is noteworthy that all nations in the world
unanimously adhere to this principle of confidentiality and privacy.
This goes to show that this principle is so sacred that it must be
guarded and protected at all times, without prejudice to the honor of
the patient. This duty has to be upheld at all times, as patient records
can be used against the patient himself in his honor or reputation, or
that others may use them sinisterly for their selfish interests. Classic
examples of these are those patient records used treacherously in
court proceedings to disinherit people or to remove them from the
administration or ownership of money. There had been recorded
instances at least in the Philippines during which people were legally
removed from the use or disposal of their properties alleging thereat
that they do not have the mental competence to do so. Even spouses
are forced to separate as one or the other cannot mentally fulfill his
obligations as a married man and woman by using the medical
records as weapons against him/her before the bar of legal courts. It is
worth remembering that health care activities are done for the interest
or benefit of the person of the patient. Anything less than this is
brazenly unethical.
The Oath of Hippocrates on Confidentiality. One area where the
principle of confidentiality and privacy has been flagrantly broken
and abused and contravened with impunity can be seen among the
health providers who are supposed to be patient advocates. Such
breach has been so pronounced and contemptuous as if health
providers have not known the provisions of the Oath of Hippocrates.
But privacy and trust in the patient-doctor relationship have been
essential elements in medical ethics and the practice of medicine.
Thus, it's worth examining what the Oath of Hippocrates states
regarding this issue below:
Whatever, in connection with my professional
practice, or not in connection with it, I may see or
hear in the lives of men which ought not to be spoken
abroad I will not divulge, as reckoning that all such
should be kept secret.
While I continue to keep this oath unviolated,
may it be granted to me to enjoy life and the practice
of the art, respected by all men at all times, but
should I trespass and violate this oath, may
the reverse be my lot.
 Confidentiality
and privacy, then, are not only a time-honored principle of medical
professional practice, but indeed, a sign of strong covenant of the
ethics of Hippocrates, inherent to the honorable medical profession.
Thus, the health professional should treat them as if they were also a
part of the patient’s dignity and person. It must be borne in mind that
a good doctor identifies himself in the person of the patient and
should be encouraged to feel and experience with the person and his
dignity, as well as, his pains and sufferings. If he does so, he will
keep watch over the patient as a father or mother does to his or her
child, and will keep him or her immune from unnecessary intrusions
that can harm the patient’s personal integrity or honor.
The Patient Record and the Health Care Professionals. The
patient record is an essential part of the person of the patient. It
therefore belongs to the personal domain of the patient. Thus, the
patient has an absolute right over it that must be protected from
misuse or abuse. Even the health care professionals who have been
given the privilege to have access to it, have no right to just divulge
any information to anyone, especially to those who do not have any
concern in the personal health of the patient. Although the patient
record is owned by the health institution, the data are concrete truths
that belong to the patient. Therefore, the hospital cannot just dispose
of them nor show them to anyone without the express permission of
the patient save those whom he has authorized to share such
information.
 The patient record
is the subject of the Principle of Confidentiality, while the patient’s
person is the subject of the Principle of Privacy. This is a
fundamental distinction between the two principles, although in
practice, there may not be an expressed articulation of the distinction
since the patient record is a part of the person of the patient. Thus, in
Ethics or morals, violation against the principle of confidentiality may
also be a violation of the principle of privacy. Simply, the subject of
the principle of confidentiality is the written record pertaining to the
person of the patient, hence external to him, whereas, the subject of
privacy is the person himself, hence internal to him.
It must be noted that unnecessary leaks or disclosure of the
patient’s records to others may have ethical and legal implications.
When those responsible cannot be trusted with the records of the
patients, they cannot also be trusted with their lives. Thus, utmost
care must be given to the patient records by the health professionals
or whoever is entrusted to have control of them.
The Principle of Confidentiality and Privacy. The Principle of
Confidentiality stems from the nature of individuals as absolutely
possessing name, honor and reputation that must be protected and
must therefore be immune from being smeared or destroyed. Dignity
is at the very heart of the principle of confidentiality. Destruction of
such dignity is reprehensible.
One of the grave reasons why confidentiality cannot just be
broken without affecting one’s dignity is because there are diseases
which have social stigma, that is, those diseases that bring with them
shame or embarrassment when known publicly. Some examples of
these are the sexually transmitted diseases (HIV/AIDS, gonorrhea or
syphilis), diseases of infidelity, diseases associated with poverty or
diseases associated with poor hygiene.
The following is the Principle of Confidentiality:
The medical record/s (or chart/s) of the
patient is characteristically personal and individual
in nature and should never be revealed to anyone by
anyone in health care except for graver causes. The
revelation of which when called for must always be
under an utmost restrictive care.
The following below are the subjects of confidentiality which
everyone must take into consideration the R.A. Act 10173 of 2012,
otherwise known as the Data Privacy Protection Law:
1. Private Secrets (Personal Secrets). These refer to written
records or secrets that are essentially attached to the person of the
patient, though external to him. These may refer to those which the
health care professional may have discovered deliberately or not, but
now forms part of the record. They may have been very personal or
essentially sensitive, or which essentially have social stigma and
therefore may be shameful upon the person of the patient when
revealed. The name of the person, his/her birthday or Identity in
credits cards or ATM are private that can be hacked and whose
identity can be stolen. Another is when a person has HIV/AIDS or
STD (sexually transmitted diseases); when a person is uncircumcised
(that is culturally and socially embarrassing); when a person has
embarrassing skin diseases; or when a person has a very small penis,
or one with erectile dysfunction that he is unable to consummate a
sexual act, etc.
Included in the private secrets are records that are essentially
included in the person of the patient such as name, age, sex, status,
race or religion which may be essentially attached to other important
records of his bank accounts, ATM, credit or debit card or the like.
Why is this included as private secrets? It is because this can be
stolen as in identity theft. And it can leave the patient bankrupt or
impoverished and other bad consequences. Even pictures or photos
of patients (especially in hospital settings) should be shown
indiscriminately in the social media especially when they form part of
the patient’s privacy. There are of course debates about patients who
are in public for a – on whether they waive their right or not over
privacy.
2. Contractual Secrets (Sensitive Secrets). These refer to
records or secrets that people have and should not be revealed as
prohibited in the provisions of the contract. A good example of these
are about those living in immoral unions be it heterosexual union or
homosexual union; those contracts that are by law sub-secreto as in
bank secrecy, or drugs given to mental patients that if these drugs are
revealed to anyone might make the mental patients become assaultive,
wild or suicidal. These contractual secrets also called sensitive
secrets that must remain like provisions of a contract that should not
be revealed unless permitted by the concerned subjects.
3. Professional Secrets (Physician-Patient Secrets). These
are essentially the records or secrets that transpire between the patient
and the doctor under a professional relationship so-called as
professional-client secrets. The medical records or charts are good
examples of the subjects of medical confidentiality. It should also
include those that transpired even if they were not written at all in the
chart or record. No one can open these records except the one with
the expressed permission of the patient himself. However, there is
ethical debate one whether or not the government has a right to open
the records of patients in order that it can know matters that are
important to collecting taxes from doctors. Another good example of
professional-client secret is the so-called confessional seal that is,
between a Catholic priest and a penitent. Almost absolutely, nothing
of these secrets should ever get out of the confessional box, hence, the
reason why it is called a seal.
It is unfortunate that the reason for the US Supreme court
allowing abortion in 1973 to those who wished to avail of said
procedure was to protect the principle of privacy which was believed
to be an absolute right. This is rather shallow since the Supreme
Court had not considered that the unborn child has a right to life and
such right is certainly more important than the principle of privacy.
Privacy, as a right, according to the Supreme Court cannot be broken
especially when it is a question of one’s personal life being intruded
into by the society. This includes the right to be singled out as to be
unable to practice one’s profession since there are cases in which
pregnancy meddles with it. This was the case of the first abortion
right invoked by one who has engaged in pre-marital sex. Obviously,
pregnancy will interfere with and preclude the exercise of the job by
the seeker of the procedure. But the right to privacy is not equal in
hierarchy with the right to life of the unborn. This is ethically
undebatable.
Grave Causes, Reasons for Breaking Confidentiality. In
Bioethics, there are recognized ethical reasons that are considered
grave causes by which the Principle of Confidentiality can be broken
without ethical responsibility. First, this principle is not absolute. It
is subordinate to a higher right, the right to life and human dignity.
Second, the common good referred to (in previous chapter) here is
more important compared to the demands of confidentiality which is
more essentially personal. The following are the reasons, namely:
1. Autonomy of the Patient. The Principle of Confidentiality
may be broken if it is the wish of the patient to do so. It may well be
that the patient himself will do for a purpose that he deliberates upon,
presumably for something good, like stopping rumors about him for
having a disease that has a social stigma. The case of the patient Ms.
Sarah Salazar, who in the 90’s, allowed herself to divulge to the
public that she had HIV/AIDS. The announcement was significant as
she was the first known Filipina to have the dreaded disease. In the
end, the public announcement served as a means for health education
in order to make the public aware of the modern world pandemic that
had become trans-national, trans-cultural, trans-gender and cross-
sectional among all ages.
 2. Public
Safety. The state has the responsibility to the citizens to control
diseases at the earliest possible time. Therefore, it has a responsibility
to announce to the public urgent information about epidemics or
pandemics. When there is a reason to believe that there are people
carrying some deadly diseases, the state can break the principle of
confidentiality for the common health good. Thus, it is ethically
tenable that people with dreaded diseases must be reported to the
proper agencies not only for record purposes, but also for preventive
and curative measures. Even hospitals in the Philippines are obliged
to report diseases of reportable nature (without making public the
names of the carriers), like HIV/AIDS, meningococcemia, SARS,
AH1N1, Ebola, STD, MERS, COVID-19 or the like.
3. Medico-legal Case. This refers to those cases that have a
criminal element and/or forensic concerns. Gunshots or knife wounds
for example are reportable to proper government agencies like the
police, NBI, the Department of Social Welfare or Bantay Bata, in the
interest of justice. Included in these are those who are sexually
abused, such as victims of incest, rape, child abuse and the like. The
society has a larger stake in these cases and hence, confidentiality can
be breached legally and ethically.
4. Court Summons. The legal courts of the land usually
assume accountability or responsibility over the affairs of the citizens
so that justice can be served and in order to preserve peace and order
in a civilized society. When the court needs expertise or facts that are
substantial to the establishment of the guilt or innocence of the
accused, witnesses can be summoned and in the process may reveal
the names of patients whose illnesses have social stigma. This
situation though could break the Principle of Confidentiality (under
court litigation), more so when the liability in question is criminal in
nature. The reason why the court can break said principle is because
the goods of the State are greater than the goods of the individual.
Under the above circumstances therefore, the Principle of
Confidentiality or Privacy may be broken because said causes are
greater and graver than those causes that accrue to the individual
person’s goods. Thus, the Principle of Confidentiality or Privacy is
not absolute, and can ethically be broken and those who disclosed it
are not in any way accountable.
Case Studies:
A. To Tell or not to Tell (1)
A 30-year-old married man consulted a physician complaining
about his difficulty in urinating. He attributed this to what he had
taken five days ago when he attended a convention. Although he did
not tell the doctor about his sexual escapade with an unknown
partner, through the examinations of his blood and urine, he was told
that he had Gonorrhea. He was afraid that his wife might discover it.
So he told the Doctor not to tell anyone, including his wife for fear
she might get angry and leave him. He loved his wife and family.
The wife however, after a week, asked the doctor regarding the
condition of her husband because she felt apprehensive why her
husband had not made love with her for the duration of the week.
1. If you are the doctor, should you confide to the wife about
her husband does condition know that you know the obligation
attached to the Principle of Confidentiality? Why?
2. Does the wife have a right to know the condition of the
husband? On what basis/es?
3. Aware of the Principle of Confidentiality, what practical
way could you do to resolve the seeming sensitiveness of the case so
that you could not be accused of breaking the Principle?
 4. What other principles could you use to resolve the issue of
trust accorded to you by the patient?
B. To Tell or not to Tell (2)
Jane is 14 years old and pregnant as a result of incest with her
father. On a routine visit to the family physician, Dr. Punsalan, she
explains what has happened to her and she confirms the pregnancy.
She begs her not to tell her parents, because then her mother would
discover what happened to her. She is convinced that her mother will
blame her, rather than her father, because her relationship with her
mother is very bad. Dr. Punsalan tells her she never performs
abortions, so Jane asks her to refer her to a physician who performs
the procedure. Dr. Punsalan wonders whether professional
confidentiality and perhaps even legal complications forbid her from
informing the mother and trying to stop the abortion and the
continuation of the incestuous relationship. But she is also worried
that Jane might go to a disreputable and unsafe abortionist.
1. What principles can you use to help solve Dr. Punsalan’s
dilemma?
2. If the doctor cannot tell the parents, can she tell the
government agency about Jane’s predicament? On what basis/es?
3. What ethical decisions can you make to protect Jane from
further problematic situation?
4. Should the Principle of Confidentiality be better followed
than the right to life of the unborn?
C. To Tell or not to Tell (3)
In spite of the prodding of his health providers, Mr. Johnny
C., an HIV-infected man had been very reluctant to disclose any
information about his past or present sexual behaviors with sex
partners. He even promised that he will use condoms in sexual
activities with future partners. Most of those who knew of his sexual
behaviors and patterns strongly disagreed with him. Johnny C.
contended that it was not the business of the society to interfere with
his sexual behaviors at it was a private business, and that if disclosed,
he feared the isolation that will subsequently follow from it.
1. Is it true that his sexual behavior is a personal business and
that society should not interfere? Explain.
2. Can ethical principles and law oblige him or even force him
to disclose information?
3. Given the life-threatening nature of AIDS, should there be
an obligation about partner notification, whether in Ethics or in law.
4. Should partner notification be a violation of the Principle of
Confidentiality? Elaborate.
D. To Know or not to Know
Jeff B., 24 yr. old male is being treated by Dr. Secreto for
genital herpes (a sexually transmitted disease). Mrs. Alala, another
patient of Dr. Secreto noticed Jeff leaving the doctor’s clinic.
Bewildered, she tells the doctor that her daughter Kyla is to marry
him in three months and asks what he consulted him for. She asks,
“Does he have any illness my daughter should know about?”
1. Should Dr. Secreto tell Mrs. Alala about Jeff’s disease?
Why? Why not?
2. If Jeff refuses to tell his bride, what should Dr. Secreto do?
3. If Jeff has HIV, will the decision and action of Dr. Secreto
change?
4. If you are the sister of Kyla who happens to see Jeff in the
clinic, would you insist on knowing what he consulted for?
5. What ethical principle/s can you use to resolve the ethical
problem/issue?
 Chapter 17
As generous distributors of God’s manifold grace,
put your gifts at the service of one another,
each in the measure he has received.
1Pt. 4:10

THE PRINCIPLE OF JUSTICE IN THE ALLOCATION

OF HEALTH CARE RESOURCES

ealth care resources, as

in any kind of physical or earthly resources, are always limited. Thus,
whatever are available must be fairly and rationally allocated so that
that they can benefit as many people as they would as possible, rather
than allowing just a few to enjoy them. Such allocation must not
therefore be discriminative or isolative as to benefit only those who
have money fame and power, but should also consider even those
who do not have, since health is a human right universally accepted.
In other words, justice is the ethical standard that must be invoked
and observed, so that a just allocation of health care resources may be
accorded to all citizens, but especially the poor, the vulnerable and the
marginalized. It must be noted that there is no substitute for the
allocation of said resources because they are utterly scarce. If such
resources are not scarce and are always available, then there would be
no need for rational allocation or distribution. The world and its
people are finite, thus, they can only do as much following acceptable
standards of equitable (or equal, as the case may be) distribution with
the finite resources.
Justice in the Mind of St. Thomas Aquinas. Understanding the
concept of justice according to the great Dominican intellectual, St.
Thomas Aquinas (1225-1274) is in place and will set a good mental
framework. Accordingly, justice, or justitia, is a cardinal virtue and
defined as "a habit whereby man renders to each one his due by a
constant and perpetual will". Along with temperance, prudence, and
fortitude, justice habitually provides the complete structure of good
works to someone that is due him/her. Like all virtues, justice is an
intrinsic principle. It is a principle intrinsic to good action and,
thereby, subjective. Justice, as a principle of good action, is then
related to the will of the rational creature. The quality of justice
adheres to the subject which is the will. Moreover, Aquinas further
delineates two forms of justice – commutative and distributive.
Commutative justice in concerned with dealings between two
persons (or juridical persons). It is a “case of give and take, take and
give.” An example of this is when I request for lab exam worth
P5,000, I have to get the lab service when I pay it with the amount in
which it is charged of me. It should be nothing less than what I paid
for. Distributive justice relates to the order of the whole community
in relation to each single person. An example of which is when the
community, entrusted to its government that is tasked to build a
health center worth a contracted amount of P10M, the constructed
center must be worth the amount contracted. Anything less than it, is
a violation of justice. In distributive justice, the common goods are to
be applied or distributed by proportion fairly in accordance with
common good. Now, allocation of health care resources is a classic
example of the application of what is due to the beneficiary.
Ultimately, "the proper act of justice is nothing else than to render to
each one his due because he/she has claim over it."
The 5 M’s Health Care Resources. Resources in the health care are
referred to as the five M’s categorized accordingly as: Manpower
(human personnel and their set of skill, knowledge, aptitude and
attitude); Money (monetary capability and values, banking, lending
and financial institutions, investments, etc.); Machines (health care
equipment, instruments and devices, both the old reliable and modern
modalities, especially X-rays, Ultrasound, Pet Scanner, CT Scan,
MRI, Linear Accelerator, etc.); Materials (health care facilities or
structures, like hospitals, health centers or public health, wellness
clinics, etc.); and Methodologies (these are the efficient and effective
ways to prevent and diffuse the debilitating effects of diseases and
health problems, like preventive, curative and rehabilitative medical
management. E.g., medicines, vaccines, medical supplies, nutritional
supports, prosthetics, pandemic or epidemic models, etc.)

Since health care resources are

scarce, proper allocation, including but not limited to proper
distribution and allotment must be judiciously exercised. It is
unconscionable that health care facilities fiercely compete to get a
bigger slice of the patient market to gain financial advantage, while
many cannot even have primary health care. We see many hospitals
being established very close to each other because there is a potential
market in the area, without considering the capital expenditures that
can dilute local and global capital. Economically, this is not anymore
useful or advantageous to the general populace because, while
hospitals may possess big hospital equipment, they are actually
exhausting the resources of the country and are sending the capital to
other countries. Pre-occupied with their own image as a hospital of
choice for boasting comprehensive services and technologies, they
sometimes forget that they are actually serving the same (generally
poor) population. This is not, by and large, beneficial to the
population. There must therefore be stringent regulations by the
government agencies to allocate resources that would benefit more
the general population including those in remote and unserved areas.
Furthermore, preventive medicine is still the best medicine.
Thus, primary health care must be emphasized for a country to enjoy
high quality health status and longer life expectancy. It is against
justice to see that the bulk of the resources are concentrated in a
particular area, as in cities, while other equally important areas are
neglected and the people die because of the lack of health service
support system or medical attention. In the Philippines, up until now,
even with the modern communication and transportation, there are
eight (8) million people who have not seen a doctor in their lifetime.
This is lamentable. It is therefore imperative that a just allocation of
scarce health resources be in place.
Paradigms of Health Care Resources Allocation. There are four
(4) paradigms of health care allocations that are applicable under the
principle of justice and even under humanitarian causes that must be
considered in order to maximize or optimize health care services for
all under a particular milieu or geographical circumstance. Moreover,
these four paradigms serve as an appropriate framework to rationalize
the distribution of scarce health care resources. They too, can be used
as a parameter for purposes of prioritization and budget allocation.
The following are:
1. Giga Allocation. This refers to allocation that is global or
trans-national in scope. This means that health care allocations must
cut across national boundaries and must reach even remote locales
that are far flung but are equally needful of health services and health
or life-saving supports. Countries that experience pandemics or
epidemics must be given priority. Also in the war torn areas where
civilians are most vulnerable must be given priority. Refugees must
be given emergency and speedy health care to avert mass death due to
malnutrition and poor health care.

Since this allocation is global in scope, rich countries must

feel obliged to help those who experience a dearth in health care
services. Here is where the UN, through WHO, must work hard to
avert world health crises, with or without political pressures. Support
must be selflessly offered to the Medecins Sans Fonrtieres (Doctors
Without Borders) which is the world’s largest private humanitarian
relief organization. The same can be said of the International Red
Cross. These organizations have been very efficient and helpful to
millions who have been affected by wars, pandemics or epidemics,
ethnic cleansing, political repressions or famine and natural or man-
made calamities. (Repressive) Governments do not have therefore any
moral authority to stand on when they prevent the entry of food and
medicines in these affected areas. This is so because health is a
human right. And human survival must be responded to with deep
concern.

2.
Macro Allocation. This refers to allocation that is national in scope.
Policy makers and legislators should look into the priority needs of
the citizens and should give importance to the causes of morbidity
and death, and the improvement of health status. Health expenditures
could be focused on people’s needs rather than politicians’ greed
through graft and corruption that are sadly characteristic of
developing or third world countries, including the
Philippines. There must therefore be solid and sound
programs that cater to those that are usually vulnerable. Vaccination
and other preventive medical care must never be forgotten, but should
rather be included in health reform agenda. Health programs must be
in place and appropriate budget must be automatically legislated.
Included here are legislations that oblige the government to
earmark decent and sufficient national health budget for its citizens
and must be pursued persistently. At present, the Philippines, as
provided by the constitution, earmarks five per cent (5%) of the Gross
Domestic Product (GDP), a measure of national income and output
for a given country. It is equal to the total expenditures for all final
goods and services produced within the country in a stipulated period
of time. If the Philippines has a GDP budget of P4.1 trillion pesos for
fiscal year 2020, then, the legislated five per cent budget
automatically earmarked for health gives an allocation of P205B. If
there are 108 million Filipino citizens, then this budget translates into
P1,898.00 per Filipino per year (or P5.21 per day). But since the
actual budget is only P175.9B this FY 2020 (P175.9 ÷ 108 million
Filipinos), then this gives a pale and sick health budget of P1.62 per
Filipino per year.
The previous FY 2019 has also been very pathetic because the
budget for health was a miniscule amount of P69.4B. For a long time,
individual Filipinos dismally received practically a low average of
P1.56 per year. This is so minute compared to the national health
budget of many developed countries which is more than $2000.00 per
citizen annually. No wonder, the Filipinos are not that healthy
compared to their counterparts in developed countries like Japan,
even if the survey says that Filipinos are one of the happiest people in
the world. It is good to note that to date, the life expectancy of the
Filipinos is sixty-eight (68) years, while that of the Americans is 78.2,
and that of the Japanese and Singaporeans is 82 according to general
references. This life expectancy of Filipinos has been dragging so
slow and has not really improved fast enough since the last decade.
For comparison, a curious look at the Philippine GDP for
Fiscal Years (FY) from 2017 to 2019 is properly in place. We will be
able to see where the government priorities rank different government
departments in terms of budgetary allocations. The health budget
deserves a special focus as well as how the government allocate hard
earned monies by Filipinos.
It is good to examine the changes in budgetary allocations that
have occurred through the immediately preceding years. The
dramatic rise of DepED for example and the DOH from among the
priorities are noteworthy. The DND has gone down from first to fifth
in rank since the Marcos regime. The DPWH has risen up and DILG
is in the 3rd, higher than in most of the years past. The DA is now in
8th place compared to some years before. Note that priority budgets
change every year usually depending on who the siting President is to
feed on his agenda. Below is a four-year chart of the priorities of the
national government as reported by the Department of Budget,
namely:
Table 1. Top 8 Departments in the Philippine National Budget,
Department of Budget and Management (DBM)
(Excluding the IMF-WB automatic loan servicing which takes
almost 40% of the total budget, 2017-2020)

DEPT’S 2017 2018 2019 2020

Billions Rank Billions Rank Billions Rank Billions Rank
DepED 568.4 1 691.3 1 665.1 1 692.6 1
DPWH 467.7 2 643.3 2 465.2 2 581.7 2
DND 237.4 3 145 5 186.5 4 192.1 5
DILG 149.4 4 172 3 230.4 3 241.6 3
DOH 98.4 6 164.3 4 168.5 6 175.9 6
DSWD 128.4 5 138 6 177.9 5 200.5 4
DOTr 55.7 7 73.8 7 69.4 7 100.6 7
DA 45.9 8 54.2 8 49.7 8 64.7 8

Source: Philippine Department of Budget and Management

In addition to what had already been mentioned above,

important observations the below are highly significant and
consequential in the understanding of the priorities of the Philippine
national government, namely:
a. The Department of Education (DepEd) still ranks
(consistently for the immediate past three years) as the highest budget
among the priorities of the government for this FY 2020 as the
present dispensation claims that the said department’s budget is
consistent with the Constitutional mandate. As legislated the IMF-
WB servicing of loans is the highest among the priorities since it
takes the biggest slice in the pie, consisting almost 40% of the whole
budgetary allocations. This translates into almost 408 billion pesos as
payment for loans the majority of which had been wasted for projects
that did not so much benefit the Filipinos nor the country in general.
It began with then President Marcos (then to Cory Aquino, to Ramos,
to Estrada, to Macapagal-Arroyo) until the present government of
President Rodrigo R. Duterte. The general perception is that a big
slice of this fund has gone into individual pockets while the country is
left with a gripping poverty. This grim reality still very much haunts
the present dispensation and is not going to end soon or sooner. It is
not surprising too that corruption of the highest kind is unabated.
Finally, there is no effort to either cut or even suspend payments of
IMF-WB loans.
As of June 2020, the total debt of the Philippine government is
P8.6 trillion pesos divided into local debt, P5.86 trillion, and the
foreign debt, P2.74 trillion pesos. In the past twenty years, since
1990, the government had a runaway average loan of P200+ billion
pesos every year. This implies that even the next four generations of
unborn Filipinos already bear the debts that they have to pay with
their hard-earned money (that is not even earned yet). The colossal
debt that has already breached the five trillion-peso mark, certainly
has also huge implications to health budget, and therefore to the
health status of the country.
b. It is laudable that next to the IMF-WB servicing of loans,
the DepED was given the first priority which for many years had been
in the cellar with a budget now of P692.6 billion pesos. Although it
would take around five to six decades to close the educational gap,
fortunately, education ranks as the highest in the government
priorities. Singapore is an example of a country that invests highly
and heavily in education, the first priority in its national allocation.
Singaporeans believe in an educated citizenry as the means and link
to productivity and progress. For them, an educated citizenry makes a
healthy nation. A healthy nation makes a productive citizenry. The
same can be said about Japan and Canada.
It is sad to note though that a study made some fifteen years
ago showed that out of ten (10) pupils who enter elementary schools
in the Philippines, only six (6) proceed to secondary school. And out
of these six (6) secondary students, only two (2) continue through
college. It is safe to conclude thus that a great number of out of
school youth in the country are living in uncertainty. Unfortunately,
serious social liabilities are the logical consequences of this
uncertainty. And with the horrid consequences of the COVID-19
pandemic for this year 2020, the prospect for the education of youth
seems not to be so bright because of the shift in teaching and learning
methodologies where the usual classroom methods change to online
way of teaching and learning. This will have a heavy toll on
government schools and a great number of private ones who may not
have the necessary means to go to electronic methods. Sadly, the
result of this is the lower number in enrolment.
c. Health budget ranks sixth (6th) in 2020 Fiscal Year. It has
already taken the 4th rank in 2018, higher than the Department of
National Defense (DND) and Department of Social Work and
Welfare (DSWD) yet is now lower in rank than DPWH by four
levels. As in previous years, DOH is higher than Department of
Transportation (DOTr) and Department of Agriculture (DA).
The budget for DOH has a little improvement from the past
budget allocations which placed health in the 10th ranking for many
years. It is now sixth (or seventh if we place IMF-WB in the first
rank) for the Fiscal Year 2020. Status quo ranking makes DOH
remain in the 6th place by getting a budget allocation of P175.9B.
Note that advanced countries worldwide treat health as the highest in
its priority. Again, it believes that a healthy citizenry is a
productive/progressive citizenry.
d. There is something to be happy about the great jump of
health budget of P27.9 billion for the FY 2009 as it increased its
allocation by almost 6.51 times for FY 2020. But its rank went down
a little bit compared to the bigger budget allocations of DepEd, etc.
However, as mentioned above, it is back to 6th for the FY 2020.
Sadly, its budget is still not in accordance with the constitutional
mandate of allocating 5% annually out of the whole GDP.
Constitutionally, it must have a minimum allocation of P 77 billion
pesos for FY 2010. This amount will certainly promote and improve
the health and lives of the Filipino people, especially in their access to
health and insurance no matter how insufficient. One reason why it
cannot get such amount is discussed below.
e. The so-called Priority Development Assistance Fund
(PDAF) popularly called “pork barrel” has been met with so much
indignation by the citizens because this fund has been a source of
graft and corruption by insensitive politicians that to date, dominate
the legislative estate. One reason why such graft and corruption is
easily consummated is because this fund is immune from government
audit. It has been claimed by the so-called politicians that this is
being used for rural development, intelligence fund and the like. But
many believe that this is primarily so designed to open the flood gates
for legislators to easily fill their pockets and they seem to claim it as a
reward for being powerful members of the legislature. To date every
congressman receives a “pork barrel” of P80 million pesos each year
(excluding allowances which run into hundreds of millions) for the
268 congressional legislators.
Theoretically, this translates to P21.44B that Filipinos give
reluctantly to his or her congressman. If the congressman/woman has
a term of three years then he receives P240M. No wonder, after
his/her term (or even during such term), he/she must have already
erected mansions, built resorts, owned a fleet of cars, host of
expensive gadgets and joined exclusive clubs, while the electorate
wallows in poverty, homelessness, hunger and deprivation,
dilapidated mass transports, rickety public hospitals and isolated from
progress.
The senators are allocated each an amount of P200 million
pesos every year for his/her pork barrel (excluding their allowances
which run into hundreds of millions). This makes him a multi-
billionaire after his six-year term (assuming those said allocations do
not really go to social services but somewhere else). If there are 24
senators, then they must have accumulated a whooping total amount
of P4.8 billion pesos per year. Theoretically, that makes P28.8 billion
pesos for six years (the term of senators). If only all these monies
were truly used for infrastructures and support of services in health
and education, the Philippines would have landed in the Guinness
Book of World Record as one with the longest and most number of
concrete roads, bridges and highways compared to many countries in
the world and probably, the most educated and healthiest citizens.
But, what we see are useless waiting sheds, foot bridges and
overpasses built on the most remote highways and which even the
chicken would not have any difficulty crossing. As a consequence,
they have become monuments to folly, disservice and inanity (with
the names of the politicians visibly inscribed on them) since no one
uses them anyway. Some have even converted these footbridges into
barangay offices atop the highways. Had the money been used to
build health centers and purchase medicines and health supplies, we
can expect a progressive citizenry in the whole country.
Unfortunately, in the past Fiscal Years, the so-called PDAF budget
has been retained. Incidentally, the budget for the Autonomous
Region for Muslim Mindanao (ARMM) is still miniscule what with
the devastation brought to Marawi siege. Unfortunately, since its
creation, there has not been real development in the area but only
creation of warlords who lord it over the region. The recent
Maguindanao massacre that claimed 57 innocent lives is a gruesome
reminder of its anomalous existence.
3. Meso Allocation. This refers to allocation that is
institutional in scope. The institutions of health like hospitals, clinics,
municipal or barangay (village) health centers must make rational
decisions in order to optimize the use of the financial resources and
make them sound and beneficial. Institutions should avoid purchases
that do not benefit the majority but work to the detriment of their
financial capability. It is unconscionable to be very obsessed with
hospital image by acquiring high-end equipment, which only becomes
a financial burden to service loans incurred from these big purchases.
It is not either ethically tenable that hospitals are trying to outdo and
compete against one another by making it appear that they are the
number one medical institution or that they have the best facilities,
doctors or nurses who offer the best services. The truth is that
hospitals should never make an enemy out of other hospitals since the
real adversary are the diseases of the people. Thus, hospitals should
never be so obsessed with image as to degrade other hospitals that do
not belong to their league. It must be borne in mind that doctors and
hospitals are supposed to be allies against the inhumanity brought
about by diseases, illnesses and their consequences, hospitalization.
Instead of competing for the top ranking, they should put in place
programs for cooperative work and effective coordination to optimize
or maximize the use of whatever health care resources available.
4. Micro Allocation. This refers to allocation that is
individual in scope. It is an allocation that gives so much autonomy
to an individual to decide over what goods or services he uses his
money for. Observably, on an individual capacity, the Filipinos
budget their money under the following priorities, namely; first, food;
second, shelter; third, education; fourth, entertainment, and fifth,
health. This is the reason why only less than 50% do have health
insurance, and the rest are dependent on out of pocket health
schemes. Unfortunately, some even die due to absence of medical
attention and around eight to nine million Filipinos have not even
seen a doctor in his lifetime. Worldwide, still millions of children
die of starvation and around 36 million are trafficked every year.
It is imperative that Filipinos must be well educated about
what matters most to live in dignity and not only to survive, and must
be encouraged to invest in health or buy health insurance so that when
illness and disease strike, they would feel confident that they will be
taken care of and that their health needs would be provided for.
Ideally, entertainment must be downgraded among the Filipino’s
priorities by making it the last in the list. It is sometimes ridiculous to
see the poor buying cell phones rather than purchase Health
Maintenance Organization (HMO) insurance for their health needs.
It is against the Principle of Human Dignity to see discordance or
dissonance in the priorities that leave the more important needs last in
the hierarchy. Moral discernment is to be instilled among the citizens
if they were to make their life healthy and with dignity. Healthy
choice is needed if people are to choose life over everything else.
Rationalization therefore of choices must be in place so that the health
aspects are not sidetracked into the gutters.
The Principle of Justice in the Allocation of Health Care
Resources. As explained above, the Principle of Justice in the
Allocation of Health Care Resources stems from the obligation of
every person to give what is due to others in all places, at all times
and all situations, without exemptions and habitually. The following
is the principle:
Justice is a virtue which inclines man to give
others what is due them. It is a respect given to a
rightful claim that belongs to others. The effect of
this virtue is respect or recognition of a right that
belongs to others, either to God or to fellowmen.
Since health is a right, justice can be served by
respecting that rightful claim to health care.
Bioethics will never be good bioethics unless some virtues be
exercised in the care of patients and that such care effect the
development of virtue in the health professionals. Foremost among
these virtues is Justice in the allocation of health care resources.
This is a practical virtue that inclines man to give as a matter of duty
to others their due. In health care, justice must always be promoted
because without it health care may only be unfairly regarded as a
profane or civil service that can only cater to the needs of the body
without any regard for the spirit. Or that it is regarded as a service for
business or profit. We may very well know that patient caring is
holistic in character. It is never fragmentized nor done on piecemeal
basis, dedicated only to cure a particular organ or system, but rather
intended to heal the whole person. This is so precisely because man
is an embodied spirit, and any attempt to separate the body and spirit
in health care would lead to unhealthy segmentalization. This is
never a good practice of medicine. Good medicine considers the care
of the totality of the person as a person who is an embodied whole
and should never be fragmented. Justice demands that as a part of
the duty of health professionals, medical attention must be focused on
that embodied spirit. To fulfill that, justice demands that care has to
be of quality, that is, effective, safe, reliable, affordable, accessible,
and of course, ethical.
The bases by which claims of justice may be demanded in
health care are those that are provided in the ff.: Eternal law, Natural
Law, Constitution of the land (including the criminal, civil and
administrative rights), policies of the health institutions, privileges
and benefits meant for the health professionals as private and
government employees, children, senior citizens, general public, etc.
(as dictated by the Magna Carta of Health Workers, RA 7305, 1994
and RA 6972, RA 6758 and RA 7641), as well as members of the
health societies. It includes also those retirement funds which legally
belong to the employees, and not to the institution. Thus, the
institution has no legal or moral right to use them except for the
retirement of the health workers.
Theories of Justice in the Allocation of Health Care Resources.
There are times when health professionals and medical facilities find
it hard to solve dilemmas in terms of allocating health care resources.
Fierce debates rage over allocation of health resources because people
or government use different models to apply to various situations of
people. It must be noted however that society has a collective
obligation to provide health goods and services to the extent that they
are available. The following theories may help diffuse the seeming
difficulty in resolving them. Let us take a look at these various
paradigms or theories and see where they can best be applied when
faced with different situations.
1. Egalitarian Model. This model emphasizes “equal access
to goods and services in health.” Egalitarian thinkers believe that the
society, especially affluent and powerful societies, must find a way to
find universal coverage for all citizens in their health needs. This
dwells comfortably well with those who believe that “health care is a
right.” This is a model followed by Canada, the United Kingdom and
Scandinavian countries. Thus any deviation from this universal and
equal access to health care is unjust. Legislations must be in place in
order to advance the good of all in the whole spectrum of the health
care dimension of the society.
2. Utilitarian Model. This model pursues the view that
defines “the greatest good for the greatest number.” It uses
methodologies that seek the distribution of health goods and wealth to
bring about public utility for the majority. Health is considered as
one of the needs that must be served through public utilities like
health care facilities or supplies. It would be unjust if hospitals are
well equipped with advanced technologies and supplies, while the
majority of the poor do not get the health care that belongs to them.
We cannot let our bridges fall and leave our roads unpaved in favor of
a few medical centers. This theory therefore believes that even in
times of crisis in the health care services in the society, health care
must be rationed and provided only to those who will benefit most
and denied to those who will benefit less or nothing.

These rationing schemes are necessary to stave-off the uncontrolled

gap between the resources and our expanding health needs caused by
the flaws in the system of our governance, as well as the increased
needs of the population whose life expectancy has dramatically been
compromised in the past decades. Thus, this model takes into
consideration that what matters in the society is the majority, since
allocation here is both a numbers’ game and perception of
convenience which is characteristic of partisan politics both in
developing and developed countries.
 3. Libertarian Model. This view emphasizes personal or
organizational right to social and economic liberty. There is not much
concern about equitable distribution of health goods and services for
as long as the allocation scheme is freely chosen. This is called the
“free enterprise approach” in distributing health care. This free-
market approach is one that is utilized by the United States and some
others around the world. It may not be able to generate a unified
system of delivery, although some sectors may work and some may
not. This model is mostly applicable to rich countries in which
affluent citizens can freely choose the category of health care they
need or want. This oftentimes works under the managed care model
of health care delivery, as popularized by western countries. The
obsessive penchant for autonomy and individuality is paramount
because rich citizens usually have a wide variety of choices and
extensive access to health. In this model, patients are primarily
responsible for selecting their own health care plans, design and
coverage. They cannot demand for something beyond the coverage
of their health plans since health here is considered a commodity for
which they must pay, and one deserves only that which one pays for.
4. Distributive Justice Model. This approach believes that
health care delivery must be such that “both benefits and risks” are
equally distributed to all the members of the population. This detests
biased or discriminative scheme of putting all risks to one segment of
the population and giving all the benefits to another. In human
research for instance, justice of this kind must be observed so that
those who are included as subjects for experimentation or research
must be well randomly selected with neither bias nor manipulations,
otherwise the result may be invalid. Distributive justice takes into
consideration that everyone must have a right to have access to health
care but that he must be willing to make corresponding sacrifices
since not everybody can get equal benefits that health care can offer.
Everyone must have to bear both risks and benefits so that no one can
be accused of unjust or discriminatory practices. In this model, the
dignity of every person is highly recognized so that no one
unnecessarily wallows in discomfort while others engulf themselves
in extravagance.
 5. Social Justice Model. This view promotes the belief that
“we give back to society what we took from it.” The beneficiaries of
this model are primarily the poor. Here, the poor are given more
privileges since they do not have anything or anyone to cling to or
hope for save the help of the society that is known for its
philanthropy. There must be more justice given to those who have
less in life. It believes that the rich can take care of themselves and
their needs since they have the financial capacity to support
themselves. Social justice is justice to those who otherwise cannot
help themselves and whose survival and pursuit for decency depends
upon the capability of the society who is indebted to the poor who
labor for their well-being. This model is usually applicable to third
world countries where the poor comprise the greater bulk of the
population inasmuch as they should have more in law for what they
lack in life.
6. Pragmatic or Popular Model. This model plays around
the political dispensation or milieu of the body politic. What is
pragmatic or popular is the basis for the rationalization of health care
even if it breaches the cultural, moral or religious aspects of health.
For example, the free distribution of condoms or other contraceptives
can be done, for as long as the people accept even without regard for
the customary beliefs or moral values of the community. The
popular or populist view regards the allocation of health services as
temporary, and can therefore change anytime according to the
convenience or sometimes the whims and caprice of the body politic
or its leader/s. Thus, in this model, low prices of health goods and
commodities are a favorite policy even if it is disadvantageous to
business and economic state. Since health goods and services are
cheap, people do not give as much importance to health care as when
they are expensive. This leads to curative health care rather than
primary health care or the preventive one. The pragmatic model is
rather Machiavellian in characteristic since it thrives on the fanciful
and not on the necessary. This is especially applicable to welfare
states since the citizens’ needs are subsidized and makes health care
inexpensive.
7. The Natural Law Model. This model is hinged on the
most fundamental and general principle that in health care one should
“do what is good and avoid what is evil” or that one which is always
guided by the golden rule that says, “do not do unto others what you
do not want done to yourself.” Natural law demands that justice be
an attribute that must be present in all health care activities. Above
all, the element of charity must always be accorded to those who
cannot help themselves in their health care needs. Neither the
hospitals nor the attending physicians take advantage of those who
may have the capacity to pay or they be guilty of opportunism. This
Natural Law model therefore always takes into consideration the
element of charity as an essential component of health care that
should always pervade as an important quality in any health service,
whether the patient is a charity or paying patient.

8. Other
Minor Models. There are other minor models that can be
enumerated and can serve as criteria for the delivery of health care
goods and services. The following may be worth considering: a.
“First come, first served basis,” that is, the patient who comes first
into the hospital has more right to medical attention and must be
served accordingly for his health needs cannot be postponed.
Otherwise, one must risk irreversible damage. b. “Survivability
(prognosis) of the patient,” that is, the first ones who must receive
medical attention are those whose chances of survival are more likely
compared to that of others. Immediate attention may be waived (for a
while) to those whose condition, though serious, but do not stand a
chance for survivability. This can be done with those who figure in
accidents or in time of war or pandemic as the practice of triage. c.
“Social status,” that is, the important position of the person in the
community, like the president of the country or commander-in-chief.
It may well be that priority may be given him over those who have
already been in the hospital. d. “Age of the patient”, that is, between
an 80-year-old kidney transplant patient and a 20-year-old patient,
who may have the priority to receive a donated kidney, the rest being
equal. There is no dilemma if the donor chooses who may receive it.
This is in keeping with the time-honored principle of “intentio
dantis” that is, according to the intention of the giver. e. “Severity of
the disease,” that is, those who should receive medical attention are
those whose diseases are severe and need immediate attention. This
is especially true with the intensive care patients. Other patients can
still wait since the former are under emergency condition. Health
institutions that do not have complete health care support or medical
professionals must take this into consideration.
In case of pandemic (adopted Alora, MD recommendation), as
the COVID-19 of 2020 (secondary with Acute Respiratory Disease to
High Risk Pneumonia), any of the appropriate principles above can be
applied as it is possible and appropriate. Herein, the medical team
may withhold cardiopulmonary resuscitation on critically-ill patients
with no reasonable hope of recovery. When there is an advanced
directive by patients (or the proxy in case), DNR must be followed.
But based on futility, the medical team can make decision for
patient’s best interest and use of scarce resources. Finally, efforts
must be made so that spiritual care and counselling for the patient and
family are available.
Disregard for Justice in the Allocation of Health Care Resources
Worldwide. Below are grim raw statistics released by WHO, IHME
and Johns Hopkins in Maryland.
 The data shown below gives a quick idea on how worldwide
health care activities give priorities to combat or not combat causes of
death and how might the worldwide health resources are spent as
regards the issues of the causes of death. It is extremely ironical that
the first cause of death with the most number is abortion and it is
more than seventeen million (17). Compared to other causes of death,
abortion is completely preventable, yet public and private funds are
poured for it for total population control. And yet the

world especially WHO does not help to stop this gravely evil scheme
and design. Heart diseases and cancer rank second and third
respectively and is controllable. And yet, billions of dollars are spent
to combat them and which is a tall task to reach. The same can be
said of other causes of death and they are well funded for. Herein,
one sees erroneous placement of priorities as the helpless unborn
babies are being killed with impunity and senselessness. Unarguably,
this iniquitous action is in no way humane and is unethical in all
fronts. The best way to combat abortion is to remove funding from it.
Pope John Paul II’s View of the Allocation of Donated Organs. A
question of great ethical significance is that of the allocations of
donated organs through a waiting-list in the assignment of priorities.
In his address to the 18th International Congress of Transplantation
Society, 2000, Pope John Paul II raised concerns about the efforts to
promote the practice of organ donation and observed that the
resources available in many countries were currently insufficient to
meet medical needs. Hence, there is a need to compile waiting-lists
for transplants on the basis of clear and properly reasoned criteria.
Fortunately, USA seems to be the only country that has these criteria,
but to date, unfortunately, it has more than 28,000 candidates for
kidney transplants annually.
From the moral viewpoint, an obvious principle of justice
requires that the criteria for assigning donated organs be in no way
“discriminatory” (i.e., based on age, sex, race, religion, social
standing, etc.), or “social usefulness” (i.e., based on work capacity, or
social or political status). Instead it must be determined on a fair
selection basis on which that judgment must be made due to
immunological and clinical factors. Any other criterion would prove
wholly arbitrary and subjective, and would fail to recognize the
intrinsic value of each human person as such, a value that is
independent of any external circumstances.

Case Studies:
A. To Give or not to Give
One day before her delivery, Mrs. S. Coronel came to the
hospital. Her OB-Gyne anticipated and advised her that her baby be
placed into an incubator right after delivery. Her doctor, aware of the
lack of needed equipment told her to reserve for 3 days the only
incubator left. Solicitous of her first baby, she reserved and paid in
full the amount to the hospital for the needed incubator. In the
meantime, another mother delivers her baby who needs badly an
incubator.
1. Should Mrs. Coronel give the incubator to the other baby
even at the prospect of needing it anytime soon?
2. Should the hospital have the right to get the incubator from
Mrs. Coronel even if it had already been reserved and paid for?
3. In cases such as this, what should you as a doctor or
administrator of the hospital do to prevent the same problem in health
care to occur again?
B. A Case of Resistant TB
Bayani B. is a 46-year-old jobless man diagnosed to have
PTB. He went to a private charity Tuberculosis Clinic who provided
free standard first line anti-TB drugs. However, he failed to respond
and was later diagnosed as having multi-drug resistant TB that would
require more expensive second line anti-TB drugs. The charity clinic
did not have resources for this.
1. What is there to do to resolve the health needs of Bayani?
2. Do government health institutions have an obligation to
help Bayani with his predicament? On what basis/es?
3. Should Bayani B. be obliged to go to a government hospital
and be confined there? Justify.
C. D. Lemma’s Dilemma
In 2003, D. Lemma was a death-row convict in the National
penitentiary. He was slated to be administered a lethal injection in a
week’s time. Six days before the scheduled date, he got ill and the
next day he was sent to the hospital for an evaluation of his illness. It
was found out that he had contracted infection and that he had to stay
indefinitely in the hospital as his health required. The law states that
no one should be executed when found to be ill. He can only be sent
to the death chamber once he becomes healthy.
1. Is it ethically tenable to let D. Lemma stay in the hospital
and be treated until he is healthy and strong enough to stand the lethal
administration procedure? On what grounds, if any?
2. Is the law just to treat death-row convicts before they are
sent to die of capital punishment? Of what use will it be?
3. What ethical principles can be used to resolve the ethical
dilemma above? Explain.
4. What can be done practically and ethically to resolve the
dilemma?
D. To Go out or not?
Christine N. is an inmate who had served eight (8) years in a
state female penitentiary. She was convicted of killing her husband
who was very abusive. While in prison she was diagnosed to have 2nd
stage cancer and was being treated in a state hospital. She was due
for parole in a month’s time. Her dilemma was that she would not be
able to enjoy the privilege of treatment once she would be out of
prison based on the policy of state prisons. She is poor, and once out
of prison she would face the prospect of not going to the hospital to
continue cancer treatment.
1. What practical measure/s should Christine do to avail
herself of the treatment referred to in the case?
2. Is it ethical to stay in prison and use its resources even if she
is not anymore an inmate? Explain.
3. What ethical principle/s can you use to favor or disfavor
Christine?
E. To Cut off or not
Mr. Gabby K. is a terminally-ill patient and is in coma. He is
kept alive through a ventilator. As the dying process had set in
beyond all doubt, the attending doctor saw no point in prolonging his
life. He intimated to the family to cut off the oxygen supply to make
the limited equipment available to another patient whose life may
thereby be saved. The family disagreed by justifying that Mr. Gabby
was going to die anytime soon. They wanted to just wait for him to
die. They continued by saying that they regularly paid the hospital
charges for the oxygen anyway.
1. What can be done ethically to make way for the impending
death of Mr. Gabby K. without having to make a difficult decision?
2. Is it ethical to cut off oxygen supply to allow the use of the
limited equipment to those who can be saved by it? What process
should be done (if there is) to remove opposition to the removal of
oxygen?
3. What principles of bioethics can be used to assure the
ethical decision to cut off the oxygen? Explain.
F. The Israeli Gambit
Just recently, the President of the Philippines issued an
executive order banning the priority given to eight (8) Israeli and
other foreigners to have kidney transplant in favor of the local
Filipino kidney patients due to the many abuses in kidney organ
trafficking and its sale. The ban became effective in April, 2008. But
the problem with the Israeli patients was that they had already been
worked out and prepared before the ban was issued. The National
Ethics Committee on Transplantation of the Philippines gave
exemption to the eight Israeli patients because of the reason above.
Howls of protest against the said exemption saw print in the
broadsheets claiming that this would be discriminatory and prejudicial
to their local counterparts. Even the Secretary of the Department of
Social Welfare was furious after learning about it and even challenged
the Secretary of the Department of Health and the members of the
Ethics Committee to first donate their kidneys.
1. What can you say about the exemption to the ban in favor of
the Israeli kidney patients? Explain.
2. Should the ban cover the present Israeli patients?
3. What can you say about the challenge the Secretary of the
Department of Social Welfare posed to the Secretary of Health and
members of the National Ethics Committee?
4. Will your opinion change if one of the Israelis was your
boyfriend/girlfriend? Elaborate.
5. Will the exemption give a bad precedent? How?
6. What practical solution/s do you suggest to end the impassé
or deadlock in the current problem?
G. The COVID-19 Pandemic of YR 2020
 It has been well known that the pandemic brought about
Corona Virus Disease (COVID-19) has been contaminating Filipinos
all over the country and its infection rate has been steadily spiking up
rather than flattening the curve for the past month since it was
declared a worldwide pandemic by WHO. Data suggest that this
virus had been badly affecting and even claimed lives worldwide.
Lack of Personal Protective Equipment (PPE) like face masks and
shields, alcohol, hospital beds, isolations units and ventilators, and
even medical and other health personnel to combat the disease was
markedly noted.
Lately, we have known that many local and national
politicians and members of their families have asked for COVID test
at RITM and wanted to the point of pressuring the latter to rush
results or else the personnel suffer consequences. Meanwhile, may
people have protested against the obvious feeling of entitlement of
these politicians and their families while the ordinary citizens have
already been waiting and have their tests delayed to give way to these
so-call VIPs. This was immediately confronted with indignation and
criticism from the people.
1. What is your ethical assessment of the behavior of these so-
called VIPs (politicians and their families)? Elaborate.
2. What suggestions should you make about the protocols at
the RITM?
3. As a responsible citizen, what can you do to make health
rights and justice in the allocation of scarce health resources equally
applied to all citizens? Explain briefly.
 Chapter 18
There is still one thing left for you:
sell all that you have and distribute to the poor,
and you will have a treasure in heaven.
Lk. 18:22

SUBSIDIARITY OR SOLIDARITY:
THE PRINCIPLE OF COMPASSIONATE CARE

tymologically, “subsidiarity” comes from the French term,

“subsidie,” which means “to gift by way of financial aid.” Usually, a
subsidy connotes an act of giving that is public or government in
character. Thus, to subsidize means “to aid or assist an individual or
community deemed advantageous to the public.” This act is made
because a donor sees that someone or a community is not self-
sufficient such that it needs some external help, in terms of monetary
assistance or in kind, in order that the individual or community would
be able to survive either temporarily, or permanently as in the case of
welfare beneficiaries in many of the welfare states around the world,
like the USA and Europe. Subsidiarity however, when done in a
more profound passion or commitment to help the needy and the
helpless, it becomes a compassionate principle of care.
The Principle of Subsidiarity or Solidarity. The Principle of
Subsidiarity is sometimes called the Principle of Solidarity.
Although subsidiarity is more focused on the general need of the
public, solidarity is specifically focused on the needs of the poor (or
poorest of the poor) hence, more appropriately used in Social Ethics.
These two terms are interchangeable and depend on the particular
context they are used. It is the position of this book that the sick are
“the poorest of the poor.” Hence, Solidarity can be used as
subsidiarity for the sick who are “the poorest of the poor.” The sick
are actually those who are deemed helpless and no one could be more
helpless than the sick who are immobilized or are basically committed
to others because they are unable to help themselves. They are at the
mercy of medical science and those who practice it.

Popularly
though, Subsidiarity is meant as an act to benefit those who have little
in the society in terms of health care resources. Solidarity means
being one and being able to feel the pain and suffering of the poor.
This is where solidarity is almost synonymous to compassionate care,
hence subsidiarity or solidarity is a Principle of Compassionate
(Health) Care. Commonly understood as being able to put “one’s
feet in the shoes of another,” Subsidiarity calls for feeling with
“passion with another” who is suffering both in mind and body. This
is compassion at its best.
The following Principle of Subsidiarity runs thus:
 Subsidiarity stems from the demands of the virtue of
justice. It recognizes that no individual is self-
sufficient. When he is unable to help himself, a
stronger or higher entity in the society is called to
assist him. This is well reflected in the Christian
commitment to live and concretize Christ’s
exhortation. “Whatever you do to the least of my
brothers, you do it to me.” (Mt. 25:40)
Experience tells us that it is the poor who bear the heavier
burden more heavily than the rest, since the poor are more usually
stricken with illness compared to those who are economically well-
off. When the poor fall ill, they do not only face the prospect of
medical inattention, but also the scarcity of medical support that
includes among others nutritive support. In cases of the rich who are
ill, they usually have complete support including medical specialists,
needed comfort in suite rooms and/or nutrition while the poor cannot
complain when they are placed in wards with tattered bed linens and
substandard food provisions. Sometimes, health professionals are
faced with the poor and the sick who cannot afford the financial
implications of care, yet whose sick condition is treatable and
reversible. What happens therefore when one is confronted with such
cases? This is where the principle of subsidiarity or solidarity must
be well considered. Ethical health professionals understand well the
plight of the poor and the sick, and feel it deeply as if it is their own.
In subsidiarity, the person is understood to have no self-
sufficiency, especially in terms of economic and health support. This
of course includes all others who are unable to help themselves
amidst the financial necessities or physical inabilities. When a patient
is unable to bear the financial burdens, the stronger entities in the
society are duty bound to help, beginning with the family. When the
family is unable to do so, the higher society is called to assist, like the
community of the sufferer. If the small community still cannot do
that act of solidarity, then a bigger one should step in, like the
province or district. When this is impossible, the state must assume
the duty in favor of the sick. This is where the state is duty bound to
promote public health and support government hospitals. For the
goal of the government hospitals is precisely to help the financially
needy whose health needs depend substantially on the government
subsidy which is essentially the taxes of the citizens. The same
meaning of solidarity is extended to those who are physically
handicapped and who are unable to help themselves unless a stronger
entity in the society pitches in to offer the needed help. Hence, the
intensive care unit (ICU), critical care unit (CCU), or mobile care for
those who are wheelchair bound patients become more meaningful
when they would include the care of the needy. Subsidiarity is called
for such help and the principle is best implemented in this case.
Hospitalization discounts or the so-called zero balance for the poor is
laudable as there is nothing the needy can hope for but the assistance
coming from a stronger entity whose aim is to make the citizens
productive when they recover or become healthy again.
We should note that the Principle of Subsidiarity sits well with the
examples Christ demonstrated through the paralytic, the deaf, the
blind and the dumb. As a matter of fact, this principle is very
Christian in quality and essence. Incidentally, the compassion of
Christ is clearly seen with those who died but was resurrected back to
life by him, thus integrating them once more to the bereaved family.
Furthermore, for him, human life is premium, and he was willing to
suspend the effects of the law on Sabbath (or even abolishing it), if
this would mean saving someone from hunger, sickness and death.
More so, Christ was particular and solicitous when it comes to
healing the spirit, especially the consequences of sin. The woman at
the well and the woman caught in adultery are beautiful examples of
Christ practicing the Principle of Subsidiarity. No one comes to
Christ and goes away unhealed, unfed, unrestored to life and
unforgiven of the maladies of the soul. Christ therefore is the
“primum analogatum,” (the primary analogate) or “summum bonum
(the highest good) that is, the fullness of healing action in favor of
persons bonded by an embodied spirit crying for help.

In a deeper context, the poorest of the

poor are in fact, the sick. This is because, even if they may be
materially rich, when they are sick, they are in the most vulnerable of
all conditions. They have to rely on others for help to become healthy
and productive again and be finally integrated into the community.
Isolation from the community throws the

sick into their

weakest and lowest state in the community. The leprous man during
the time of Christ was a classic example of a sick person who became
an outcast and isolated from the mainstream of human society. He
was the most vulnerable and the poorest of the poor. He was like a
walking cadaver. Solidarity is the best response for a sick man in his
pitiful condition. It recognizes his dignity and makes him always an
integral part of the human community. Solidarity makes the health
professional united in the sufferings of the sick and therefore of Christ
who himself suffered poverty and pain. This is Christ’s attitude to the
poor, the hungry and the sick. He is God who became man to be in
solidarity with humanity. Solidarity is doing something more than
the minimum, or grabbing the opportunity to help when it presents its
way to one who has the capacity to serve. The Principle of
Samaritanism is another name for subsidiarity principle.
The Principle of Subsidiarity Concretized in Health Care. The
view of a nurse by the name of Ms. M. M. Rosales (1998) offers
beautiful subsidiarity (solidarity) courses and methods that can soothe
the patient in pain and suffering. The following aspects may be worth
considering, namely:
 1. Sense Aspect. The good doctor or nurse encourages giving
to the sufferer or the dying everything that the latter may wish to have
or behold. One can even send in colorful non-allergenic flowers or
their favorite pets (dogs, cats, birds or fish) in the hospice setting for
them at home. This may be banned in the hospital setting though.
They should not be given reverse isolation measures. One should
allow them to eat anything as they please except those with radical
contra indication to their condition. What is important is that they do
not suffer deep pain and must be accorded comfort and consolation.
It must be ensured that they are clean and fresh, and that bed sores are
avoided.
2. Emotional Care. Words of comfort may be offered as part
of emotional care. One however need not say anything because just
being there could be enough and is understood as a stabilizing
emotional act. The sick must be made to feel that they are not alone
which can lead to the dissipation of fear. Holding their hands maybe
very comforting. Telling healthful jokes that lift their spirit is good
and laudable. Telling beautiful redemption stories are music to their
ears and must be encouraged.
It is also good to prepare the sick/sufferer by hinting that death
may be imminent in a language that is gentle and encouraging.
Relatives especially the family must be called when such time is
about to occur. They should never be left alone in the cold
environment of the ICU or CCU. Playing a classical music may be
soothing, or any music that they love hearing even if they are
outlandish to our senses.
They should be asked as to what can be done to help them in
terms of unfinished business, like family affairs and reunions. An
inquiry about the education of their small children can be made.
When there are legal matters to attend to, help can be offered.
3. Spiritual Care. Encouragement that lifts the human spirit
even in the most trying times should be provided, like praying for the
sufferer and probably showing sacred pictures that are most
comforting relative to their religious affiliation. Their spiritual
advisers, priests and other spiritually inclined volunteers can be
contacted. One should talk to them even if they cannot answer. Most
often they can hear us. They must be encouraged to seek forgiveness
from others and while others should seek forgiveness from them.
Keeping them company is like keeping company with Christ in His
most difficult moment at Gethsemane. The most victorious thing that
we can see or hear from the dying is to know that finally they accept
death. One must not talk prematurely with funeral agents for a
discounted deal as this may prick sensitivities and cause uncalled for
irritations to their loved ones.
It is highly laudable to see the patient’s doctors present at
deathbed until one breathes his or her last. This is an amazing
episode that the bereaved family/ies will remember and be grateful for
throughout their lives. Nothing could be more beautifully
reminiscing than these episodes on the last minute presence in a
patient’s life on earth.

Case Studies:
A. To Video without being Told
In this modern world, technology has offered very useful tools
for learning, not only in humanities courses but more so in life
sciences. Teachers and students increasingly use video as a useful
tool in many areas of their learning. To maximize the learning of
students in the surgical procedure, a clinical faculty member, Dr. B.
Novem recorded several procedures performed on his patients. He
also taped, for purposes of critical evaluation by his medical clerks,
interns and residents. Dr. Novem removed a large cyst from a
patient’s ovary. As a charity patient, she is not told that the entire
procedure is being recorded. Dr. Novem said that informing her may
not be necessary.
1. Does Dr. Novem act in solidarity with the patient?
2. Was the procedure primarily for the interest of the patient?
3. Is the patient’s charity status a good reason for the
videotaping without her permission?
 B. To be Actually with the Poor in Remote Areas
Dr. Cabito is a surgeon, and a member of a Rotary Club, a
civic organization. He had been invited many times by the Club to
join a medical-surgical mission in a remote barangay in the province.
Not for a single occasion had he responded positively as he already
made alibis by saying that he always gave charity services to many of
the poor patients who come to him.
1. What can be said about the attitude of Dr. Cabito?
2. Was his service to the poor, as he said, a sufficient reason to
make such alibis not to join the medical-surgical mission?
3. Should his membership in the Rotary Club give him a sense
of obligation to do extra service to the poor?
C. “Not Clinically Indicated”
Many times, we hear of doctors saying that the proposed
treatment is not “clinically indicated”. Sometimes we do not even
know clearly what this phrase is all about. Mrs. M. Nunez, an
indigent patient had cancer of the cervix with widespread metastases
and her condition was irreversible. She developed cough, fever, mild
tremors and was in pain. She seemed to have pneumonia. She was
mentally awake. Her oncologists stated that only comfort measures
should be applied to her, because other means were “not clinically
indicated.”
1. What does it mean by “not clinically indicated” here? Does
it have a clear meaning? What does it mean to Mrs. M. Nunez?
2. If Mrs. M. Nunez is in pain, should it be responded to with
pain relievers? Can the treatment here be regarded as being in
solidarity with her?
3. If medical futility was determined, should we not give her a
temporary relief from the recent development of illnesses?
4. What comfort care can be given to Mrs. M. Nunez?
 D. A Mother who can’t Let Go
Mrs. Annabella S., a mother of a three-year old only daughter,
Rufina who is dying of leukemia, insists that everything should be
done and that she believes that only “God knows when He should
take her.” The very aggressive treatment sought for prolonging the
child’s life or prolonging her dying process was painful for the child.
The health team in the unit felt very uneasy about the treatment that
will only prolong the child’s ordeal. They were reluctant though to
say “no” to Mrs. Annabella.
1. What role should Mrs. Annabella S. be allowed to play in
this case? Is her religious belief in accord with the principle of
Solidarity?
2. Guardianship can only be ethically accepted for as long as it
is for the best interest of the patient. Does the aggressive treatment
warrant such motive here?
3. Does solidarity mean doing everything for the child until
“God takes her away?”
4. Should not letting go of her daughter be equated with
solidarity with the patient?
E. Hospital Nixes Rescue of Pregnant Lady
It was told that the ambulance of a certain hospital carrying a
certain A. Celina entered the campus because of the floods around the
district when its engine conked out. A. Celina was then suffering
from birth pangs when the ambulance she was riding in got stalled
inside the USC University campus that was supposed to bring her to
J. F. Hospital. When they asked for an ambulance from the USC
Hospital, an official said that its ambulance personnel had already
checked out and that there was no team of doctors and nurses that can
accompany the patient as part of medical protocol. Further, Dr. E. O.,
administrative director of USC Hospital claimed that he cannot
respond immediately to emergency situations such as Celina’s since
its ambulances do not offer out-of-hospital emergency medical
services that provide treatment to people in need of urgent medical
attention. Dr. E. O. said that “USCH couldn’t help Celina because it
was her attending physician who requested for assistance. The
request should come from the patient herself.” He added that “the
hospital may face legal consequences if it just enters a situation
without the patient’s consent.” Thirty minutes later, Celina was
“rescued” by another an unknown doctor from another hospital who
brought her in his own car and transferred her to the J. F. Hospital.
1. What do you think is the function of an ambulance service
of any health care?
2. What do you think are the ethical lapses of Dr. E. O., or that
of USCH, if there are any?
3. Were the excuses made by Dr. E. O. ethically tenable before
the bar of patient advocacy and principle of solidarity? Critique each
one.
4. What is the main difference between Dr. E. O. and the other
unknown doctor who helped Celina in her moment of need? Who
“stood by” and who “ran away” between the two doctors when a call
of need presented its way to the precarious situation of Celina? Who
is the biblical Levite, Pharisee or Samaritan among the two doctors
and personnel?
F. Which is the Way to Do? To Help or not to Help
Ms. M. de la Rocha was riding a car along the Southern Luzon
Expressway. She is being driven by Pablo, the family driver.
Suddenly, the car she was riding on lost control and turned turtle.
Trapped inside the car, she and her driver struggled to get out of the
car in an upside position. Gerardo M., a bystander who witnessed the
accident, thinking that the car might explode hurriedly tried to rescue
M. de la Rocha from inside the car. It was a struggle to get her out.
In his effort to help Ms. de la Rocha, the latter sustained a dislocated
elbow. An ambulance took Ms. de la Rocha to the closest hospital.
Two months after the accident, Mr. Gerardo M. received a demand
letter asking him to pay Ms. de la Rocha for the injury she sustained
while being helped at by him get out of the car. Gerardo M. felt
disgusted and did not agree to the demand. Ms. de la Rocha pressed
charges for physical injury.
1. Is there an ethical basis for the demand by Ms. de la Rocha
against Gerardo M. and more so press for charges? How about a
legal basis?
2. Was Gerardo M. ethically obliged to pay Ms. de la Rocha
for the injury she sustained as alleged?
3. Do you think that Gerardo M.’s assistance a form of
Samaritan act? What do you think about Ms. de la Rocha’s act of
pressing charges against Mr. Gerardo M.?
4. Should Ms. de la Rocha be grateful to Gerardo M. rather
than be antagonistic to him?
5. What do you think are the ethical implications if Gerardo
M. is found guilty of committing a slight physical injury against Ms.
de la Rocha?

Stock Vector
 Chapter 19
Masters, act in the same way toward everyone,
and stop bullying, knowing that both they and you
have a Master in heaven
and that with Him there is no partiality.
Eph. 6:9

THE PRINCIPLES THAT GUIDE RESEARCH

ON HUMAN SUBJECTS
A

research is a systematic inquiry aimed at discovering verifiable

phenomenon or knowledge that demonstrates scientific truth/s. The
truth which is the goal of said research is a result of validly accepted
procedures and methodologies commonly used in scientific
undertakings. Therefore, a research that does not follow accepted
procedures and methodologies may run the risk of being invalidated
or considered illegitimate or a plain hoax. Thus, whatever may be the
outcome or results cannot be accepted as scientific truth. Researches
for instance, in pharmacology, medicine and other life sciences have
to follow accepted research designs and methods. This should
include right interpretations and applications.
It must be worth noting that a research must follow some
ethical guidelines, if it has to be accepted as legitimate by the society
even as it has to consider the society’s cultural, religious and moral
dimensions, let alone the legal aspect. Research cannot therefore be
done as purely scientific endeavor without regard for the cultural,
religious and moral sensitivities of the people. When these are
disregarded, it may well be that no matter how good the research
result will be, it would be met with resistance and skepticism.
Besides, it will be a waste of time to engage in research if the people
respond adversely to it. Many researches have already been done
worldwide that sparked criticisms and condemnations because they
had been done without ethical considerations.
Furthermore, researchers must be willing to take the oath of
honesty and objectivity if they have to be credible. It has already
been proven that many researchers have been found to be dishonest
and fraudulent and as a consequence make a travesty of the wonders
and truth about scientific inquiry. A lesson in justice is also essential
as the contrary may lead to the blatant violation of human dignity and
free and informed consent by the subjects. Sometimes said
violations, if not checked and controlled, can bring about irreparable
damages, both physical and emotional, and may not be able to bring
back the balance of justice to the victims. The Code of Nuremberg (cf.
Appendix V) and the Declaration of Helsinki (cf. Appendix IV) offer
rich and valuable references that can guide researchers along this line.
The so-called breakthrough in human cloning which was
announced by some Korean researchers on TV and newspapers in the
recent past has been found to be fraudulent. Due to the dismay and
embarrassment of the Korean scientific circle and of the world, the
researchers have been recommended for severe sanction and were
punished by being stripped of their license and served prison time.
This fraudulent occurrence had led to some stringent legislations that
govern research activities with the idea of preventing the same
mistakes and making the researchers accountable to the profession
and the public. Further, the legislations should include strict
screening criteria in terms of state funding as it may be misused or
abused in the process.
Due to many unethical practices in the conduct of research, it
is imperative to set guidelines that will govern research activities.
And this is more so when a research involves human subjects. There
is therefore a reason to set sanctions and censure researchers who do
not respect this scientific endeavor.
Research is very important as this has been the reason for the
advancement of knowledge in the pursuit of better quality of life in
the world. Through research, scientists have discovered truths which
would have otherwise remained unused, hidden or sedentary. The
benefits that research has brought to the world have been so enormous
and have broadened horizons never before imagined. Life has
become more bearable and understood, although complicated, with
the advent of truths found through research. Research is like an
anchor that insures stability of ships in the harbor even amidst natural
calamities or catastrophes.
In particular, though, when it comes to research or
experimentation involving human subjects, careful consideration must
be put in place in order that human dignity would not be violated.
Thus, guidelines must be set in place and researchers must bind
themselves to these guidelines so that abuses and excesses would be
avoided and frauds are immediately dissipated. In research, it is
always the human subjects’ safety, security and freedom that must
first and foremost be insured in the minds of the researchers.
The Principles that Guide Research on Human Subjects. The
following are the generically and ethically acceptable norms that
researchers should abide with when they involve themselves or
participate in medical or health care research involving human
subjects (cf. Code of Helsinki, App. IV and O’Rourke and Ashley,
2002):

1. The
knowledge sought in research must be important and obtainable
by no other means and the research must be carried out by
competent people. Obviously, this is self-explanatory. As a matter
of fact, the knowledge must be as important as not to border or
straddle on the bizarre or the whimsical truth, like the odious research
scandal made by Russian biologist Ilya Ivanovich Ivanov in 1927, to
produce an offspring from a woman’s egg and a gorilla’s sperm.
Neither should the research satisfy only the personal caprice or self-
aggrandizement of the person of the researcher. Rather, the
knowledge sought must have universal implications, i.e., to improve
or benefit the universal community and to ennoble or make life better,
or more appreciated. Included in this research is the production of
medicines or vaccines that can cure diseases, or produce drugs to
reduce or alleviate human pain and suffering, etc. Such research can
only be done by knowledgeable or competent people, who must be
virtuous, just and honest. The truth sought must only pursue that
which cannot be obtained otherwise.
2. Appropriate experimentation on animals and cadavers
must precede human experimentation. It is just logical that before
any experimentation is done on live human beings, it must first be
applied to animals or guinea pigs or cadavers, as any mistake may be
costly to human life when applied directly to the latter. Mistakes in
human experimentation may injure limbs or destroy life. The case of
the experiments done at the behest of Adolf Hitler upon humans
without securing the feasibility and safety on them and without first
experimenting on brute animals and cadavers was clearly unjust and
repugnant. As a matter of fact, they were consequently denounced by
the whole world. It was the reason why the Code of Nuremberg has
been crafted to prevent others from doing the same and punishing
those who do whimsical and inhumane research without ethical
regard for human beings.
3. The risk of suffering or injury must be proportionate to
the good to be gained. Good researchers always take into
consideration the harmful consequences that can or may happen due
to research conducted. This is due to the fact that injuries may be
irreversible or might even cause the death of the subject. If injury or
suffering is a necessary consequence of the experimentation, the good
or knowledge that would be gained must be greater than the injury
sustained. Scientists must therefore commit themselves to the
Principle of Proportionality. If the good to be gained is
insignificant, capricious or whimsical, all such research must be
stopped immediately. This case does not do any good to science or to
the integrity of the researcher. It is a travesty of the pursuit of
scientific knowledge and truth.
 We have known of many researches in pharmaceuticals that
have contributed to the eradication of TB, venereal diseases and other
infectious diseases, and up until now, the world has enjoyed the
benefits they have offered, in spite of some risks that have been
reported. Pasteur and Curie are among the big names that are paid
tribute to because of their experiments in medical research. But their
researches are not without risks. Nevertheless, the risks were
insignificant compared to the immense benefits the world gained and
enjoyed.
When there is a question of high risk research, it is encouraged
that the researchers be included as subjects, so that it will bring home
the message that their research is highly significant and that they are
willing to subject themselves to the research even at the prospect of
danger to their own limbs and life.

4.
Subjects should be selected so that risks and benefits would not
fall unequally on one group in society. Justice must be a guiding
principle that must be observed in the selection of subjects, so that
risks and benefits would not fall unequally on one group in the
society. A case in point that must be remembered here is the
Tuskeegee syphilis experiment (see below discussion) that
discriminated against the black Americans in the past several
decades. The same can be said about the Willowbrook research that
discriminated against the institutionalized persons. Care must also be
considered on research involving institutionalized persons, as they are
most vulnerable to abuse and excesses, like the mentally retarded,
prisoners, battered women, abused children, orphans and those who
are under welfare.
5. To protect personal integrity, free and informed consent
must be obtained. This is a very basic requirement that must be
obtained from the subjects (or their legitimate proxy) before any
research is conducted on them, especially if they are most vulnerable.
Obtaining free and informed consent is a respect to the subjects’
autonomy (free will), integrity and dignity. It does not follow that
when individuals are under welfare or are charity patients, researchers
can just do anything on them without seeking first their consent. If
subjects are incompetent, proxy consent must be sought. (see
Principle of Autonomy, Ch. 14, ad supra). A careful examination of
memoranda of agreement or understanding that covers the contract
must be explained well to the subject/s or his guardian/s in a language
he/she understands. If it need be, the document must be translated
into the language the subject is familiar with. Also included is the
accountability of the researcher in case something awry happens.
Any research done without the individual’s consent is an injustice to
him and must be meted with rebuke or just punishment. For doing
such research without free and informed consent is an invasion of
privacy, dignity and can be considered theft of one’s identity.
6. At any time during the course of research, the subject
(or the guardian who has given proxy consent) must be free to
terminate the subject’s participation. It is always for a reason that
subjects do not want to continue with the research even in the middle
of the process, or no matter how important his presence is in the
whole spectrum of the experimentation. Whatever is the reason of the
subject, pertinent or not, must be respected. Thus, when the subject
has expressed his intention to keep out of the research, he must be set
free with dispatch (at any time of the said research protocol/phase).
The subject is not obliged to be a part of the research until it is
brought to a conclusion. This must be well spelled out in the
memoranda of agreement. A subject who wants to keep himself out
will not in anyway be interested in cooperating with the researcher.
Thus, it is to the disadvantage of the whole research itself when a
disinterested subject is being forced to continue participating in the
endeavor.
7. In psychological experimentations, which shade
imperceptibly into social research, the researcher should work
with rather than on the human subjects. There are many kinds of
experiments that are conducted in view of (a) knowledge being
sought. Psychological experiment is one of them, and this certainly
poses a lot of problems since psychological research is sometimes
imperceptive in the knowledge obtained. It is claimed that knowledge
gained are mostly conclusions brought by perceptions since to date, it
is hard to understand the intricacies and depth of the functions of the
brain or mental ability/capacity. There are neither gadgets nor
instruments that can accurately determine the mental status of the
individual. Even the most obvious conclusions can sometimes
change as the discipline of psychology or psychiatry advances.
Because of the many indeterminate conditions of the mental
ability/ability, the researcher must work with the person, rather than
work on him. The distinction of these two modalities clearly gives
warning on how subjects have to be treated with utmost honor and
respect. This means that the human subjects must not be treated as
objects but as persons created in the image of God. This will also
guarantee the promotion of privacy and confidentiality, even as they
have to be carefully treated and given due respect because of their
dignity.
8. The researcher must avoid breaking down human trust
by lying or manipulation, although subjects can give free and
informed consent to experiments in which they must learn to
interpret ambiguous communications or meet puzzling
situations. Lying and research cannot mix. When a lie is detected,
immediately there is a breakdown in trust. This will not promote the
truth through research. When a subject feels he is manipulated and
his person is compromised, he will resist continued participation in
the project. This is where we understand why researchers must be
competent, not only technically but also ethically. A research based
on lie and manipulation may bring an invalid conclusion and
therefore, a questionable outcome. And this will be detrimental to
the society who will be at the receiving end of the results produced in
the experiment, as in the case for instance of drugs or procedures
generated from fraudulent researches.

9. Researchers must not take

serious risks in reducing the subjects’ ability to perceive reality as
it is or to make free choices except as a temporary experience
through which the subjects can learn to cope with distortions of
truth and attacks on their freedom. It is so highly difficult to
remove 100% risks in experiments involving human subjects. In
psychological or psychiatric research, for instance, the subject may
experience reduced ability to perceive reality or to make free choices
because of the effects of the experiments on one’s mental
ability/capacity. This is but natural and should not be regarded as a
negative setback. For as long as this experience is temporary and
does not affect the person in the long run, then it must be taken as a
necessary risk. Take into consideration the Principle of Double Effect
in this case.
10. Financial implications of the research on the human
subjects must be the sole responsibility of the researcher. It must
be the sole responsibility of the researchers or whoever is responsible
for the research to carry the financial burden. We refer here
especially to the financiers, like the pharmaceuticals who want to
make profits from the drugs that will be manufactured later as a result
of the experiment. There has to be justice here, since a substantial
bulk of the problem that can happen may always take its toll on the
life of the subjects. While the financiers can lose resources in
monetary terms, the subject may lose his/her limbs or even life. The
subjects must be aided commensurate to their earnings of the day,
month or even year, as the case may be. They must be compensated
in case of ill effects that they may sustain during the course of the
experiment and even beyond. This should include their transportation
allowance, daily allowance and other incidentals that they could have
earned had they not been a subject. If the subject is jobless, they must
at least receive a minimum daily wage. In all these cases, the
researchers or the financiers must be generous to the subject included
in the experiment. No one mourns a person or an institution who is
generous.

The Case of the Tuskegee Syphilis Research. Jones, J.

(1981) described in his book, Bad Blood: The Tuskegee Syphilis
Experiment: A Tragedy of Race and Medicine, (NY: The Free Press),
as reported by Tuskegee University, the following:
The Tuskegee Syphilis Study is one of the most horrendous
examples of research carried out in disregard of basic ethical
principles of conduct. The publicity surrounding the study was one of
the major influences leading to the codification of protection for
human subjects.
In 1928, the director of medical services for the Julius
Rosenwald Fund, a Chicago-based charity, approached the U.S.
Public Health Service (PHS) to consider ways to improve the health
of African Americans in the South. At the time, the PHS had just
finished a study of the prevalence of syphilis among black employees
of the Delta Pine and Land Company of Mississippi. About 25% of
the sample of over 2000 had tested positive for syphilis.
The PHS and the Rosenwald fund collaborated in treating
these individuals. Subsequently, the treatment program was expanded
to include five additional counties in the southern U.S.: Albemarle
County, Virginia; Glynn County, Georgia; Macon County, Alabama;
Pitt County, North Carolina; and Tipton County, Tennessee.
During the set-up phase of the treatment program, the Great
Depression began. The Rosenwald Fund was hit hard and had to
withdraw its support. Without the Rosenwald Fund, the PHS did not
have the resources to implement treatment.
During this period, there was a debate occurring in health
circles about possible racial variation in the effects of syphilis. Dr.
Taliaferro Clark of the PHS suggested that the project could be
partially "salvaged" by conducting a prospective study on the effects
of untreated syphilis on living subjects. Clark's suggestion was
adopted.
In the beginning stages of the project, the PHS enlisted the
support of the Tuskegee Institute. Since the Tuskegee Institute had a
history of service to local African Americans, its participation
increased the likelihood of the "success" of the experiment. In return,
Tuskegee Institute received money, training for its interns, and
employment for its nurses. In addition, the PHS recruited black
church leaders, community leaders, and plantation owners to
encourage participation.
At the time of the project, African Americans had almost no
access to medical care. For many participants, the examination by
the PHS physician was the first health examination they had ever
received. Along with free health examinations, food and
transportation were supplied to participants. Thus, it was not difficult
to recruit African American men as participants in the study. Burial
stipends were used to get permission from family members to perform
autopsies on study participants.
While study participants received medical examinations, none
were told that they were infected with syphilis. They were either not
treated or were treated at a level that was judged to be insufficient to
cure the disease.
Over the course of the project, PHS officials not only denied
study participants treatment, but prevented other agencies from
supplying treatment.
During World War II, about 50 of the study subjects were
ordered by their draft boards to undergo treatment for syphilis. The
PHS requested that the draft boards exclude study subjects from the
requirement for treatment. The draft boards agreed.
In 1943, the PHS began to administer penicillin to patients
with syphilis. Study subjects were excluded.
Beginning in 1952, the PHS began utilizing local health
departments to track study participants who had left Macon County.
Until the end of the study in the 1970s, local health departments
worked with the PHS to keep the study subjects from receiving
treatment.
The project was finally brought to a stop 1972 when Peter
Buxton told the story of the Tuskegee Study to an Associated Press
reporter. Buxton was a venereal disease interviewer and investigator
for the PHS who had been attempting to raise the issue within the
PHS since 1966. Despite his protestations, the "experiment" was still
being carried out when the story appeared on the front pages of
newspapers around the country.
Congressional sub-committee meetings were held in early
1973 by Senator Edward Kennedy. These resulted in a complete
rewrite of the Health, Education, and Welfare regulations on working
with human subjects. In the same year a $1.8 billion class action suit
was filed in U.S. District Court on behalf of the study subjects. In
December of 1974, the U.S. government paid $10 million in an out of
court settlement.
The Tuskegee Syphilis Study remains one of the most
outrageous examples of disregard of basic ethical principles of
conduct (not to mention violation of standards for ethical research).
In 1976, historian James Jones (1981) interviewed John Heller,
director of the Venereal Diseases unit of the PHS from 1943 to 1948.
Among Heller's remarks were the following: "The men's status did not
warrant ethical debate. They were subjects, not patients; clinical
material, not sick people."
The suspicion and fear generated by the Tuskegee Syphilis
Study are evident today. Community workers report mistrust of public
health institutions within the African American community. Alpha
Thomas of the Dallas Urban League testified before the National
Commission on AIDS: "So many African American people I work with
do not trust hospitals or any of the other community health care
service providers because of that Tuskegee Experiment." (National
Commission on AIDS, 1990).
The Southern Christian Leadership Conference (SCLC), one
of the country's major civil rights organizations, has been providing
AIDS awareness education through a program called RACE
(Reducing AIDS through Community Education). In 1990, the SCLC
conducted a survey among 1056 African American Church members
in five cities. They found that 34% of the respondents believed that
AIDS was an artificial virus, 35% believed that AIDS is a form of
genocide, and 44% believed that the government is not telling the
truth about AIDS.
The Tuskegee syphilis research was denounced as a highly
irregular research activity because the researchers were only after the
history of the disease without taking into consideration the dignity of
the human subjects. Those who were afflicted with the disease were
not given treatment until they died. And it was racially
discriminatory as it was only done to the black population, hence a
defect in the research sampling method. Besides, the deceptive
bribes offered to the participants were done in complete silence and
did not consider the free and informed consent and knowledge that
must be given to the subjects. It used black research assistants to give
semblance of objectivity to the research.
Recently, for the unethical conduct of the PHS, the US
government has paid enormous amounts of money as compensation to
the victims of the research.
The Case of the Willowbrook Research. The National Economic
Press reported that during the ‘60s, several research practices
involving children gained unprecedented attention. In an often cited
1966 article in the New England Journal of Medicine, Henry
Beecher reviewed 22 studies, most of which involved
“experimentation on a patient not for his benefit but for that, at least
in theory, of patients in general.” Four of the studies discussed in the
article included children. As described by Beecher (1966), one used
multiple spot X-rays to study bladder filling and voiding in babies;
another involved the suturing of adult skin grafts to the chest wall of a
subset of children being treated for congenital heart disease to
examine the effect of thymectomy (operation to remove thymus) on
growth and development; and a third included some children with
mental retardation who were given an antibiotic (for the treatment of
acne) to determine whether it caused liver dysfunction (which it did).
The fourth study involved children at New York’s
Willowbrook State School. V. L. Debello (2008) posted that
throughout the first decade of the Willowbrook research operation,
outbreaks of hepatitis were common at the school, and this led to a
highly controversial medical study being conducted there between
1963 and 1966, in which healthy children were intentionally injected
with the virus that causes the disease.
These studies were designed to gain an understanding of the
natural history of infectious hepatitis and subsequently to test the
effects of gamma globulin in preventing or combating the disease.
 The subjects, all children, were deliberately infected with the
hepatitis virus; early subjects were fed extracts of stools from infected
individuals and later subjects received injections of more purified
virus preparations. Investigators defended the deliberate injection of
these children by pointing out that the vast majority of them acquired
the infection anyway while at Willowbrook, and perhaps it would be
better for them to be infected under carefully controlled research
conditions.
During the course of these studies, Willowbrook closed its
doors to new patients, claiming overcrowded condition. However, the
hepatitis program which has its own space at the institution, continued
to admit new patients. Thus, in some cases, parents found that their
children would not be admitted into Willowbrook unless they
participate in the studies. This case caused a public outcry forcing the
study to be discontinued because of the perception that parents and
their children were given little choice as to whether or not to
participate in research.
More scandals and abuses dogged the institution. In early
1972, Geraldo Rivera, then a reporter for television station WABC
in New York, conducted a series of investigations at Willowbrook (on
the heels of a previous series of articles in the Staten Island Advance
and Staten Island Register newspapers), uncovering a host of
deplorable conditions, including overcrowding, inadequate sanitary
facilities, and physical abuse of residents by members of the school's
staff. This resulted in a class-action lawsuit being filed against the
State of New York in federal court on March 17, 1972. A settlement
in the case was reached on May 5, 1975, mandating reforms at the
site, but several years would elapse before all of the violations were
corrected. The publicity generated by the case was a major
contributing factor to the passage of a federal law, called the Civil
Rights of Institutionalized Persons Act of 1980. The Willowbrook
State School had since been closed because it had become a
monument to man’s inhumanity to man.
The deceptive process by which the research was conducted
has been well noted when the demands of justice in research were
clearly ignored. The coercion done to parents, just because there
were no other institutions that would accept the children infected with
hepatitis, was evident in the activity. The institutionalized children’s
dignity was not respected on the pretext that they would get infections
anyway, aside from very deplorable conditions in Willowbrook that
the children and parents had to endure and about which they could not
do anything.
The Hitler’s Nazi Experiments Involving Human Subjects. In
"Medical Experiment,” Jewish Virtual Library (2008,
www.google.com) and "The Doctors Trial: The Medical Case of the
Subsequent Nuremberg Proceedings,” The United States Holocaust
Memorial Museum (2008), were reported about a Nazi human
experimentation that were done on large numbers of people by the
German Nazi regime in its concentration camps during World War II.
At Auschwitz, under the direction of Dr. Eduard Wirths, selected
inmates were subjected to various experiments which were
supposedly designed to help German military personnel in combat
situations, to aid in the recovery of military personnel that had been
injured, and to advance the racial ideology backed by the Third
Reich. After the war, these crimes were tried at what became known
as the Doctors' Trial, and revulsion at the abuses perpetrated led to the
development of the Nuremberg Code of Medical ethics. (Appendix V).
The Contents of the Experiments. According to the indictment at
the subsequent Nuremberg trials, these experiments included the
following:
 1.
Experiments on Twins. Experiments on twin children in
concentration camps were created to show the similarities and
differences in the genetics and eugenics of twins, as well as to see if
the human body can be unnaturally manipulated. The central leader of
the experiments was Dr. Josef Mengele, who performed experiments
on over 1,500 sets of imprisoned twins, of which fewer than a
thousand individuals survived the studies. Whilst attending University
of Munich (located in the city that remained one of Hitler's focal
points during the revolution) studying Philosophy and Medicine with
an emphasis on Anthropology and Paleontology, Mengele got swept
up in the Nazi hysteria and even said that "this simple political
concept finally became the decisive factor in my life". Mengele's
newfound admiration for the "simple political concept" led him to
mix his studies of medicine and politics as his career choice. He
received his Ph.D. for his dissertation entitled "Racial Morphological
Research on the Lower Jaw Section of Four Racial Groups", which
suggested that one could define a person's race by the shape of his (or
her) jaw. The Nazi Organization saw his studies as talents, and
Mengele was asked to be the leading physician and researcher at
Auschwitz concentration camp in Poland in May of 1943. There, Dr.
Mengele organized the testing of genetics in twins. The twins were
arranged by age and sex and kept in barracks in between the tests,
which ranged from the injection of different chemicals into the eyes
of the twins to see if it would change their colors to literally sewing
the twins together in hopes of creating conjoined twins.
2. The Freezing Experiment. A cold water immersion
experiment at Dachau concentration camp was presided over by
Professor Ernst Holzlohner and Dr. Sigmund Rascher. The subject
was wearing a Luftwaffe garment.
In 1941 the Luftwaffe conducted experiments to learn how to
treat hypothermia. One study forced subjects to endure a tank of ice
water for up to three hours. Another study placed prisoners naked in
the open for several hours with temperatures below freezing point.
The experimenters assessed different ways of re-warming survivors.
The freezing/hypothermia experiments were conducted for the
Nazi high command. The experiments were conducted on men to
simulate the conditions the armies suffered on the Eastern Front, as
the German forces were ill prepared for the bitter cold.
The experiments were conducted under the supervision of
Dachau and Auschwitz. Rascher reported directly to Heinrich
Himmler, and publicized the results of his freezing experiments at the
1942 medical conference entitled "Medical Problems Arising from
Sea and Winter."
The freezing experiments were in two parts. First, to establish
how long it would take to lower the body temperature to death, and
second how to best resuscitate the frozen victim.
The icy vat method proved to be the fastest way to drop the
body temperature. The selections were made of young healthy Jews
or Russians. They were usually stripped naked and prepared for the
experiment. An insulated probe which measured the drop in the body
temperature was inserted into the rectum. The probe was held in
place by an expandable metal ring which was adjusted to open inside
the rectum to hold the probe firmly in place. The victim was put into
an air force uniform, then placed in the vat of cold water and started
to freeze. It was learned that most subjects lost consciousness and
died when the body temperature dropped to 77 °F (25 °C).
3. Malaria Experiments. From about February 1942 to about
April 1945, experiments were conducted at the Dachau concentration
camp in order to investigate immunization for treatment of malaria.
Healthy inmates were infected by mosquitoes or by injections of
extracts of the mucous glands of female mosquitoes. After contract,
the subjects were treated with various drugs to test their relative
efficacy. Over 1,000 people were used in these experiments, and of
those, more than half died as a result.
4. Mustard Gas Experiments. At various times between
September 1939 and April 1945, experiments were conducted at
Sachsenhausen, Natzweiler, and other camps to investigate the most
effective treatment of wounds caused by mustard gas. Mustard gas
wounds were inflicted on the subjects, who were then tested to find
the most effective treatment for the wounds.
5. Sulfonamide Experiments. From about July 1942 to about
September 1943, experiments to investigate the effectiveness of
sulfonamide, a synthetic antimicrobial agent, were conducted at
Ravensbrück. Wounds inflicted on the subjects were infected with
bacteria such as Streptococcus, gas gangrene, and tetanus.
Circulation of blood was interrupted by tying off blood vessels at both
ends of the wound to create a condition similar to that of a battlefield
wound. Infection was aggravated by forcing wood shavings and
ground glass into the wounds. The infection was treated with
sulfonamide and other drugs to determine their effectiveness.
6. Sea Water Experiments. From about July 1944 to about
September 1944, experiments were conducted at the Dachau
concentration camp to study various methods of making sea water
drinkable. At one point, a group of roughly 90 Romans were deprived
of food and given nothing but sea water to drink by Dr. Hans
Eppinger, leaving them gravely injured. They were so dehydrated that
others observed them licking freshly mopped floors in an attempt to
get drinkable water.
7. Sterilization Experiments. From about March 1941 to
about January 1945, sterilization experiments were conducted at
Auschwitz, Ravensbrück, and other places by Dr. Carl Clauberg. The
purpose of these experiments was to develop a method of sterilization
which would be suitable for sterilizing millions of people with a
minimum of time and effort. These experiments were conducted by
means of X-ray, surgery, and various drugs. Thousands of victims
were sterilized. Aside from its experimentation, the Nazi government
sterilized around 400,000 individuals as part of its compulsory
sterilization program. Intravenous injections of solutions speculated to
contain iodine and silver nitrate were successful, but had unwanted
side effects such as vaginal bleeding, severe abdominal pain, and
cervical cancer. Therefore, radiation treatment became the favored
choice of sterilization. Specific amounts of exposure to radiation
destroyed a person’s ability to produce ova and sperm. The radiation
was administered through deception. Prisoners were brought into a
room and asked to fill out forms, which took two to three minutes. In
this time, the radiation treatment was administered and, unknown to
the prisoners, they were rendered completely sterile. Many suffered
severe radiation burns.
8. Typhus (Fleckfieber) Experiments. From about December
1941 to about February 1945, experiments were conducted to
investigate the effectiveness of spotted fever and other vaccines. At
Buchenwald, numerous healthy inmates were deliberately infected
with typhus bacteria in order to keep the bacteria alive; over 90% of
victims died. Other healthy inmates were used to determine the
effectiveness of different spotted fever vaccines and of various
chemical substances. In the course of these experiments, 75% of the
selected inmates were vaccinated with one of the vaccines or
nourished with one of the chemical substances and, after a period of
three to four weeks, were infected with spotted fever germs. The
remaining 25% were infected without any previous protection in
order to compare the effectiveness of the vaccines and the chemical
substances. Hundreds of the subjects died. Experiments with yellow
fever, smallpox, typhus, paratyphus A and B, cholera, and diphtheria
were also conducted. Similar experiments with like results were
conducted at Natzweiler.
9. Experiments with Poison. In or about December 1943
and October 1944, experiments were conducted at Buchenwald to
investigate the effect of various poisons. The poisons were secretly
administered to experimental subjects in their food. The victims died
as a result of the poison or were killed immediately in order to permit
autopsies. In September 1944, experimental subjects were shot with
poisonous bullets and suffered torture and often died.
10. Incendiary Bomb Experiments. From about November
1943 to about January 1944, experiments were conducted at
Buchenwald to test the effect of various pharmaceutical preparations
on phosphorus burns. These burns were inflicted on subjects with
phosphorus matter taken from incendiary bombs.
11. High Altitude Experiments. In early 1942,
prisoners at Dachau concentration camp were used by Rascher in
experiments to aid German pilots who had to eject at high altitudes. A
low-pressure chamber containing these prisoners was used to simulate
conditions at altitudes of up to 20 km (66,000 ft). It was rumored that
Rascher performed vivisections on the brains of victims who survived
the initial experiment. Of the 200 subjects, 80 died outright, and the
others were executed.
The Aftermath of the Nazi Experiments. Accordingly, many of the
subjects died as a result of the experiments conducted by the Nazis,
while many others were murdered after the tests were completed or to
study the effect post mortem. Those who survived were often left
mutilated, suffering permanent disability, weakened bodies, and
mental duress. On August 19, 1947, the doctors captured by Allied
forces were put on trial in USA vs. Karl Brandt et. al., which is
commonly known as the Doctors' Trial. At the trial, several of the
doctors argued in their defense that there was no international law
regarding medical experimentation. In response, Drs. Leo Alexander
and Andrew Conway Ivy drafted a ten point memorandum entitled
Permissible Medical Experiment that went on to be known as the
Nuremberg Code. The code calls for such standards as voluntary
consent of patients, avoidance of unnecessary pain and suffering, and
that there must be a belief that the experimentation will not end in
death or disabilities. However, the Code was not cited in any of the
findings against the defendants and never made it into either German
or American medical law.
Current Ethical Issues. The modern body of medical knowledge
about how the human body reacts to fatal freezing is based almost
exclusively on these Nazi experiments. This, together with the recent
use of data from Nazi research on the effects of phosgene gas, has
proved controversial and presents an ethical dilemma for modern
physicians who do not agree with the methods used to obtain these
data. Similarly, controversy has arisen from the use of results of
biological warfare testing done by the Imperial Japanese Army's Unit
731. However, the results from Unit 731 were kept classified by the
United States and the majority of doctors involved were given
pardons in spite of the gruesomeness of their activities.
While there were no international laws then that govern
experimentations on human subjects, yet the ethical norms that are
tacitly included in the Natural Law cannot be disregarded as the
respect and honor that must be duly given to humans as naturally
possessing dignity cannot be overemphasized nor forgotten.
Further, there are still some big ethical problems when
experiments and researches can endanger the whole of humanity
when such are sloppily handled and recklessly managed as in the case
of virulent virus that could escape from laboratories as may be the
case of Novel Corona Virus – 19 (COVID-19) which transmission
has become a worldwide pandemic. To date, this virus has infected
millions and has already killed hundreds of thousands and the number
is still counting.
Case Studies:
A. A Research Challenge
Nurse S. Madrigal did a research on the history, epidemiology
and cure of HIV infection. She wanted to test if “virgin oil” was
effective in delaying on long-term basis the spread of the virus and
eventually prove if the substance could be a possible cure for the
infected. In St. Lazarus Hospital, a center for infectious disease
control where she works, S. Madrigal conducts the said research but
does not tell the patients that they are included in the study. She
justified it by saying that the result of the study will anyway greatly
help the patients in their health needs in case they are found to be
effective. Moreover, she says that the subjects are charity patients
whose stay in the hospital is completely under the care of the hospital
without any monetary obligation to the latter. Lastly, there is no harm
that can ever happen to the patients under study as the doses of
“virgin oil” given them have no known ill-effects.
1. How do you explain the ethical perspective of the
justification of nurse S. Madrigal?
2. Is there anything ethically wrong with the nurse’s conduct
of the research? What is it?
3. Does being a charity patient warrant the loss of free and
informed consent? Explain.
4. Should the claim of “no known ill-effects” from the use of
virgin oil warrant the exclusion of free and informed consent from the
patient under study? Explain.
B. A Chimpanzee’s Heart for a Baby
Baby Sonia P. is a newborn infant who was born with a severe
heart defect which according to her doctors would cause her death
within a few weeks if she does not undergo a heart transplant. No
infant heart is available and time is ticking away for her unless a
transplant procedure is done in the soonest possible time. The doctors
planned to transplant her with a baby chimpanzee’s heart which has
been experimented in a few cases and promises good prognosis. The
doctors justified that since there was no known cure for her condition,
rather than see her die, it was better that the procedure be done; it
would give her a fighting chance for life.
1. Should a transplant procedure for Baby Sonia P. be justified
under the condition that the transplant promises good prognosis?
Elaborate.
2. Does the poor prognosis of Baby Sonia P. justify the
administration of the procedure even if it is in the experimental
stage? Elaborate.
3. If you were the mother of the baby and knowing that
financial constraint would not be a problem, should the fledgling
procedure be ethical enough to merit ethical justification? Elaborate.
C. Bribe to Arrive at Good Results
A group of medical residents have been tasked by a
multinational pharmaceutical company to conduct research on poor
TB patients to know the prospect of a new and potential medicine for
tuberculosis. An ethics committee gave a go-signal to start the
research but the residents must abide by the principles of research in
the conduct of the same. They were able to recruit a substantial
number of subjects under study for six (6) months. As the research
progressed and was going into the last half of the period of study, a
marked number of subjects drifted away. The residents were alarmed
as the attrition of the subjects would substantially alter the results of
the study. They went out of their way to the subjects’ houses one by
one to lure them back. This time they promised to give more
monetary benefits including fare, food allowance and the subjects
were assured that they would be given health insurance as long as
they would religiously go to the hospital for the scheduled
examinations. The research was subsequently completed.
 1. Is there anything unethical to promise subjects with
monetary rewards in the conduct of research? Explain.
2. Is it within the purview of justice in research involving
human subjects that to avoid attrition more incentives should be given
away? Explain.
3. What should be the relationship between the pharmaceutical
companies and the medical residents in the conduct of human
research such as this? Explain.
4. Should it be ethically right to substitute original subjects
with new ones because attrition could substantially alter the result of
the research? Why?
D. Clinical Trials on Children
The first stage of a series of clinical trials is performed as
important on human subjects to gather information about toxicity or
maximum tolerable levels of drug use. The trial was meant for future
subjects.
A team of hematologist and oncologist researchers approached
the parents of a four-year old girl, Jennie, with leukemia whose death
is impending. Chemotherapy had not worked well for the small
girl. The team requested the parents, Mr. and Mrs. Jorge Moreno to
enroll the girl in the first stage of the trial for a new drug. The parents
were in a dilemma. Although they felt the pain of their small
daughter and they also wanted to help other children in the same
situation, but they also wanted to do what was best for their daughter.
1. If the research is non-therapeutic (not intended to benefit the
person), may Mr. and Mrs. J. Moreno ethically consent?
2. The study may benefit future children in the same situation,
is it ethically tenable to conduct the trial even if it would add to the
suffering of Jennie?
3. At her age, is her verbal permission (body language)
significant? Is it permissible without her expressed consent?
 4. How can one ethically justify a proxy consent like that of
the parents?

Chapter 20
. . .that their hearts may be encouraged
as they are brought together in love,
to have all the richness of fully assured understanding,
for the knowledge of the mystery of God, Christ,
in whom are hidden all the treasures
of wisdom and knowledge.
Col. 2:2

THE PRINCIPLE OF PROFESSIONAL RELATIONSHIP

IN HEALTH CARE

here are
basically two popularly known and accepted types of relationship in
health care, namely: patient-doctor relationship (including allied
health professionals) and doctor-colleague relationship. This
particular concept is important in health care since health caring is
fundamentally a collaborative work primarily to help the sick and
eliminate the inhumanity of hospitalization. Without collaborative
work, it is impossible to combat the scourge of diseases in human
population. We cannot imagine the kind of human population the
world would have if people are left to themselves to fight diseases. It
is for this reason that in health care, the characters, namely, the
patient (and the family), the doctors and health professionals are
related to one another in a bond of relationship based on trust. Trust
is essentially an attitude of respect and honor given to others in the
role they play in the whole gamut of health caring. When trust is
present, a working relationship is created and everyone recognizes his
important role in health. It is not simply an attitude of belief in one’s
capability or capacity, but it is also a telling confidence in one’s
devotion to the job in a professional and steadfast manner. In this
attitude, a person shows one’s unswerving dedication to his work and
his avowed commitments. Smooth inter-personal relationship (SIR)
can easily be detected in health care when compliance with one’s
duties is easily done and perfected, and people behave as if they know
each other well. In health care relationship, people concerned have
openness of heart and communication lines are easily linked among
those involved in the health care. Relationship knows the position of
one vis-a-vis others and the avenues through which they are able to
effectively contribute to the established objectives of health care.
There are relationships that are formal, some are informal
and both are recognized to benefit both the patients and health
professionals or the health professionals with their colleagues. Not
every relationship can be structured so as not to leave any room for
unstructured ones. In this concept of relationship, everyone is
recognized for his distinct role, skill and knowledge. It is
presumptuous to say that in health care, doctors are more important
than others and must be accorded more dignity than others. All health
professionals are important because they have their distinct
characteristic and no one among the health professionals can
monopolize the immense practice of the art of healing. It is always
the hope of patients that those who take care of them would be able to
work together to help them in their predicament. This is the only way
to hasten the patients’ improvement.
The Patient-doctor Relationship. Patients always look to the
doctor and other health professionals as carers who will understand
and sympathize with their condition. They want to see in the health
professionals the solicitous workers who will offer their sacrifice,
time and talent so that the patients can go through smoothly with the
health problems they face no matter how difficult. They must be
trustworthy so that there is no breakage of communication between
them. Any breakage of relationship is a betrayal of trust and will be
very hard to recover. It must be remembered that sick people are
usually emotionally charged. They see in their condition a threat to
the integrity to their limbs, life, work and family. That is why, when
they feel they are betrayed, the first thing that vanishes is trust and
they would experience the irony that the very institution which they
believe can help them in their trying times would turn out to be
unreliable.
When patients submit to medical and surgical procedures, they
put their lives trustingly into the hands of people whom they believe
are allies. They are willing to open their lives, privacy and
confidentiality at their mercy in a manner that their lives can hang in
balance if they are not well taken care of. The stakes the patients put
are too valuable to lose and the consequences are costly. It is as if
when they put their lives in the hands of others, they tell them
straightforwardly: “Handle it with care. It’s all I got!” This is why,
trust is premium in a patient-doctor relationship. In fact, it is
essentially a quality that is never an accident in health care.
The Doctor-colleague Relationship. Professionalism is at the helm
of health care professionals that can never be overemphasized.
Doctors and other health care professionals are allies and friends.
They can never be otherwise. Lest the consequences can be costly
and likewise ethically and legally distressing. Cooperation and
coordination are laudable activities that can enhance the work of
health professionals in the noble art of healing. Personal and
professional bickering among health workers are an anathema to
health care and the society as a whole. Jealousy and envy are
anathema in the world of cure. Instead of competing against each
other, health care professionals should just compete on how to combat
the scourge of disease. Health workers are part and parcel of the
whole tapestry of the art of healing. A tapestry can never show its
full splendor, beauty and wonder when there are visibly annoying
foreign components and irritating holes created by the unwelcome
personal strains in the art. Anything indeed can never be beautiful
unless it is integrally whole. Peter M. Senge (1990) in his book, The
Fifth Discipline, has a soulful thought to teach us in this area. He
said,
There is something in all of us that loves to
put together a puzzle; that loves to see the image of
the whole emerge. The beauty of a person, or a
flower, or a poem lies in seeing all of it. It is
interesting that the words “whole” and “health”
come from the same root (Old English and French
“hal”, as in “hale” and “hearty”). So it should
come as no surprise that the unhealthiness of our
world today is in direct proportion to our inability to
see it as a whole.
In the codes of professionalism, health care professionals are
especially expected to cooperate with one another in a professional
way in order to maximize or optimize the benefits their particular
professions can offer to the society. When competition is present, it
may be welcome, for as long as it is managed in a highly professional
way, by respecting one another’s rights to engage in professional
endeavors, like bidding on a proposed project or offering artistic
works to cultural heritage collectors. But this practice is exercised
more in a business venture. Health care delivery is very much
different. Health care profession is collaborative, collegial and ally-
based. The real object is combating the disease that plagues the
population. Doctors or other health professionals who are fighting
each other are a no-no in the world of health profession. When they
fight one another, such can well be understood as a fight that is
personal (like jealousy, prestige or competitive advantage) and
monetary (profit-driven or a race for big slice of the market) in
nature. Otherwise, what is it that they are fighting about? In the
health care setting, doctors and colleagues are better seen as allies
than as competitors, more so as enemies. They become a disgrace to
the profession when they treat one another as enemies.

The
Ethical Referral System among Health Professionals. No doctor
or health professional is an expert in all the facets or aspects of health
care, hence, the reason for specialized expertise and proficiency. It is
not quite conceivable to see doctors, for instance, acting as a “jack of
all trades.” Life is just too vast for a single doctor to be an expert in
all the dimensions of medical care. With this view, there is always a
rationale why specializations must be pursued, although there is a
disadvantage in focusing and seeing every medical complaint under
the single aspect of treatment. There is no single therapy for a single
disease. There is also plurality of diagnosis as every condition can be
seen differently since a diagnosis is just an opinion. Every doctor
however, must be able to see other dimensions of the health condition
outside his own expertise. He must be able to transcend beyond and
beside his particular specialization and consider the view outside a
particular territorial fence. Here is where the wisdom of the referral
system lies. It is not ethically right that a geriatric doctor accepts
pediatric patients under his care. He might be accused of negligence
or malpractice since it is common sense that a geriatric doctor cannot
give as much to a pediatric patient as a pediatrician under any
condition, unless a specific condition is emergency in nature. In this
case, all doctors are expected to do emergency medicine. When the
patient has been stabilized, the doctor concerned should not usurp
unto himself that care, but refer him to someone who can best take
care of said patient. This is the referral system at its height. Behind
this referral system is recognition of one’s limitations even as one has
to work above all for the best interest of the patient. We can therefore
say that a referral system can only work best when doctors also honor
what we call in human resource management as the “smooth
interpersonal relationship” that must be pursued and promoted at all
times. After all, all health care professionals entered the world of
health care in order to serve humanity which had become a cliché and
been said “ad nauseam” by those being interviewed in the medical or
nursing school. It is therefore always good to remind all health care
practitioners to go back to those times when they were being asked
why they wanted to pursue the health care profession.
Referring a patient to another doctor is never a sign of one’s
incompetence but a sign of professionalism and a matter of principled
nobility and honor. It is a tribute to one’s marvelous humanity and a
testimony to one’s admirable humility. It distinguishes an ethical
doctor from an unprincipled one. One should take pride in the fact
that there are other doctors whose competence is higher/deeper and
whose understanding of health and disease is more substantial. Such
could be a mark of distinction even when one is not rewarded for it.
It must be noted that solicitation of patients is very
unprofessional and is awfully distasteful. Solicitation of patient is
unduly attracting a patient away from a fellow doctor in order to shift
his loyalty from the latter. It includes depicting the other doctor in a
bad light (by questioning his integrity and competence) so that the
patient would shift consultation needs and eventually, the economic
benefits to him. Solicitation is anathema in the world of health care.
Let us take a look at the wisdom of the forerunner of
medicine, Hippocrates:
 It is not improper if a physician, who is
momentarily in difficulty regarding a patient and
gives his instructions in the darkness of inexperience,
calls in also other physicians, so that they may
discuss the case together and in order that each may
contribute to the easier discovery of a mode of
treatment. During their consultation, the physician
must never wrangle with each other or treat each
other scornfully. Never – I say under Oath – must a
distinguished physician envy the others, for that
might appear despicable. (The Art of
Prognostication)
The Principle of Doctor-patient Relationship. The Principle of
Doctor-patient Relationship can be articulated thus:
The collegial action of doctors or health
professionals can best promote the optimum benefits
of the society and appropriately respond to the
health needs of the individuals through:
a. the recognition of the health profession as a service to
humanity;
b. the recognition of the health professionals of their brand of
expertise;
c. an honorably acceptable referral system as provided in the
professional code;
d. avoiding unprofessional conduct that destroys the trust and
integrity of one’s colleague;
e. and promoting smooth interpersonal relationship and
cooperative endeavor to assist the patient in all his medical needs.
From the above principle, it can be concluded that there is no
substitute for a good relationship between a patient – and doctor or
doctor – colleague in the distinct goal of combating the inhumanity of
illness and hospitalization.
The Health Care Professional and the Pharmaceutical Industries.
In health care, we can mention with certainty that the physician and
the pharmaceutical company have an enviable mutual relationship
because such relationship benefits both in various ways. The
monetary implication is an aspect that cannot simply be dismissed in
that relationship. Although both have patient health as their ultimate
goal, they sometimes have different means and perspectives to
achieve it. This gives rise to some issues that need to be given
ethical clarification.

Accordingly, a
physician must always update himself on his skill and knowledge,
what with the fast explosion and ever advancing medical and
technological knowledge. To stop doing this is to invite obsolescence
in the near future. So he undergoes special training, attends post-
graduate courses, joins societies or just simply travels to know the
current methodologies and modalities in diagnostics and therapy. But
these entail financial expenses. Financial constraints may restrict him
to do all these unless some pharmaceutical companies assist him in
one way or another. Dr. Angeles Tan-Alora of the University of Sto.
Tomas Faculty of Medicine and Surgery pointed out that “aside from
the pharmaceutical assistance to doctors in their training needs, they
also receive gifts, hospitality, service and research grants. They
readily accept these efforts to gain their goodwill and prescriptions
either because they otherwise cannot afford these benefits or merely
because to refuse them is to be a fool and be missed out.”
With the above affairs, a mutual dependence develops
(usually) innocuously. And Dr. Alora continues by saying,
 The physician needs the drug company
sponsorship and without realizing or while refusing
to realize, ends up prescribing maybe needlessly or
maybe recklessly products of these companies.
Brand loyalty while profitable for the company might
be the result of biased scientific information, or the
effect of the dependent relationship. In either case,
brand loyalty may result in poor prescription and
suboptimal healthcare that are obviously signs of
incompetence. Sadly, it is the patient who is at the
receiving end and as a result usually bears the
harm. This state of affairs is unethical as it
contravenes the physician’s duty to “do no harm.”
Promotional activities by the pharmaceutical companies have
always been the order of the day for many doctors. No day would
pass without medical representatives loitering around in the hospitals
for the purpose of encouraging prescriptions by doctors. Oftentimes
these promotional activities are disguises that doctors are sometimes
unaware of. In reality, they are deceptive means that violate the right
to truth. The bottom line is profit. And this goes against the principle
of justice since it is the patient who will pay for it but would not
benefit from the prescription and other interventions anyway.
According to Dr. Alora, “to deceive physicians with wrong
information in addition to inflicting harm and being unjust is also a
sign of disrespect” to his person and profession.
Further, “asking physicians to lecture on supposed objective
and impartial topics, but with insinuations of proprietary intent is
using physicians as means towards the requirements of the industry
and is disregard for respect for persons,” Dr. Alora continues.
Of course, there is nothing wrong for the healthcare provider
and the pharmaceutical industry to mutually cooperate for as long as
the cooperation is primarily for the health benefit of the patient. But
such cooperation, aside from the health benefit of the patient, there
must be mutual respect and responsibility. This therefore requires the
moral virtue of altruism, like patient over self-interest and health over
profit from both the physician and the industry. We do not begrudge
the financial gain that both physician and industry deserve to earn.
But it must be noted that in health care (especially) profit with honor
is noble and simply right. And both the physician and industry must
adhere to it.
The Medical Professional Fee. The Medical Professional Fee (See
brief discussion in Chapter 3, ad supra) is worth discussing more
lengthily here under the Principle of doctor-patient and doctor-
colleague relationship as this topic sometimes becomes one of the
irritants not only among patients but more so among doctors. When
this concept/practice is mishandled, it sometimes becomes annoying
and the cause of conflicts among patients. It also dissipates whatever
goodwill is left among professional practitioners.
One basic question that begs an answer is the ff.: “Does a
doctor deserve to be paid?” Dr. Patrick Moral (2002) reported that
Paolo Zacchias, the physician of Pope Innocent X, stated three
reasons in denying a physician the right to be paid. Firstly, the sale
of spiritual goods is a mortal sin and the practice of medicine is
considered spiritual. Secondly, Hippocrates said that “one who
accepts any fee whatsoever, is a slave, and one who sacrifices the
liberty of his own will, is a man to be treated with contempt. Thirdly,
the physician is already granted so many privileges that a fee would
be redundant.
The same Dr. Zacchias however refutes these with the
following statements: Firstly, according to the Scriptures (Ex. 21:19)
“the physician should be paid for the cure.” Secondly, the physician
receives his honorarium not for the treatment, but for his efforts: it is
not humiliating to receive money for the effort. Thirdly, the
privileges do not replace but complement.
The next basic question that many ask is “What is a fair or
appropriate professional fee?” Though generic, a simple definition,
according to Dr. Moral is that a professional fee is one that will allow
the physician to practice his profession and permit him to live a life
without distractions. A physician should be able to provide services
to his patients without any interruption from other concerns and
endeavors to earn a living.
Further, Dr. Moral said that fees that are too low, with the
intention of undercutting other physicians and those that are too high
are unacceptable. Standard professional fees can be done by collegial
agreement by the members of the medical associations to which the
physicians belong. It is always good to observe the patient’s right to
be informed of fees in a very discreet and prudent way.
Referral fees for services of patients and fee splitting is
frowned upon with reluctance. Separate fees must be issued and
collected only for services rendered. Problems are waiting when
managed care has replaced some of the usual fee-for-service
relationship between patient and physicians. This has to be
determined in the spirit of benevolence and selflessness.
Of course one can waive his fees. It is highly encouraged to
waive one’s fees to a fellow doctor colleague. Hippocrates has even
made it as a duty to a brother in the profession. This must be done
more so with immediate family members (and relatives) even if they
are covered by health insurance. Of course, abuses of this kind must
always be avoided. It is always laudable for health professionals to
guard his ethical practice.
Paradigms for Charging Professional Fee. The following concepts
can offer some bases for standardization by which this simple yet
very important matter of charging patients may be practiced to insure
a smooth relationship between patients and doctors:
1. Socialized Fee. This is a fee that is based on the capacity of
the patient to pay as his economic status would allow. An adage says
that “No one can squeeze honey from a turnip.” It should behoove a
doctor that it is unconscionable or reprehensible to the society to turn
a patient away due to his inability to pay his professional fee, most
especially during an emergency situation. This should not be true to
elective procedures though. The kind of community being served
must be taken into consideration and physicians must avoid any
scandal related to monetary matters, most especially on fees that in
the standard of the community are outrageously exorbitant.
 2. Experience-based, Expertise-based or Specialization-
based Fee. A relative value scale must be in place to be able to
determine what a particular medical service by a physician is worth in
monetary terms. The more experienced the doctor is, the costlier his
specialized service and product of expertise becomes. The contrary
must be upheld, too, that the less of these must be less costly. This is
not to disparage the generalists who may be deemed unable to offer a
better service than those with more expertise. The best medicine is
still one which is preventive and it starts in the primary care.
3. The Theory of Free Enterprise. Since health is a
commodity, its service has a price. And a service depends on the
demand and supply of commodities. Thus, the best paradigm through
which health can be availed of is through a democratic capital-based
enterprise. Those who wish to avail themselves of health and its
benefits must pay for it in a way that they want. No one is forced to
enjoy health if he is not willing to pay for it. This paradigm though is
more comfortable with the first world nations as people could have
larger latitude and freedom of access to health services depending on
their wants or even delight.
4. Level of Difficulty Standard Fee. The more difficult the
condition of the patient is, the larger should be the financial
implications. This is so because such condition will necessarily need
more time, effort, gadgets and instruments and certainly deeper
intellectual diagnostic, therapeutic and prognostic undertakings
heaped up on the shoulder of the medical man and woman. It is not
fair that doctors spare a lot of effort and time and are not fairly
compensated for it. Doctors should not be treated like beggars that
they cannot be choosers. They must be treated with dignity which
they too deserve to maintain in the community. Clearly, there is no
right price tag for service. But, doctors must always watch out for the
integrity and the nobility of medical art.
Further Wisdom on Professional Relationship. Hippocrates said it
well and plainly that “My colleagues will be my others.” He simply
implies that his co-workers are close to his heart that he wants to be
identified with them and the nobility of the profession they practice.
 In a rather candid tone to his fellows, Sir William Osler,
(1849-1919) remonstrated them, himself included, thus:
Many a physician whose daily work is a daily
round of beneficence will say hard things and think
hard thought of a colleague. No sin will so easily
beset you as uncharitableness towards your brother
practitioner. So strong is the personal element in the
practice of medicine, and so many are the wagging
tongues in every parish, that evil-speaking, lying,
and slandering find a shining mark in the lapses and
mistakes which are inevitable in our work. From the
day you begin practice never under any
circumstances listen to a tale to the detriment of a
brother practitioner. And when any dispute or
trouble arise, go frankly, ere sunset, and talk the
matter over, in which way you may gain a brother
and a friend. (Cf. “After Twenty-five Years”)
Moreover, Robert Louis Stevenson (1850-1894) wryly
interjected and said,
There are men and classes of men that stand
above the common herd, the soldier, the sailor, and
shepherd not infrequently, the artist rarely, rarelier
still the clergyman; the physician almost as a rule
generosity he has, such as is possible to those who
practice an art, never to those who drive a trade;
discretion tested by a hundred secrets; tact, tried in a
thousand embarrassments. (cf. “Underwoods”)
In view of the wisdom above, Aimee A. Silva, MD (2002)
concludes that it takes more than going through years of studying,
training, and passing exams to become a good doctor. Years of
practice can never guarantee perfection of craft. Values and virtues
will serve as beacon to guide the healers through the perils they
encounter.
Case Studies:
A. The Loathsome Patient
Mr. Cabago is a patient in the hospital who requires more than
the usual attention. He makes many unreasonable demands, confronts
nursing staff, insults the resident, and makes life miserable for them,
including the orderlies and janitors. Dr. Angelica Amora and the
whole nursing ward staff tried their best to provide a lenient and high
level professional care for him but increasingly found themselves
tempted to do the minimum necessary. They, after all, are humans
who have limited level of tolerance. And they also want to be treated
with dignity. They want to discharge him as he is beyond tolerable
management. They further argue that the hospital is a place for those
who wish to comply with the policies so that treatment becomes
effective.
1. Is it ethical to discharge Mr. Cabago for his actuations?
Justify.
2. Should health professionals be entitled to courteous
behavior by patients?
3. Should patient-doctor relationship demand tolerance even to
the point of being insulted ourselves so that the relationship may be
maintained?
4. What measures should be taken to handle well the said
loathsome patient?
B. The Patient and the Health Provider
Mrs. M. Perez and Nurse Almirah have become friends after a
month long hospitalization of the former. Mrs. M. Perez became
close to Nurse Almirah due to her caring attitude. The patient
sometimes gifted the nurse with anything as a sign of her gratitude.
She was in fact very generous to her. Soon Nurse Almirah would
borrow some money from Mrs. M. Perez for her immediate needs.
She would return the amount when she received her salary. Later,
Nurse Almirah would borrow bigger amounts which had made it
difficult for her to pay back. Mrs. M. Perez never complained to the
hospital authorities. But the modus operandi of Nurse Almirah was
known to all the nursing staff in the ward.
1. Should any relationship between a patient and health
provider be made under the limits of professionalism? Should
friendship between them be “outlawed” in health care?
2. Does borrowing money from the patient have to be treated
as inappropriate?
3. Suppose the nurse pays the money back, should it still be an
ethical issue?
C. Conflict of Interest?
Dr. Senen Conde convinced his doctor colleagues to invest in
his ambitious plan to build a tertiary hospital and once erected, they
could practice there with great privileges, like free parking fee, free
clinic rent and a promise of a double take or dividend on their
investment after five years. After receiving five hundred thousand
pesos each from the investor-doctors, Dr. Conde collected the amount
of P28M and promised them that in five years the building would be
completed. Now, after twenty-years, not even a single pillar had been
put up. The doctors were very mad at him but could not complain as
he was the President of the hospital where they all work at present. In
the meantime, relationship has gone so sour that the investors want a
refund of their contribution. Dr. Conde explained that the investment
was bad and that a substantial amount of money was lost from initial
undertakings. But Dr. Conde could not produce any accounting of the
loss and neither the expenses. Mulling lawsuit against Dr. Conde is
now in the initial plans of the doctor-investors.
1. Do you see any conflict of interest on the part of Dr. Senen
Conde who is building another hospital while serving as a President
of a present hospital?
2. Does Dr. Senen Conde deserve to be hurled into the court
for not making good on his promise to build a hospital?
3. Is it ethical for the doctors to be refunded of their
investment?
d. What suggestion can you give to repair a badly damaged
relationship between Dr. Senen Conde and the doctor-in

Chapter 21
Then you will again discern
between the just and the wicked;
between him who serves God,
and him who does not serve Him.
Mal. 3:18

THE PRINCIPLE OF MORAL DISCERNMENT

AND ITS CONSEQUENT MORAL COURAGE

T he discussion of the Principle of Moral Discernment could

have been done right after the discussion of the Principle
of Well-formed Conscience in Chapter 2 (ad supra) under
the Fundamental Concepts of Bioethics. This chapter was placed
here for the simple reason that though discernment is natural for any
moral person, he can exercise or use well this principle when he has at
least significant knowledge or has been initiated into the said basic
principles as discussed above. After acquiring this knowledge of the
various principles discussed above, it is therefore logical that this
principle be placed much later and be where it is now. Nevertheless,
there is nothing wrong if this is placed under Chapter 2.
The Nature of the Principle of Moral Discernment. Moral
discernment is inherently present in all humans because they are all
capable of rational comprehension and analysis. This means
therefore that human nature has gifted them with a capacity to judge
actions to be right or wrong although such judgment may initially be
primitive or flawed. This shows that as humans we are naturally
capable of knowing and possessing a sense of right and wrong.
Education to reason and faith however is necessary in order to perfect
that sense of right and wrong and make judgment on actions that are
either good or evil. This is called Moral Discernment. It is the
capacity of every person to make (almost naturally) a rational
judgment on actions that are essentially moral or ethical in nature and
distinguish them from the immoral or unethical. It is an act of
conscientious decision in matters that relate

to moral
actions. This so-called moral discernment is like a “sensus fidei” in
dogmatic theology that is present in him like a natural quality inherent
in his judgment. No matter how untrained or uneducated a person is,
he possesses that capacity to discern what is right or wrong, although
such discernment can be at times deficient or incipient. This is so
because a person is a moral being and can make prudential judgment
no matter how imperfect. This discernment however can be obscured
and confused due to continuous ignorance brought about by a flawed
culture, wrong beliefs or incorrect education perpetrated by the
society where he belongs, as in the case of continuous brainwashing
upon humans which are not ethically based. Fortunately, as can be
observed even in the midst of these flaws, a person continues to
question existing paradigms in his mind or in the society until he
finds enlightenment and is able to distinguish what is right from
wrong and vice-versa. This is moral discernment at work. When a
person is able to make discernments and distinguish right from wrong
even in an uninitiated state of a human, yet the more he is able to do a
better judgment when initiated into the science of ethics or morals.
Evidently, there is in every person an immediate or mediate sense of
right and wrong in the perception he makes where ethical
circumstance is present. Whether or not he makes clear judgment
upon such ethical condition, the fact remains that he is aware that
something is right or wrong. This becomes even clear when the acts
done are obviously repugnant. Herein lies a distinct wisdom of moral
perception present among men, called the Wisdom of Repugnance.
It is no wonder that even primitive people who have not been
initiated into modern civilization or education, have always their own
distinct sense of right and wrong, and therefore a sense of morality.
This sense may not be as advanced, extensive or deep, but their
human nature, which is good in itself, possesses an inherent judgment
on what is good, different from what is evil. Human nature is
naturally capable of goodness because its Creator is good and
therefore its creation is naturally good. Thus, it naturally recognizes
good as distinct from evil, inasmuch as the latter is radically and
diametrically opposite to an essentially good attribute.
Corollary to moral discernment is the concept of moral
courage. It is creditable that a person with moral discernment must in
the process necessarily lead himself to concretize moral courage.
Courage is a virtue by which one is able to overcome or confront
evil, danger or fear when something should necessarily be done or
undone. In a more distinctive manner, moral courage is a virtue by
which one takes action for moral reasons despite the risk of adverse
consequences. It is a virtue that is required when one has doubts or
fears about the impending consequences. This virtue involves
deliberation or careful thought. This is a virtue that doctors or health
professionals should hold onto when facing some moral good that
must be done or moral evil that must be avoided in the practice of
one’s profession.
Making Conscientious Moral Discernment. The Principle of
Moral Discernment maintains that a person, being a moral being and
possessing inherent moral goodness can make conscientious decisions
in favor of moral truth. But to make conscientious ethical
discernment, one must necessarily consider doing the following: (see
also. Ashley and O’Rourke, 2002)
1. Start in a prayerful and insightful attitude/manner.
Any honest-to-goodness intent of pursuing a morally discerning mind
or spirit must first be characterized by a prayerful and insightful
attitude/manner since prayer makes one person honest with God and
himself. One cannot lie to God and self. In prayer, a person becomes
humble before God, who is a “mysterium tremendum” (great
mystery) and an all knowing Superior Being. In prayer he becomes
conscious of his humble condition as a creature and is but a recipient
of the goodness of truth. When one sets this up as a pre-condition,
then it is easy to make insights about the things he personally or
collectively experiences and makes truth as a friendly object and thus
easy to grasp. In this context, one can also easily discern that an act is
either good or bad, or reasonable or not. “An unreflective life is not
worth living,” said the Greek philosopher Socrates.

2. Make a
fundamental and honest commitment to God and to the dignity of
persons, including oneself. Any health professional must subscribe
to values that must not only be human but transcendentally good or
right. These values can guide his imperfect judgment and actions,
while being enlightened. These can also dispel any personal interests
by the health professional and only that of God’s and the patients’.
Such values must serve as his first and foremost paradigm through
which he commits his judgments and actions. An overriding sense of
responsibility before God must be committed in favor of the patient.
This means that a surgeon, for instance, must consider other
alternative ways of treating the patient’s condition with minimal risks,
like non-invasive therapies (if it so warrants), and exclude those
which are highly risky, ineffective and even experimental. The
patient’s dignity, rights and informed consent must always be taken
into consideration as non-negotiable as his other human basic needs.
The Principles of Beneficence and Non-maleficence are truly good
guides that must pervade in all the stages of medical care.
The first and foremost commitment that any health
professional can emulate is the love for those who suffer due to pain
and poor health conditions. This is in imitation of Christ’s
commitment to the sick and the sinners for whom he offered his life
even without expecting anything in return “for greater love no one has
than to lay down his life for his friends.” (Jn. 15:13)
3. Among possible options/actions that can promote that
commitment should exclude those which are intrinsically evil.
Any medical or surgical procedures must pass the test of
goodness/rightness or indifference of the so-called, object of the act,
to make the procedure essentially ethically acceptable. Thus, any
decision or action must have that quality that should promote one’s
commitment to the source of goodness, even as it should promote the
goodness of the patient. Direct abortion therefore cannot pass that
gauge of goodness since this procedure is intrinsically contradictory
to one’s commitment to God and the right of the unborn baby who is
essentially a human person. The same can be said of transsexual
surgery. It is also violative of the person’s dignity and is
contradictory to nature. For in this procedure, one has to violate
him/herself before the procedure is performed. When such happens, a
flawed action is carried to the end and it will be concluded to be
wrong. Intrinsically evil actions can never be morally right.
4. Consider how one’s motives and other circumstances
may contribute to or nullify the effectiveness of the other possible
actions as means to fulfill one’s fundamental commitment. Clarity
of intention of every health care professional must distinguish him
from other professions, like business, whose main motive may be
profit (or fame). This is so because the profession of doctors or
nurses is characterized by nobility and altruism. Thus, every health
professional must conscientiously consider the good of the patient
entrusted to him to the point of even waiving his own interest so that
this would not cloud his intention that advances any form of
selfishness. Thus, the health professional must remove any personal
aggrandizement like financial gain, fame or anything that may
prejudice or compromise the whole credibility of the medical
profession. Lastly, he must always work for the optimum benefit of
the patient and chose only those which will most likely favor the latter
in his health condition as a person. It must be remembered that
motivation in view of selfish interest can invalidate any noble act
done in the health profession. Such should take secondary or even
tertiary role in the list of one’s concerns.
5. Among the possible means not excluded or nullified,
select one most likely to fulfill that commitment and act on it. The
medical profession is a moral enterprise. Thus, every medical act is a
moral act. And in all medical decisions there are options that one can
choose from (good or evil). This can be gleaned from the fact that in
medical practice, there is not a single disease or diagnosis that entails
only a single therapy. There are certainly multiple therapies that one
can chose from to approach the disease effectively. Among these,
one can choose a therapy that can be utilized as the best approach to
cure the disease. Therefore, since there are multiple means that one
can choose from to best treat the disease, one should only choose that
which can most likely fulfill one’s commitment to God and patients.
Imperatively, every health professional must engage in continuous
medical education as a matter of duty. This will ensure better and
quality health care.
For instance, there are various ways to remove a
kidney stone depending on the facts known about the diagnosis. If
guaranteed, one can use the medical means, the percutaneous
procedure, the laser procedure or the electro-shockwave lithotripsy
(ESWL) or the surgical procedure. Every procedure has ethical
implications. Considering the length of recovery, the financial
implications, the ease by which these are done and the effectiveness
they are expected to deliver, one must consider only that which will
achieve the maximum benefit for the patient while fully aware of his
needs and dignity and his/her capacity to afford. If not, the Principle
of Subsidiarity must be invoked.

Case Studies:
A. The Canister Scandal
A surgery has been performed in a government hospital in the
southern part of the Philippines, to remove a perfume canister lodged
inside the rectum of a gay florist following a bout of kinky anal sex
with a stranger sex partner. “A group of doctors, nurses and other
medical personnel took part in a controversial procedure. The
procedure sparked howls of protest when an amateur video
photographer took a footage of the operation through his video
capable cellular phone and posted on social media website, showing
what appeared to be doctors, nurses and other medical personnel
screaming, shouting and otherwise teasing and humiliating the
patient, particularly after the aberrant object was successfully
removed from his rectum,” according to a news item. The health
personnel defended themselves by saying that the screaming was only
a demonstration of relief after they successfully removed the object.
The issue therefore was not the fact that they screamed but the
uploading of the video footage without the permission of the patient.
Some moralists said that the issue is not only a violation of
confidentiality in health care but also first and foremost the gay sex
performed by the patient. Meanwhile, it was reported that the patient
planned to sue the hospital, doctors, nurses and other health personnel
for violating his right to privacy and confidentiality.
1. What are the ethical issues in the case? Why are they
considered ethical issues?
2. Why do you think there was almost immediate uproar and
complaints by the people who knew about the ethical problem in the
newspaper? What ethical principle can be applied about their reaction
to the ethical issue?
3. What ethical actions can you do to prevent a similar case
from happening in a health care setting?
4. What ethical principle/s is/are considered to have been
breached in the case? Explain.
B. Male is Better in One-child-policy
For decades in China, couples are obliged as a rule to follow
the one-child-policy. Any violation or breach is dealt with the full
force of the law. When a mother is caught having a second
pregnancy, she has to suffer the consequences of her acts. Sometimes,
the couples are forced to hide from the law and would choose to have
a private delivery which leads to having “illegal” children. Since, the
law about one-child policy is very stringent, the couples are obliged to
have only a child and would usually and culturally choose a boy over
baby girl. As a result, today, there are twenty-five million more
males than females in the population of China. Thus the sex
population ratio of 1:1 has become markedly imbalanced.
1. Under the concept of the principle of moral discernment,
what are the ethical issues that can be gleaned from the case?
2. Why are they ethically unacceptable?
3. What other ethical principles have been breached under the
one-child-policy and their consequences? Explain.
C. Women, the Lesser Creatures
In many rural places in some conservative countries, the
usually biased belief against women is still held to this day. When a
woman is caught in adultery, she is supposed to die by stoning. When
a woman is raped, she is considered an embarrassment to the family
and community and is usually discriminated against and sometimes
encouraged to commit suicide or subject to “honor killing.”
Moreover, the women’s place is the home to take care of children and
serve the husband’s needs. They are discouraged to pursue higher
education. Thus, women are treated like second class citizens and
maids. They are also prohibited from occupying the same status as
men.
1. Under the principle of moral discernment, what are the
ethical issues that can be drawn from the case?
2. Why are they unacceptable under ethical principles? What
are the ethical principles that are violated by the belief and practice
mentioned above?
3. What can be done to alleviate the second class treatment of
the women in these countries?
D. Equality under the Law
In many western countries, like Canada, USA and Spain laws
have been passed that recognize the equality of sexes of men and
women. These laws have been interpreted liberally to give men and
women the freedom to marry or be married. Thus a man can marry
a woman and such marriage is protected and defended by the
countries’ constitutions or current laws. By extension however, that
law, according to the liberal thinkers, should also give right for
anyone to contract same sex marriage. Accordingly, since their
sexual orientation is naturally led to the same sex relationship as they
allege, then contracting marriage with whomever they feel in love
with cannot be restrained further asserting that every citizen can
exercise freedom to marry. If they cannot have children, then they
can legally adopt. If none, their pets can be treated as members of
their family and be given equal social and legal rights before the law.
Some conservatives argue that giving gays the right to contract same
sex marriage under the right to freedom is an outright abuse of said
freedom and contrary to natural law. Moreover, said exercise only
subscribes to the concept that there is such a thing as absolute
freedom. The conservatives further argue by saying that “if they will
be given the right to exercise it, what would stop them from marrying
animals later?”
1. From the point of view of moral discernment, what are the
ethical issues in this complex case?
2. Should legalizing same sex marriage be equated to a moral
act? Explain.
3. How do you argue against same sex marriage?
4. What are the ethical principles that you can use to explain
the moral acceptability or non-acceptability of the practice? Which
among them is the best ethical argument?
5. What can you say about the thoughts like, “if they will be
given the right to exercise it, what would stop them from marrying
animals later and have their pets considered children?” Elaborate.
E. The Safely Recognized Universal Precaution
Many healthcare providers wish to gain further information
about patients nowadays, such as their HIV status or COVID-19
infection, to protect themselves from contamination. This is mostly
true when they handle surgical or ICU patients. Dr. Asencion and
nurse Assumpta agree with the above plan to be made into a policy by
the hospital. Others argue that consistent and strict observance of
universal precautions that they have been taught should assure them
of maximum realistic safety.
1. Is there something ethically wrong about asking patients
about their HIV infection/non-infection status? How?
2. Are the doctors and nurse mentioned above morally
discerning when they agree to ask patients about their HIV status?
3. Is it an invasion of the patients’ privacy to ask them to
disclose their HIV status? Is there anything that they would lose if
disclosure is forced upon them?
d. Is the so-called universal precaution 100% effective, as
experience will tell? Any comment.
 collectors.com

Chapter 22
Rejoice with those who rejoice,
weep with those who weep.
Have the same regard for one another;
do not be haughty but associate with the lowly;
do not be wise in your own estimation.
Rom. 12:15-16

RIGHTS, HUMAN RIGHTS, PATIENT RIGHTS

AND PHYSICIAN RIGHTS
le our concern in this chapter is to have a good and basic
W hi knowledge and understanding of the concept of patient
right, it is good to first make a brief discussion of the
concept of human right under a general understanding.
 The Concept of Human Right.

In a loose
sense, the concept of right connotes something which is straight,
unbent or rectified in contrast to what is wrong, i.e., crooked,
distorted or twisted. Thus, in humans, a right action is that which
passes a standard or norm of goodness or morality, and a wrong
action is that which deviates from such standard or norm.
Objectively, the term, right means in Ethics what is just,
reasonable, what is due, what ought to be, or what is justifiable.
Thus, right in this context is the object of Justice. What is right is
what is due as belonging to the claimer of such due.
Subjectively, the term, right refers to a moral power or claim
to do, to possess or receive from others as belonging or due to a moral
agent. This claim is based on various sources or foundations as will
be discussed in the next section of this Chapter.
What we call as human right therefore is a moral claim over
something that has basis in the nature of a man as man that is, his
being a rational being called to pursue a higher vocation. Simply, a
human right is what is due to a person who has a moral claim over
something that belongs to a human person that helps him to live a life
of decency or dignity. The various hierarchical needs mentioned by
Abraham H. Maslow are concrete objects of human rights that belong
to this category of human needs.
An Objective Understanding of Human Right. Manlangit, a
bioethicist (2004) asserted that the understanding of the concept of
human is closely connected with an understanding of the natural,
innate or fundamental goods or needs that essentially belong to the
nature of human life. These so-called innate, natural or fundamental
goods or needs are those which our instincts and powers are naturally
and essentially directed to or inclined to pursue. This term, human
right, therefore, is correlative with these so-called needs or goods. It
is a claim to these goods. If a human being possesses natural, innate
or fundamental goods or needs, then it is but logical that he should
possess corresponding rights by which to pursue or achieve them.
These needs or goods, as we know are aplenty, because human beings
are complex beings, whose needs emanate from their physical,
emotional, social, moral and the spiritual nature. Preservation of life,
forming communities, bearing offspring, pursuing knowledge or
achieving some goals are some of the goods and needs that are
closely attendant to these so-called human rights. Pursuit of these
human rights is a logical affirmation of one’s innate worth or value
called human dignity which certainly cannot be over emphasized.
Fr. O’Rourke (2002), a bioethicist observed that:
Each innate and fundamental good has other
goods closely allied with it. As we seek to generate
and educate children, the necessity of monogamous
relationship becomes evident. As we seek to acquire
knowledge and wisdom, we realize that study,
reflection and research become evident and
necessary human goods. As we seek wholeness and
health, we realize that medicine is a necessity.
Hence, an analysis of fundamental human goods
reveals that there are several goods that are also
considered to be fundamental or basic.
Moreover, through the years there is a realization that
knowledge is a fundamental good because it is necessary to pursue
the well-being of individuals and human communities. Many
centuries ago, a great number of people could acquire the knowledge
necessary to live a healthy and fulfilled life without going to school.
But as life became more complicated and more knowledge was
needed to survive and thrive, society realized that well-being and
health can best be achieved through schooling, education and
research. In time, schooling and education became a basic need, and
now society agrees that there is a right to education for all.
It must be well noted that Fr. O’Rourke pursued further that
the first implication of the term, human right is that persons have a
relationship toward a good which is fundamental that is, toward a
good which is essentially connected with leading a good and fulfilled
life. Of course, we also use the word “right” to connote a relationship
to a good which is not fundamental---for example, the right to have a
car or a piece of jewelry. But because these goods do not pertain
essentially to human well-being, this type of right is not included in
the term, “human rights.” Probably, to human wants or delights.
Thus, the term, human right implies a relationship or natural
orientation to a fundamental good, a good that without which, one
cannot live or survive as a human being. Take note of these
fundamental needs as purported by Abraham H. Maslow and St.
Thomas Aquinas (in Chaps. 5 & 8, ad supra).

This
proposition about human rights implies the following:
 1. that human beings strive to acquire these fundamental
goods;
2. that persons should not be impeded by others in their quest
for these goods; and
3. that if one cannot strive to achieve these fundamental goods
through personal efforts, then the community of persons should help
in this endeavor. The Principle of Solidarity must be exercised here
as earlier mentioned in the Chapter 18.
The Moral Bases of Human Right. For any human right to be
effectively exercised and claimed, a firm moral basis or bases must be
laid down, and if not fulfilled, may only result into chaos and conflict
in the community. It is assumed that in one’s claim to a human right,
a person is the subject vested with the moral power to do, to possess
or exact something as his own. Only human beings are capable of
rights. Animals are incapable of such rights because they are
incapable of fulfilling duties that are attendant to the rights, which are
the properties inherent in man. “Whoever kills a dog,” asserted
Panizo (1964), does not violate the right of an animal but the property
rights of the owner of the animal (either the person’s or the state’s).
If all actions that lead to the killing of animals are against rights, then,
humans do not have the right to kill them even if they have to be used
as meat for food. However, a man who is cruel to animals offends his
own reason which forbids him from inflicting needless pain upon
irrational animals. Thus, only sinister actions that lead to the
suffering against animals are immoral and must be condemned.
Further, we note that the object of a (moral) right is the claim
by a person considered to possess it. Now, the title of a right is the
foundation upon which the right is based so that the person has the
power to exact something as his own. And the term of a right is the
person or entity from whom/which is found the duty attendant to give
that right.
The following are the bases of human right/s:
1. The Divine or Eternal Law. This is the very basis of all
laws as this law is the divine will or order that commands that the
natural order of things be preserved in the universe and forbidding its
disturbance. Its lawgiver is God who in his wisdom knows in eternity
all actions and movements that will lead to the good and perfection of
created beings. From this law comes not only those that govern the
universe in all its physical order, but also the rights of individuals to
pursue a transcendent good which is his union with his Creator. A
very basic right that is included in this law is one’s right to human
dignity. Included in this law are the ten commandments that are
essentially ethical.
2. Natural Law. This concept has already been discussed in
Chapter 2 and thus, this section will not discuss it at length. Natural
law is the first and foremost law in which all human beings are
subject to since its contents are recognizable, universal, obligatory
and immutable or unchanging. This law embraces divine wisdom
with regard to the way human beings ought to live his life. It directs
rational creatures and irrational creatures to their proper ends. In
human beings, this is called natural moral law that is founded or
based on man’s nature. It is the sum total of human beings’
obligations, consisting of the imperative proposition or precepts of
reason on things and actions that are intrinsically good or bad,
ordained to the common good of the natural perfection of man,
legislated by an all-knowing Supreme Ruler, God and a God of
nature.
 Human beings
only need education to it, in order that these characteristics or
qualities of natural law may be applied. Foremost among the
specifics of this law is the right to life and human dignity. Natural
law lays down the fundamental rights of every person that are
inviolable, like the right to life or the right to education.
3. Constitution of the Land. Every country has a constitution
which serves as its over-arching law and backbone by which it
pursues its collective good. As known, the constitution is the
supreme law and is the fundamental reference in which all laws must
be implemented. In the constitution are found the bill of rights of the
citizens, and how they should conduct themselves as law-abiding
constituents. There certainly are specific laws that suit the particular
and distinct culture, milieu, traditions and customs of a people. The
constitution spells out their obligations as subjects of rights, basically
a right to life, including but not limited to right to education, right to
health care, right to decent wages or right to have a family. A caveat
must be remembered, that the Constitution as moral bases of law must
in itself be morally sound.
4. Human Positive Laws. These are specific laws that are
applied to specific situations which are criminal, civil or
administrative in nature. These laws promote the application of
natural law. These are ordinances of reason for the common good of
humanity, promulgated by one who has a care for the human society.
They involve obligations, not merely counsel, based on some insights
of reason into what will perfect the human society. As human
positive laws, they are results of some positive acts of legislations
which essentially appear to cover the global community, and applied
in various ways within each nation and are invested in their civil
laws. When not abided with, forceful and appropriate punishments
are applied with.
The corresponding liabilities by the constituents are dealt with
or meted out depending on how the courts of law make jurisprudence
of legal cases. In these laws are spelled out those rights of an
individual or entities in order for individuals and societies to live in a
peaceful and orderly manner. Whatever conflicts that may arise are
resolved by way of various litigations in the legal courts, although it
is better to settle them through ethical undertakings. These human
positive laws have a way of meting out penalties upon those who
violate them or giving reward to those who are found to be law-
abiding or whose rights have been violated.
5. Entitlements and Privileges. These are endowments given
or offered by generous fellowmen or legitimate donors through their
generosity or goodwill. When these endowments possess moral
goodness, they have the force of law and morality in such a way that
those given a claim over them can demand attendant respect by
others. Such endowments are called entitlement or privileges and can
be withdrawn when provisions or conditions for their enjoyment and
utilization are breached. But for as long as they are faithfully
complied with, the subject has a right over them. An example is the
right to health care discounts given to senior citizens or indigent
families’ zero balance provided for by legislations and the Philippine
Health Insurance Corporation. Similar entitlements or privileges are
also given by Health Insurance Organizations (HMO’s) upon those
who are legitimately enrolled in them.
It must be noted that when these so-called rights are not well
grounded on eternal and natural law, they may be illicit and any claim
on them may be ethically unacceptable. Any law of the land is based
essentially on these two laws.
The Right to Life. The right to life is the most fundamental right
that any human person can claim as it is the most ethically grounded
right. This right has for its basis the fact that it is a gift from the
Creator and an attendant obligation must be in place so that it is
protected from undue harm, defended vigorously from destructive
elements, its potentialities promoted and developed to fullness, until it
achieves its ultimate destiny. Man, therefore, has an attendant
obligation to give it a just stewardship as this is his well-defined and
uncompromising response to the Creator for accepting it.
The right to life is inviolable and any violation against it is of
utmost gravity, since it is of the highest value one can ever possess. It
is for this reason that all laws have been legislated to either directly or
indirectly promote and protect it. Even the mere act of risking life
unnecessarily is in itself a disservice to it and must be avoided as a
travesty of an inherent respect due to it.
The right to life is not only an attribute accorded to adults but
more so to the very vulnerable members of the human community,
especially the unborn. For the unborn already bears with it the nature
of a rational human and therefore deserving the same treatment as
their older counterparts. It is therefore within the domain of Bioethics
that all human life deserves protection and defense in all its stages of
development, that is, from womb to the tomb. Hence, in all stages of
development of a human being, such right exists and must be
respected with audacity.
The “Right to Die”. While it is a truism that every person has a right
to life, a question may be asked, “Is there also a right to die?” While
some may claim such right, the truth is, there is none. In the first
place, life is a gift from the Creator and no person can claim absolute
stewardship on it. Absolute stewardship can only be reposed on the
Creator since He is the one responsible for its existence. That being
so, He is also the One who has the absolute responsibility to take it
away. “The Lord gives, the Lord takes away.” (Job 1:21).
 If man is
given the distinct right to exercise an absolute stewardship over life,
then he must also be given the absolute right to exercise acts that may
be prejudicial and inimical to it without accountability. But this is
preposterous. Man’s stewardship is only a shared stewardship and
never an absolute one. He cannot do any act that can lead to undue
destruction of life. Man therefore, cannot be an absolute presider of
life as to commit suicide, homicide or murder as he pleases.
Further, if “right to die” is a right at all, then there is a
corresponding obligation on others to respect it. Incidentally, if one
wants to die and asks someone to kill him, then the other person
should better do it as a matter of obligation. If he does not do it, then
he can be penalized for not doing it under the obligatory force of a
right that must be respected. This is utterly ridiculous. To conclude,
while there is a right to life, there is no such thing as a “right to die.”
The Patient Rights. Patient rights are rights of health seekers to
fundamental goods or needs that contribute to their health or well-
being. Access to health care and other support systems, including but
not limited to medicines, equipment, facilities, medical supplies and
health experts that help promote one’s well-being are subject of
patient rights. These rights properly refer to those claims that patients
may demand in order to promote their natural striving or advancement
to health for as long as they are essentially life saving.
Respect for patient rights is respect for the intrinsic value of
each person. These rights include those that ensure equality, equity,
fairness, and justice to reduce disparities and promote respect for
differences in beliefs, culture, ethnicity, sex and the like. Thus,
patient right is an entitlement for one’s humanity rather than it being a
privilege. It is not charity. It is borne out of one’s natural striving to
enjoy health and life.
Categories/Modes of Patient Rights. There are several rights that
relate to patients, but for purposes of brevity, these have been reduced
to classify them under five main categories/modes, and each of which
is buttressed and guided by several bioethical principles. These rights
are the following:
1. The Right to Preservation of Bodily Integrity and
Totality. This right is an essential claim to bodily (and spiritual
wholeness). Consequently, none of the bodily tissues or organs can
be sacrificed unless they are for the benefit of the whole person or the
preservation of one’s life. This includes access to medical and
surgical procedures that are life-saving, including food, oxygen or
water, or medicines that help contribute to one’s bodily integrity.
Herein, the bioethical principles of human dignity, totality, double-
effect, organ donation and the concepts of innate physiological goods
must be considered. The principles of justice and solidarity are
applicable to this right. This right precludes euthanasia or patient-
assisted suicide and abortion, since they are diametrically
contradictory to the above principles.
2. The Right to Adequate Health Care. A patient as a
person has a right befitting a human being and should be accorded
with the following: (1) Considerate, respectful and compassionate
care; (2) reasonable continuity of care; and (3) reasonable response
time for his/her request for service, especially emergency care,
regardless of any discriminating circumstance, like race, religion,
color or economic status. This right includes the patient’s need for
any service that would make him feel comfortable for the duration of
his stay in a health care facility, such as familial and social support.
The right to adequate health care is in line with the principles of
justice and solidarity, and comfort care. This takes into account the
patient’s need for quality care that is safe, accessible, affordable,
effective and, above all, ethical.
 3. The Right to Information. This right is borne out of one’s
innate desire for truth. St. Thomas Aquinas speaks about this in no
uncertain terms. Hence, patients should never feel embarrassed to ask
questions that are important for their cure, like the doctor’s advice,
prescriptions, ill-effects of any medical procedure and the like. They
have a right to information necessary to enable them to make free and
informed consent prior to the start of a therapeutic regimen. If the
patients are unable to do this, health care professionals must take the
initiative to help them especially in their predicaments and fears.
Moreover, the patients have a right to know the name/s of persons
responsible for the administration of the procedures. Ghost surgeries
and anesthesiological procedures are ethically abhorred. Patients
must have access to their medical records. They have a right to obtain
information as to any relationship of his hospital to other health care
institutions insofar as their health is concerned. They can examine
and receive explanation of their hospital bills or any item thereof
regardless of source of payment. They have the right to know
existing hospital regulations and policies that apply to his conduct as
a patient. This right is guaranteed under the principles of free and
informed consent, professional and truthful communication and
disclosure of health condition.
4. The Right to Privacy and Confidentiality. As a sign of
respect to his dignity and freewill, a patient has a right to one’s
privacy and confidentiality. Presumed permission should be obtained
when procedures legitimately warrant waiving such principle. Case
discussions, consultations, examinations and treatments must be held
with beneficial care and should always be conducted with utmost
discretion and prudence. A patient’s health condition should never be
discussed along corridors or elevators within everyone’s hearing
distance. All of the communications pertaining to the patient’s
records or data must be treated in such a way that they do not reach
the hands of unauthorized persons. The principles of professionalism,
confidentiality and privacy must be always exercised in order to
maintain and gain the trust of every patient either in health
professionals or in the profession itself.
5. The Right to Self-determination. The right to self-
determination is called autonomy, (as explained in Chap. 14 ad
supra). It is a right to utilize, accept or refuse treatment as respect to
one’s freewill. This right however, is not absolute, as the patient may
demand for some particular procedures and the health care
professional may not always agree with him/her, as some acts may be
intrinsically evil. This right may include one’s demand for truth-
telling or disclosure of the diagnosis from the attending physician. Of
course, this does not include a demand for information as to when a
patient is going to die. As a matter of fact, there are no deadlines as
far as life expectancy is concerned. This right also includes refusal to
accept treatment contrary to one’s belief or culture. But such refusal
may as a consequence take its toll upon the patient himself, inasmuch
as he can be held culpable for the harm that may result therefrom. The
principle of patient autonomy is applicable to this particular right.
Corollary Concepts of Patient Rights. Patient rights are held as
authentic rights because health is a basic good. From the discussion
above, patient rights demand as their natural consequences the
following, namely:
1. Every person is obligated to respect and honor patient
rights. This respect and honor is an acknowledgment of every
person’s natural, innate and fundamental good. Such respect
ennobles one’s human dignity which is the most fundamental and
compelling reason for pursuing the right of every patient.
2. Every member of the human society especially a health care
giver must be an advocate of patient rights. To belong and to be
connected is a part of one’s natural longings and love needs. Patient
advocacy is required of a health care professional.
3. Although it will need some heroic efforts by all, we must
enable people to pursue health as a matter of right. Patient care is a
cooperative effort among the patient, care providers and society. But
the patient has the primary responsibility for his/her health. Patient
rights make this responsibility imperative and meaningful.
4. Pursuit and respect for patient rights is an act of solidarity
with the sick, who are actually “the poorest of the poor.”
A Tribute to the Patient. The following is an anonymous set of
insightful statements that have been crafted (with some improvements)
to give tribute to the sick person, the poorest of the poor in the
kingdom:
The patient is a person, not a statistic of just
an ailing body, organ or system.
He is the most important figure/character
in any health care setting.
He is not an interruption or interference
of our work – he is, in fact, the purpose of it, and
gives meaning and nobility to the health profession.
The patient is not an outsider of our day
to day operation; he is an insider and our
primary concern.
He has feelings, emotions, biases and
wants, and aspirations and dreams.
It is our distinct business to satisfy him.
If we do not take care of him, somebody
else will.
Above all, he is an instrument of our
salvation because he belongs to “the poorest of
the poor”, whom Christ identified himself
with and sacrificed for.
The Universal Patients’ Bill of Rights. A more specific articulation
of the patient’s bill of rights that is universally accepted in health care
follows:
1. The right to considerate and respectful care. The patient
has a right to personal dignity at all times. Among others, this
includes the right to be treated without discrimination based on race,
color, religion, national origin, ability to pay or source of payment.
2. The right to obtain from his physician complete current
information concerning his diagnosis, in a language he can
understand. This should include information about alternative
treatments and possible complications. He is entitled to this
information from his doctors, and the latter should not feel that the
patient is imposing when he asks a question, seeks explanation, or
asks for other information.
3. The right to obtain from his physician information
necessary for free and informed consent before any procedure or
treatment is begun. This can be accessed in Chap. 14, ad supra).

4. The right
to decide on proposed treatment. The patient has the right to life
and bodily integrity. This includes the patient’s right to refuse
treatment to the extent permitted by law and to be informed of the
medical consequences of his action.

5. The right to every consideration of his

privacy, concerning his medical care. This includes the right to
exclude from the hospital room and the examination anyone not
directly involved in care. When other persons need to be present,
especially by reason of medical education, the permission of the
patient should be sought.
6. The right to confidentiality of all communications and
records pertaining to him. When records of a patient are to be
turned over to other parties, such as in legal cases and under a
subpoena request, the patient should be informed of this immediately.
 7. The right to the best possible economical care and to
hospital management that operates efficiently and eliminates
wastes, such as unnecessary services and duplication of facilities
or procedures.
8. The right to obtain information concerning any
relationship of his hospital to other health services so far as his
care is concerned, and to the existence of any professional
relationships among individuals who are treating him.
9. The right to be advised if the hospital proposes to
engage in human experimentation or research that affects his
care and to refuse to participate in such research.
10. The right to reasonable continuity of care, including
post-discharge follow-up.
11. The right to examine and receive explanation of his/her
bill, including itemized charges. This information should be
readily available regardless of the patient’s source of payment.
12. The right to know hospital rules and regulations that
apply to his conduct as a patient.
The Rights of the Physician. It is well to note that while patients
have rights, the physicians have rights, too. After all, they also
belong to the human society, and by virtue of their professional nature
are also accorded rights as mentioned above. The following are some
of the basic rights of physicians:
1. To practice the medical profession, referrals and
anything attendant to his medical skill and knowledge. Due
process must be observed in case of malpractice charges against him
in accordance with current policies governing his practice.
2. To accept or refuse patients (except in emergency
cases). He has rights over patients as an admitting physician.
3. To therapeutic privileges according to his acquired
training and accredited by his workplace.
 4. To do clinical and scientific research, with prior
informed consent of subjects.
5. To practice his profession according to his religious and
moral beliefs.
6. To professional fees (except those which are prohibited by
virtue of outstanding policies, like those of colleagues in the
profession or of his children and spouses).
7. To legal representations in the courts of law when his
expert opinion is sought in order to serve the demands of justice.

Case Studies:
A. “I am Responsible for my Life”
Glenda S., 21-year-old single, is two months pregnant by her
boyfriend. She is a commercial model who sometimes appears on
TV to promote a skin whitening product. She believes that her
pregnancy was an accident because she does not have any plans yet to
be a mother or a wife. According to her, she is still too young to be
one. She decides to terminate her baby, firstly, because she is
unprepared for the role of a mother. Secondly, the baby is intruding
in her otherwise promising career. Thirdly, even if she proceeds with
her pregnancy, she believes she will not be able to take care of the
baby inasmuch as this task will take away a substantial chunk of her
time in her job. Fourthly, she also believes that she is the only one
responsible to freely care for her life and everything that happens to
it. Lastly, she believes that the baby is only a small part of her bodily
system and should not be unduly valued to exaggerated proportions.
1. What are the ethical issues that relate to patient rights in the
case?
2. Is Glenda’s sexual indiscretion with her boyfriend and later
her pregnancy allegedly brought unplanned matters which therefore
warrant termination? Elaborate.
3. Is pregnancy a disease to be cured through a surgical
procedure or not? Explain?
4. Are the reasons explaining Glenda’s decision to terminate
pregnancy ethically tenable? Was her issue too small that it should
not be exaggerated to undue proportions? Why?
5. What patient rights were violated in the case? Explain.
B. Disfigured and Consigned to Live in Isolation, Part I
In a remote town in France, Nicole R., a 40-year-old
housewife with three grown up children was attacked by the family’s
pet dog while feeding it and as a consequence suffered a badly
disfigured face. The left cheek’s flesh was dismembered thereby
exposing her cheek bones and teeth. The right cheek was badly
damaged, too, and the cheek bone was clearly visible. In the hospital
where she was being treated, she intimated that she wanted to die
since her condition was beyond repair and as such, would only
consign her at home and would prevent her from doing any job or
chores. She had difficulty in eating and had slowly become weak.
Meanwhile, her husband, 42 years-old, also agreed with her wish as
he could not bear seeing his wife in that situation. The only thing that
the doctor could do was to make temporary prosthetics, but this
would not really cure her. It would even expose her to infection.
The family wanted an expert ethical opinion.
1. Does the condition such as that of Nicole warrant an ethical
decision like wishing to die as shown in the case? Would the
‘helpless’ condition of Nicole be a good reason to wish to die, as her
case is therapeutically hopeless?
2. Is a request to die in this condition a part of patient right
since she cannot anymore serve the purpose of life?
c. What can be done ethically to resolve the difficult
condition of Nicole?
3. Can the government assume the right to make a decision in
her favor so she can die?
C. Disfigured and Wants to Live a Quality Life, Part II
 C. Oliveros is a 45-year-old married woman who was
suddenly attacked by their family’s pet, Doberman while feeding it.
Her face was badly disfigured at the side of her left eye. She and her
husband hoped that she could still live a quality life in spite of her
disfigurement and remain useful for her three young children. The
doctors suggested transplantation procedure that needed a large
amount of skin the same size as the half part of her face. Meanwhile
a cadaver donee was available. The procedure was successful even if
her face did not look much like her original countenance. She learned
later that for a transplantation to be legitimate, it must not radically
change the recipient’s personality. This was beginning to bother her
as the surgical result was life changing for her. She was constantly
haunted by the fact that she now looked a different C. Oliveros before
the incident happened.
1. Was there any ethical issue/s in the surgical procedure that
was done to her? Was patient right violated in the procedure?
2. Is it true that there is an ethical question over transplantation
procedures when the end result can radically change one’s
personality? Explain.
3. What must ethically be done to prevent C. Oliveros from
being bothered by the result of the surgical procedure?
D. Disfigured and Wants to Die, Part III
Richard E. is a 20-year-old graduate of a computer
programming course. He was regarded as a computer wizard. One
day he and his father went on vacation that entailed an eight-hour-
drive from the city to the province. Halfway through the travel, their
car’s engine over-heated and they stopped to check it. While opening
the hood, the engine suddenly exploded and Richard was suddenly
engulfed by the fire and as a consequence sustained a third degree
burn over 95% of his body. Both his eyes were miraculously saved
and were the only parts that remained intact. After a 48-hour difficult
surgical operation, the doctors told the family that his condition was
irreversible and that Richard would not be able to move normally,
except for his hands, and while wheelchair bound would have to be
fed intravenously throughout his life. He had to bear with constant
pain and must take strong dosages of pain killer every four hours to
make him comfortable. Richard wanted to die as he could not bear
the pain and suffering. He petitioned the court to euthanize him as
this would free him from the bodily and emotional pain. The court
decided contrary to his wish. In the meantime, he wanted to commit
suicide as it had already been three years that he suffered continuous
pain he did not deserve. Three years was enough for him to bear
everything and now he is questioning his faith in a good God.
1. In the case of Richard should the following be considered
part of his patient right, namely:
a. His petition to the court to euthanize him;
b. His plan of committing suicide due to the pain, he
continuously suffers; and
c. His attitude towards his faith in a good God
2. Do you think that Richard could have still fulfilled the
purpose of life under a very bad situation he was in? Elaborate.
3. What else was there to do ethically to help Richard in his
difficult predicament? Should death be a better option since he was
unable to fulfill his life’s purpose?
4. Will you agree with Richard if one day he decides not to
take any nutrition or hydration at all as a part of his right to
autonomy?
E. Brothers, Move over, We are too Crowded
A married American lady named Vicky T., has been married
for seven years and has not been blessed with even a single child.
With the consent of her husband, she decided to take fertility pills
with the hope that with that medical procedure she would bear a
baby. After taking the pills for fourteen months, she conceived and
was on the start of the second trimester. In her usual check-up with
her OB-Gyne and after an ultrasound procedure, her hope to have a
baby had risen to unprecedented proportions. She was told that she
was carrying seven babies in her womb. But soon her excitement
turned from ecstasy to gloom. According to her Ob-Gyne, she would
not be able to have all the babies delivered as the seven would stress
too much her uterus and this could be fatal to her and all the babies.
Therefore, three of the designated weak babies would have to be
removed before the end of the second trimester. Vicky T. got
confused and was in limbo. She wanted to be guided whether the
procedure was ethical or not. If so, any guilt feelings she felt would
be dissipated.
1. What are the patient right issues in the case?
2. Is it within her right as patient to know whether the
suggestion indicating the removal of three babies can be guaranteed
as legitimate? Explain.
3. What can be done to resolve the big dilemma in the case?
Defend your answer.
4. Can the babies invoke through their proxy guardians their
patient right to stay until delivery regardless of the consequences that
may happen later? Why?
 Willstreetden

Chapter 23
"Have nothing to do with the fruitless deeds of
darkness, but rather expose them.
Eph. 5:11

ABORTION AND ITS ETHICAL DIMENSION

bortion has been regarded as the most controversial and
A provocative issue in Bioethics, family, law and politics in both
local and international scenes. This issue has been subjected to
passionate debates in many legal and ethical fora around the world.
This is so because the issue at stake is not only human life, dignity
and rights but also the many underlying ramifications in human
affairs. The varied legislations in the west favoring abortion have
been causes for biting criticisms that usually lead to polarizations of
persons and civilization, as this issue is highly emotionally charged.
This should be one distinct reason why a rather lengthy discussion of
various topics and concepts related to abortion will be done in this
chapter.
Clarification of Terminologies. Abortion or abortion procedure has
various connotations when used depending on the ones who view it,
like WHO, DOH, pro-choice, pro-life, the legal view and the like.
Thus, abortion can be viewed to connote something based on the
opinion regarding its morality or immorality. A discussion below of
the various concepts and kinds of abortion may help in the
understanding of the concept.
1. Etymological Definition. Abortion comes from the Latin
verb “aborior”, “aboriri” and “abortus”. This term means to set, to
disappear, to fail, to perish by untimely birth. It refers therefore to an
act that has to do with ending a life span (especially of unborn babies)
before its full term. Technically, it is the termination of pregnancy,
whether intended or not, in any stage of the non-viability of the fetus.
This can happen by separating the living fetus from the uterus
(mechanical abortion), or by the dismemberment of the fetus
(embryotomy), or by the destruction of the fetal head to facilitate the
emptying of the uterus (craniotomy), or the removal of the non-viable
fetus from the extra-uterine site of the gestation process (termination
of ectopic pregnancy), or even the prevention of the implantation of
embryo into the uterus, i.e., by the use of abortifacient technologies,
like the morning-after pill RU-486 and many other pills at the market.

2.
Operational Definition of Abortion and Kinds of Abortion.
Abortion is either spontaneous or induced or direct. Spontaneous
abortion refers to the premature expulsion of the embryo brought
about by some natural causes (or artificial) and not by external agents,
such as the mother or other agents. This kind of abortion is
involuntary and unwilled by human agents. It is popularly known as
miscarriage due to some disease or illness, injury or disturbances in
the embryo itself or its environment. This kind of abortion also
includes the still birth, i.e., the baby was or may have been already
dead prior to its delivery.
Induced abortion (or direct) involves the expulsion or
destruction of a fetus by deliberate action done by a human agent. It
results in the death of the embryo in the uterus (and out of it---like
fertilized ova in petri dish) effected by various abortifacient
procedures that are mechanical (wire-coat hangers, umbrella ribs,
knitting needles), chemical (green soap, glycerine, uterine paste,
iodine potassium iodide, lead salts, kerosene, castor oil and purgative
irritants), pharmaceutical (morning-after pills, Norplants, RU-486,
etc.), herbal (plant components containing poisonous substances) or
even physical (resorting to excessive jumping, running or strenuous
exercises by a pregnant woman). Thus, induced abortion is voluntary
and willed by human agents.
There is also a kind of abortion which is termed as indirect.
This refers to a procedure in which a fetus is expelled secondary to a
primary act, like the therapeutic treatment of a woman’s diseased
uterus while pregnant, or surgical operation on ectopic pregnancy.
This kind of abortion is not considered a direct attack on the life of
the fetus and therefore permitted as a consequence of a good primary
act. The Principle of Double-effect may be applied here
In this book, abortion refers to induced/direct abortion, unless
otherwise stated.
Methods of Abortion. For the benefit of beginners and the
uninitiated, it is well to make a brief discussion about the methods of
abortion to introduce to them the complexities by which this
procedure is done. This procedure involves techniques used by either
doctors or non-doctors through which abortion is carried out, and
which may be done either in hospitals, abortion clinics or makeshift
backyard settings.
The following are the well-known medically utilized abortion
methods practiced in the hospitals and clinics, namely:
1. Dilatation and Curettage (D&C). This procedure is
employed for early pregnancy. Accordingly, this method dilates the
cervical cord or other means with a series of tapered rods and
scraping the inside of the uterus with a spoon-shaped instrument. The
surgeon must first paralyze the cervical muscle ring or womb opening
then slowly stretch it open. He then inserts the curettage, a loop-
shaped knife, up into the uterus. Then he cuts the placenta and the
baby into pieces and scrapes them out into a container.
2. Suction and Curettage (S&C). This is also used for the
early termination of pregnancy. It uses a specialized plastic tube
which is attached to a suction pump. This hollow plastic tube is
inserted into the uterus which fractures the fetus into pieces and then
cuts the placenta from the inner wall of the uterus called the
endometrium. The pump suctions the fractured fetus via the tube
through the strength of the vacuum.
3. Hysterectomy. This method is usually used during the late
pregnancy. It involves the surgical opening of the woman’s abdomen
and uterus whereby the baby is taken out and discarded.
 4.
Saline Induction or Salt Poisoning. This is used during late
pregnancy. It is the process of introducing a trans-abdominal intra-
amiotic instillation of hypertonic saline. The aim is to poison the
fetus. This entails the insertion of a needle through the abdominal
wall of the woman and into her uterine cavity, for the removal of the
fluid that encircles the fetus, and it is replaced with a concentrated
solution of salt water. Once the fetus is rendered dead, it is removed
and discarded.
5. Other Forms of Abortion. These other forms can include
the use of IUD as it functions to congest or obstruct a growing fetus
in the womb until it is finally expelled. The use of morning-after-pills
like RU-486 expels the embryo of up to fourteen days from the womb
since it is a poison embedded in the endometrium and thus, deprives
the embryo from attachment unto it. Other chemical or
pharmaceutical methods are also used to poison and kill the growing
fetus inside the woman’s womb. Some herbal medicines are also
used as they contain potent chemical poison to similarly kill the fetus
or other mechanical methods to eject the same growing fetus as is
feasibly doable.
A Brief History and Complexity of Abortion. Abortion is not a
modern phenomenon but considered a primitive practice for as long
as human societies and cultures can remember. It is believed to have
originated in China with the supposed use of mercury as an effective
method for inducing the termination of pregnancy especially in its
early stages. The Egyptians have also been known to have practiced
it as early as 1550 B.C. as can be gleaned from their papyrus writings
through a mixture of various primitive methods. Ancient Greeks,
through the writings of Plato in the Republic favored abortion for
eugenics purposes (to stave-off deformed children). Aristotle added
demographic motives (excess of population) aside from eugenics to
favor abortion. Hippocrates, for one though, did not approve and
consequently professed, “I will not give to any woman any
abortifacient drugs.”
Rome, too, accepted the practice of abortion which reached its
peak during the reign of King Caesar. Some women then favored its
practice for various reasons.
However, the Judeo-Christian belief vehemently disagrees
with the procedure because it upholds the sacredness of life and
regarded it as a Godless practice. This belief upholds that God is the
author of life and therefore every child whether in the womb or out, is
a gift.
Modern and western societies have slowly favored abortion
like the USA and in Europe and many other countries like China (due
to one-child policy) and/or for various reasons, from the legal,
technical, eugenic, demographical to practical motives. Due to its
widespread liberal practice based on legal grounds, close to 1.5
million babies and 1.2 million in the USA and Europe respectively,
have been killed annually since 1973, not to mention the abortion
cases in Asia and other continents. No wonder, USA and Europe are
becoming an old population due to negative fertility growth rate.
According to statistics, close to 67 million unborn babies have been
killed in USA since it has become legal.
Motivations for the Legalization of Abortion by Pro-Choice. To
know the motives of the Pro-choice in their drive to legalize abortion
is to know the problem in its ethical aspect. Unless we know their
motives, it would be difficult to respond to their rationalizations.
Knowing their motives would solve 50% of the argument in favor of
Pro-life. The arguments and explanations by Pro-choice in favor of
abortion are the following:
1. To safeguard the life of the mother. This occurs when
the mother who has a risky pregnancy or the so-called maternal and
fetal conflict due to some pathological disease or medical condition
can opt to have an abortion to allegedly safeguard her life. There
have been quite a number of diseases that seem to justify abortion like
cancer in the cervix or uterus, disease of the lungs, kidneys and
diabetes. The Pro-choice advocates believe that the health of the
mother is (more than) enough reason to favor her over the child that
poses a dilemma due to the fact that pregnancy makes the health
condition of the mother worse or risky or even fatal.
2. Abortion is a woman’s right. This position justifies the
practice of abortion by arguing that the fetus is but a part of the
woman’s body or just a mere product of conception. Further, as a
right, the woman must have control over everything that she bears in
her body and if there are disruptive occurrences that do make her
uncomfortable and inconvenient, she could invoke the right to
exercise autonomy to remove them, including the right to terminate
pregnancy. This right may include her right to privacy, as pregnancy
exposes her to public scrutiny, especially when pregnancy is
“unplanned” or borne out of wedlock.
This argument also includes the woman’s right to terminate
pregnancy if it is a result of violence like rape or incest. Since
violence against women must be stopped at all cost, there is an
obligation on the part of women to subdue an assaulting agent.
Pregnancy that results from such violence is a continued and
prolonged assault on their freedom and dignity and must therefore be
stopped.

3. Abortion is
an expression of woman’s sexual freedom. Sexuality and its
practice through sex acts are part and parcel of a woman’s attribute as
a sexual being. Thus, it is a part of her nature to engage in such acts
and enjoy the pleasure that is attendant to them. This does not
necessarily extend to the fruit/s of the act and thus can only end in the
sexual act itself if opted for. Further, since women are not second
class citizens and are equal with men, they must also be able to do
what men do. During their pregnancy, women are naturally
constrained to many limitations of activities which they can do
fruitfully when they are not. Men do not have this predicament. To
set an equal playing field with men, the liberationist women contend
that they are in a disadvantaged position when they are pregnant. So
abortion practice is an expression of woman’s sexual freedom.
Although women may not be opposed to motherhood, inasmuch as
their bodies are so constructed that they carry the burden of
reproductive task, yet they can insist on having the right to control
how and when their bodies will be used in this way. Thus,
termination of pregnancy is part of their right to sexual freedom
which the liberal feminists equate with reproductive rights. This
includes the use of contraceptive methods so that they can have full
control over such rights. And when contraceptive methods fail, they
can also resort, by choice, to abortion procedure.
4. The fetus is not human. The justification of abortion is
also grounded on the notion that a fetus does not have a human nature
and therefore is not considered a person per-se. It is just a growing
matter, a growing tissue, thus, it has neither human right nor a distinct
entity.
The advocates argue that the fetus is only a potential life and
maintain that this potential life does not become real and actual until
it comes to its delivery at birth. The personalization of the fetus
happens only when the parents accept it at birth.
Moreover, a person is one who exercises rational functions
and can claim rights. He must have a claim to rights, like, personal
autonomy, pursue perfection of moral and rational life, pursuit of
personal and eternal goods, bodily integrity, the right to marry and
establish a family or to associate as a social being, etc. These rights
cannot be claimed by an unborn fetus as he cannot function as a
human person. Neither can he possess a human nature inasmuch as
that so-called “nature” is absent in him since he is totally irrational in
that condition. To be human is to be able to actually function as a
rational being for a rational function is the real proof of humanity or
human nature.
5. The unwanted child syndrome. This argument is based on
the justification of abortion that treats children as burdens, and
therefore, unwanted and also as another mouth to feed. Convinced by
demographers like Robert Malthus and his protégés, they consider
children as nothing but liabilities and that a child or two will only
drain the resources of the couple or of the family.
This argument also includes those who consider the freedom
of single and uncommitted persons as a value that must be chosen for
its being a better alternative to live a full and independent life.
Moreover, it is better not to have children when one is not ready for
parenthood. Thus, when found pregnant one can opt for abortion, as
it is better not to have children when one knows he could not take
care of them or when he feels that the child will not be able to live a
normal and productive life.
6. To stave-off the birth of a potentially deformed child.
The eugenic motivation is the basis for the argument in favor of
abortion, especially the deformed and mentally handicapped child. It
would do service to parents and society if there were no defective
children, both physically or mentally, as the latter will require
ambulatory health services to take care of them and limit the
productivity of parents. The deformed children do not stand a chance
to live a fulfilled life in a highly competitive world. And the world
does not have all the time to offer compassionate care to them when
everyone has to struggle also and be tough to be able to survive.
Caring for them will drain so much of people’s time and energy that
could still be spent for bigger tasks. Handicapped children for them
are useless children and must be disposed of.
7. Abortion is a means of improving the quality of life.
Accordingly, abortion is justified as a way to eliminate poverty being
spread by the poor since they are the ones who multiply fast. Poor
people only beget more poor children. Thus poverty thrives among
the poor because they produce more children and consequently, the
quality of their life suffers the most. Poor families usually live in sub-
human conditions in squatter areas. They do not usually have gainful
employment, would beg for food to survive, or do anything illegal
just to have food even for the day. They usually are uneducated and
will most likely be in that situation until they die. Thus abortion
would ensure quality, as it will reduce poverty. Less poor people,
means better quality of life.
 8. Abortion as
a means of controlling the population. This argument is based on
the belief that the human species expands by leaps and bounds. This
has been grounded on the population theory advanced by Robert
Malthus and other pseudo-demographers (see section on the
Malthusian Theory on later pages). They believe that over-
population has been depleting the resources of the earth and when
unchecked would result into chaos and wars to fight for food. Thus,
over population invites only heightened scales of world tragedy. It
can only be controlled in an abrupt way through abortion. This is
being promoted by US National Security Agency until the 2020
timeframe.
9. The right to privacy. This right is well defended by pro-
choice advocates. It is a value that is high in the totem pole or scales
of values by western countries like USA or Europe. It is the argument
that got the nod of the Supreme Court of the USA in 1973 in the
famous case Roe vs. Wade. It is also an argument that subscribes to
the idea of “don’ mind me, mind your own business.” Hence, pro-
choice fights for this idea tooth and nail in the legal rather than in the
moral arena and they have been winning a lot of times because they
have been lobbying so strongly among politicians in the legislature
who would readily acquiesce to their whims and caprices.
Currently, abortion is considered as a method of “birth or
family planning around the world.” The majority of the delegates to
Cairo and Beijing conferences on population have been very vocal in
favor of abortion procedure as part of population control and as a
reproductive right of women, especially in third world countries.
Many reproductive rights advocate-legislators in the Philippines have
been crafting bills to pursue the practice of abortion and make it as a
means of population control, under the euphemism of patient rights,
women’s rights or reproductive rights like the House Bill #5043
advocated by pro-abortion congressmen and women. The
legislations began with the use of contraceptive methods, and when
these failed, abortion is now being pushed. Fortunately, in the
Philippines, abortion is a crime and prohibited under the Constitution.
Consequences of the Ideology of Abortion. Curiously, it is
laudable that we should have a good knowledge of the consequences
of the evil of abortion around the world based on the ideology that
supports its practice. Before we go to the actual consequences, we
will first brief ourselves by illustrating the numbers of deaths
sustained in various wars around the world. Statistics of these wars
would show below, as follows:

Figure 1.

Taking a cue from the table above, one can readily know
and understand the number of people that have been killed due to the
folly of wars around the world that have been waged and as known in
history. And what is not shown here are those who were injured
permanently or temporarily, lost limbs, properties destroyed, families
separated and health severely affected and many others. The table
shows that these wars took away 1,300,000 lives. This is why wars
are so wicked and ruthless. Figure 2 however below shows the lives
taken away due to very flawed ideology or politics.
Figure 2.

The unborn babies that have been killed after the horrid
1973 US Supreme Court decision to allow abortion are so staggering
that in just nine (9) years, 12 million innocent babies have been
slaughtered without impunity nor compunction. St. John Pope Paul II
has described abortion as an evil committed in the very sanctuary of
the home of unborn babies and is an “unspeakable crime” against the
very powerless members in the human society – so called crime
against humanity. The statistics alone are egregiously and wickedly
graphic. And this graphic rendition will certainly leave a bad taste
among decent human beings in human society. To date, around the
world, more than a hundred and twenty million innocent babies have
already been killed and counting.
Refutations of Abortion Arguments by Pro-Life. Just as there are
arguments in favor of abortion, there are also arguments to oppose
them. The Anti-choice (popularly called Pro-life) advocates
articulate the following vis-à-vis the opposite view of the Pro-choice,
namely:
 1.
(Against the first pro-abortionist argument) Focus on saving both
lives of mother and baby (case of Maternal-fetal conflicts). All
human life is valuable and cannot just be sacrificed for any reason.
Even in cases where in the physical and mental health of the mother is
at risk, abortion can never be an ethical choice since it is equated with
the killing or murdering of a person. The question should not revolve
around the flimsy or feeble choice between the mother and the baby
but rather should be focused on saving both lives, as is possible.
However, if the treatment of the mother consequently results in the
death of the fetus, abortion here is not directly intended but is only
accidental or indirectly willed. This surgical operation is ethically
accepted. What is not plausibly moral is the direct intention of killing
the baby. The ethical Principle of Double-effect can be invoked here
as a reasonable basis for the acceptance of an otherwise necessary
evil, so called in Ethics as ontic evil. The most frequently cited cases
here are the cancer of the uterus or cervix or the case of surgery on an
ectopic pregnancy.
Thus, induced or direct abortion is always ethically wrong as
this breaches the principle of human dignity and inviolability of
human life. Any direct attack on human life is always wrong, even if
baby’s life is still in its incipient state. If a simple slapping of another
person is unconscionable, how much more the fatal assault on an
unborn baby? Nevertheless, the mother’s life is equally valuable as
that of the unborn baby and vice-versa.
2. (Against the second pro-abortionist argument). A woman’s
right is never used to harm others. The Pro-choice argument here
is that a woman has a right to procure abortion because she is a victim
of rape or incest. To save a woman’s reputation and honor before a
condemning society, the only resolution is to abort the would-be child
in her womb. While it is true that a sperm of the man is an assaulting
or intruding agent in her body, it is likely to be morally acceptable to
contracept against these unjust agent(s) as an act of self-defense.
Nevertheless, a fetus though a product of violence, like incest or rape,
is a different entity that has a moral status and cannot anymore be
regarded as an assaulting or intruding agent.
Granting that a woman has been raped or gets to be a victim of
incestuous relationship, killing the fetus is committing another crime.
A crime can never be solved by another crime. Two wrongs do not
make one good. This is what happens in the practice of abortion on
babies borne out of rape or incest.
The best thing that a caring society can do is to be solicitous of
the predicament in which the woman and the baby find themselves in
order to restore their dignity even in the midst of the serious trauma
they may experience. Caring for another human being is in itself a
therapeutic means to be able to resolve a trauma one does not deserve
to have. It is never a right of the woman to destroy another,
especially an innocent life. The right to privacy is never a ground for
performing abortion or the destruction of another life, for life is of a
higher value than the mere privacy of the person. A human right is
always a positive notion and therefore can never be used to harm
others.
It is a fact that since the legalization of abortion in the world to
pursue reproductive freedom and control over their bodies, millions of
females ironically do not have control over their bodies. Since about
3 million aborted babies in the world, approximately one-half of these
are females whose lives have been taken by direct surgical abortion.
Thus, a female baby killed by abortion can no longer have a body or a
life and will never have the privilege of controlling one which the
pro-choice advocates vigorously pursue and it is ironic that they
cannot see this moral truth.
Margaret Sanger, the founder of the most scorned Planned
Parenthood, has always tied the abortion agenda with women’s rights
as well as eugenicist ideology. Accordingly, many have rebuked
Sanger for her erroneous stand because a pregnant woman can still
participate fully in the social and political life of the society. She may
want to change the society within the bounds of her rights, but this
does not include killing of babies. Here, therefore, if abortion is the
“guarantor of women’s rights”, can there be no women’s rights unless
there is a license to kill unborn children? This is a question that pro-
choice or abortion advocates must truly answer.

3. (Against the
third pro-abortionist argument). The woman’s sexual freedom does
not include that of the destruction of the fetus. Everyone must
enjoy freedom to its fullest. But freedom has limits when it adversely
affects others’ right to exercise their own freedom. While it is true
that women should be treated equally with men since both have the
same human dignity, it does not mean that they have more sexual
right than their counterpart. Women have been naturally and
biologically endowed with a structure for bearing children. But, the
fetus, while it is in their womb is dependent on that environment
endowed by nature to her. Yet, that fetus is never a part of the
woman’s body. By nature, the fetus owes its incipient life from the
mother. It is the natural right of the mother to protect her own
offspring. Even the animal world gives credence to this claim. The
destruction of an innocent life is a violation of the principle of
motherhood and an assault to the dignity of human life which regards
the womb as a sanctuary of life.
If during pregnancy, the mothers are subjected to many
limitations, it is because nature generously gives them the opportunity
and insight to be extra careful of the vulnerability and tenderness of a
new creature; they are the very natural agents enviably entrusted with
the distinct task of caring for the baby. Being able to care for the
baby is a remarkable opportunity and never to be seen as enslaving
and a sign of male domination and undue advantage over women.
Her femininity is properly a source of tenderness needed by the
fragile baby which is found wanting in the male counterpart. This
should not be seen as a weakness by women, nor should it be seen as
a prospect for men to take advantage of. That is why, abortion is not
truly an expression of women’s sexual freedom but a sign of women’s
arrogance over the innocent and a misplaced contention/argument to
make even with men. Women can always struggle for equality, but
this struggle should not be an excuse for destroying innocent lives.
 4.
(Against the fourth pro-abortionist argument). The human fetus is
truly human. From the ontological, functional and biological
nature of the fetus, everything points to the fetus as possessing a
nature that belongs to what is truly human that makes it another
human being even if its survival depends on the mother and attached
to her womb.
Under the ontological aspect, the fetus is a product of the
sexual act between a man and a woman. Thus, by way of origin, it is
truly human as the parents are human. Such fetus will never be a
plant or an animal or something else because nowhere does an entity
become something else if its parents are human. Even if at first, the
embryo is only one-celled, it becomes two-celled, then four-celled
then goes on and on until it is able to possess a complete
chromosomal structure like that of an adult human being. It is but
natural that as a living being, it undergoes stages of development in
which initially it has only simple and elementary components and
later will eventually acquire a more complete individuality.
Under the functional aspect, it is given that a human being is
one that demonstrates rational functions like reasoning, judgment,
comprehension and other intelligent acts. While this is true of fully
developed humans, it is clear from experience that over time, a fetus
grows into maturity and all of these functions can be achieved and
fulfilled by it. It is just a matter of time before a fetus is initiated into
doing intelligent functions as all other humans are and become
productive in the society.
Biological findings attest that a fetus is known to possess a
truly distinct biological individuality even in its first stages of
development. It has a DNA (deoxyribonucleic acid) which is the
chemical basis of heredity. Such DNA, even in its early stages is
different from that of its mother or father, or of anyone in the world.
It is what makes the fetus unique because its DNA has an attribute of
distinctness from any other human being except from his/her identical
twin. The complete human genome (or set of coded instructions for
making and maintaining an organism) is packaged into 46 pieces of
DNA called chromosomes. Genetically, human beings receive a set
of 23 paired-chromosomes from each parent. This complete set of
chromosomes is found in almost every one of our trillions of cells,
like skin, bone, hair, brain, heart. Exceptions are sperm and egg cells,
which contain half the amount of DNA found in the aforementioned
cells. The DNA is the chemical basis of heredity and therefore tells
about the biological nature of the human being. A gene is a piece of
DNA that contains instructions for building a particular protein that is
essential for all aspects of life. This gene dictates not only how we
look but also how well we process foods, detoxify poisons, and
respond to infections or the like. According to D. Casey (2000), a
science writer, scientists estimate that humans have from 80,000 to
100,000 genes whose sizes range from fewer than one thousand to
several million bases.
From the above discussion, the contention that the fetus is not
human is indefensible because biologically, the fetus possesses what
truly characterizes a human being. The human DNA is one attribute
that spells an ocean of difference from that of other living beings.
Moreover, in the US Senate Judiciary sub-committee, experts
testified on the question as to when life begins. Some of these
famous experts in the likes of Drs. Alfred Bongioanni (Professor of
Pediatrics and Obstetrics in the University of Pennsylvania), Dr.
Jerome Lejeunne (Professor of Genetics in the University of Paris),
Prof. Hymie Gordon (Mayo Clinic), Prof. Micheline Matthews-Roth
(Harvard University), Dr. Watson Bowes (University of Colorado)
and many others, all testified to the fact that by all criteria of modern
molecular biology and accurate scientific data, life is present from the
moment of conception. It was very unfortunate that the pro-
abortionists, though invited to do so, failed to produce even a single
expert witness who would specifically testify that life begins at any
point other than conception.
Biologically, it is a well-established fact that once fertilization
takes place, the zygote becomes its own entity, genetically distinct
from both the mother and father. The newly conceived individual
possesses all the necessary information for a self-directed
development and will proceed to grow in the usual fashion, given
time and nourishment. It is simply untrue that the unborn child is
merely “part of the mother’s body,” as alleged by the Philosopher
Mortimer Adler, “and in some sense, like an arm or leg is a part of a
living organism.” But yet again, every cell of a mother’s tonsil,
appendix, heart and lungs are of the same genetic code. Thus, these
bodily components share the same DNA. This is not true with a fetus.
5. (Against the fourth pro-abortionist argument). Everyone
deserves to be Loved. Children are supposed to be assets and
resources and not as burdens because they are gifts from the Creator.
As gifts, children are supposed to be loved by mothers who have been
given that distinct opportunity to show their maternal instinct to care
for their own. Anyone who cannot love an innocent baby will never
be capable of loving anyone else, for the tenderness of a baby is
enough reason for anyone to have his heart melt at his sight. If there
indeed is a child who is unwanted, a mother can always give him for
adoption as there are many couples who would want to take care of
babies even if they are not of their own flesh or blood. If this
argument is so strong to warrant abortion, then society should also
eliminate other human beings who are deemed unwanted because
they are sick, retarded, poor, old, etc. Even the retarded have also
stories to tell and they, too, can be as happy as anyone else.
 6. (Against the
sixth pro-abortionist argument). Life can be enjoyed by anyone
including the deformed/handicapped. Nowadays, advanced
technologies, like ultrasound, can detect physical and mental
deformities of babies even when they are still in their mother’s
womb. Abortionists contend that deformed babies ought not to be
given a chance to be born because they will not be independent or
intelligent enough to be able to enjoy life as the normal ones would.
Nevertheless, modern studies have proven that life can be enjoyed by
all, both normal and the handicapped. Both do not actually vary in
the degree of enjoyment of life. Retarded children are capable of
contentment as do the normal ones. When truly cared for, the
abnormal can also have a beautiful and meaningful existence. Thus,
no one can make a right conclusion that a deformed life is not worth
living nor deformity can reduce one’s claim to a right to life. Life
should never be graded on the scale of one’s usefulness or uselessness
in the human society. It is in itself a value worth living for.
Proofs have shown that even down syndrome babies can be as
successful as normal humans. There have even been this kind of
babies who later became millionaires and later would help a lot of
persons with disabilities. And this is laudable.
7. (Against the seventh pro-abortionist argument). Abortion
is never a guarantee for insuring quality of life. It has been
contended that to possess high quality of life, there should only be
few people and that the population of the poor should be limited
because they only multiply poverty. But, there has never been an
objective study that with only a few people the society is guaranteed
to enjoy a high quality of life. Hong Kong is one of the countries
with a large population, but it is rich and always known to have a high
quality of life. It must be said that education is one industry that can
insure the quality of life of the people. Even if there were only very
few people, if they do not possess the necessary skills, knowledge and
attitudes needed to insure quality of life, that country will never get
itself out of poverty. The western countries became economically
stable because there has been priority on the education of their
citizens, e.g., Singapore and Canada. Thus, resorting to abortion to
limit population does not lead to high quality of life but reduces
human beings into commodities that can be disposed of at will and at
any time. As a matter of fact, less people would mean less number of
resources who can produce the necessary economic growth to sustain
a country towards progress. This is the problem of Europe especially
France. China and Japan, too, will have a problem in a few years.
This has already been expressed by their governments where the so-
called population winter has already dawned.
It has been argued that more members of the family can dilute
the resources and lessen the supply for the needed food provisions. If
there were only three members in the family, they will have more
slices of pizza to eat. But, we should not forget, that more members
of the family can produce more pizza than a family with fewer
members, everything being equal.
8. (Against the eighth pro-abortionist argument). Population
control can be effectively achieved without destroying innocent
lives. In itself, there is nothing wrong about population control. The
idea of controlling population was brought about by the fear that if
there are more people, food provisions will run out and not be able to
sustain the necessary nutrition, and physical space may soon become
congested for all the people to have a decent place to stay and move
freely. Overpopulation (if there is any) will exhaust eventually
whatever agricultural space is currently utilized for food production.
Too, the world’s energy will not be able to sustain everyone with the
depletion rate this energy is being used.
On Food Requirements. Actually, Robert L. Sassone
(1994) claimed that worldwide, only twenty-five percent of
agricultural land is planted to productive crops. This does not even
include those which are covered by snow. And this 25% is more than
sufficient to feed the whole world and fill up the needed nutrition for
the 6.2 billion people around the world (and even now that it is 7.7
billion). The only problem is that there is a great inequity in the
distribution of food around the world. Only the first world countries
do have the luxury of having more and also waste them more. But
history attests that there has not been a time or era in the history of the
world that food provisions have been insufficient, except only in war-
torn areas, dictatorially-led governments or during calamities. And
this only happens not because food provision is lacking but because
delivery of supply is sometimes impossible due to physical
constraints or political limitations as in Myanmar, Darfur, Zimbabwe,
Somalia and other places where refugees cannot be reached.
Inequitable distribution of food therefore is the culprit in this case.
And the gap between the rich and the poor is scandalously wide. The
Oxford Committee for Famine Relief (Oxfam) attest to this very
clearly in its recent pronouncement. Accordingly, the world's richest
1% have more than twice as much wealth as 7.7 billion people. The
gap between the richest and the rest, especially those living in poverty
is out of control. While people at the top get influence, opportunities
and power, people living in poverty miss out on the basics they need
– like a decent education, healthcare, and jobs. Women and girls,
especially those living in poverty, are often hit the hardest. The
world's 22 richest men have more wealth than all the 325 million
women in Africa. Women and girls are putting in 12.5 billion hours
every day of care work for free, and countless more for low wages.
Their work is essential to our communities, underpinning thriving
families and a healthy and productive workforce. Yet most of the
financial benefits of the work done by women is rewarded to the
richest, the majority of whom are men. This unfair economy exploits
and marginalizes many women and girls, while increasing the wealth
and power of a rich elite.
It is noteworthy that the past 70 years have marked a very
significant increase in food production due to the new technologies
that have been invented to produce and preserve food that can even
last for years. Subsequently, food production increased by 55% since
the 1950’s and continues to do so in the coming centuries. There was
even a technology that was used to prompt chicken to lay eggs four
times a day compared to their natural manner of production. Israel
used this technology and at one time had millions of oversupply of
eggs but these were not actually sold in the market as this would
significantly affect its price. They threw them into the ocean, all in
the name of economics. Further, where before it was impossible to
plant crops in the desert, Israel defied it through a pioneering
breakthrough by planting corn, banana, wheat and other vegetables in
these once unarable lands. Nowadays, farmers can even produce root
crops, like carrots, radish or potatoes, without having to use soil.
They can grow them by just hanging them onto a wire as in a clothes
line through the hydroponics technology. Thus, food supply is not
actually a problem. Inequities are.
On Space Requirements. As regards space requirements for
the population’s use for houses, Sassone claimed that it has never
been proven that such is also lacking at any one time or another.
Again, even removing the spaces used for highways, sports
complexes and buildings presently occupied, there will always be a
space for everyone, so much so that one can place the whole
population of the world in the islands of Hawaii or Japan or the
Philippines and everyone will have a space for all the houses needed
for every family. That can be accommodated by just the land surface.
It does not have to include the second or succeeding floors that can be
built upwards. The vast spaces occupied by various forms of water
are teeming with food and can also be used for shelters which have
not been used at all. That is why overpopulation is only a myth.
On Energy Requirements. Again, according to Sassone,
advocates and minions of population control allege that we will soon
run short of many essential resources like energy, especially
petroleum, unless governments around the world accept the solution
of population control through contraception and abortion. The
supply of petroleum, natural gas, coal, metals and other removable
resources from the earth is finite and limited that the supply is in
danger of exhaustion and depletion at the current rates of use. The
rate of depletion and waste is proportional to the volume of human
population. Proponents of population control deny that advancing
technologies permit more efficient utilization of energy resources
which prevent scarcity and keeps cost reasonable.
On the other hand, the opponents of population control claim
that shortages will definitely occur. But this is very, very remote.
Probably it will only occur when the earth would have been
annihilated or the sun would have dimmed its light. It will require
trillions of years for this to happen, almost the same length of time as
when they were formed.
There have been appropriate materials as reference to know
how enormous is the earth’s reserves for petroleum, natural gas and
coal. We are not yet mentioning here other natural energies that are
equally potent for use of the world, like, solar, wind and hydropower
as tidal waves, rivers and lakes. What stops the world from using
these equally potent powers is economic greed. Some countries with
enormous amount of petroleum do not want these other powers to be
developed as yet as this will substantially deplete their profit with the
presence of potential competitors. If only all these resources have
been developed, probably, we will only pay fifty centavos per liter of
commercial gasoline.
Moreover, water has never been depleted since the world used
it for its hydration needs. It is now easier to obtain drinking water
since technologies have also progressed. The same can be said with
perennially present oxygen and even wood, except in some areas
where deforestation has been unabated in spite of many laws
legislated by countries around the world to control its use. In the
USA, there are about 800 trees for every human being. The increase
in atmospheric CO2 around the world has apparently vastly increased
the growth of young trees. The world has its subtle way of repairing
and renewing itself. This needs the cooperation of human beings.
For all intents and purposes, it is not fair to label countries to
be over populated just because they are poor. The Philippines is
branded to be so because it is poor. But suppose it is very rich, and
with the same number of population as it has today, can it still be
regarded as over-populated? The answer is no. The same can be
said of many African countries. Suppose USA is poor, will it not be
branded as over-populated, what with a 329 million population to
reckon with? Japan has 125 million inhabitants and is not counted as
overpopulated. And its land area is a little more than the size of the
Philippines. Therefore, it is not right to equate poverty with
overpopulation and vice-versa.
Moreover, in demography, it cannot be said that a particular
country is poor because it is over-populated. Rather, it is over-
populated because it is poor. The poor normally could hardly afford
education and enjoy gainful employment. Their usual idleness prods
them to procreate children, more children --- and that, leisurely.
Education, and not abortion, is still the best weapon for the reduction
of population. Why destroy when one can utilize the manpower for
economic progress? Why remove someone at the table when we can
add another plate so he can eat? After all, food awaits those who
would like to be nourished.
There is certainly nothing wrong with controlling human
population for as long as this is done in the way that respects the
value, sanctity and dignity of human life. What is important also is
not to regard humans as commodities to be disposed of any time.
They must be regarded as resources to be tapped and respected.
9. (Against the ninth argument). The right to life. More
than any other human value, human life is at the apex and nothing is
even to it. This life has from its beginning already possesses
everything that mature humans possess. We do not have to invoke
the values Christian faith tells us. Our recognition of the value or
dignity of humans and the bond that exists among human beings are
enough to show that life is so valuable and precious that any
downgrading of its value is off-track and unhinged. And it cannot
gain a rational argument because it is highest, much higher than the
argument on the basis of the right to privacy. The right of privacy
draws its force and potency from the right to life. When there is a
conflict between these two values, the right to life wins hands down.
That is why people have to realize that anything and everything that
upholds the value of human life is at its highest level of argument.
Good News in the Aftermath of Abortion around the World. The
following are some very positive narratives about those who defied
and fought for pro-life activities.

1. Andre Bocelli, an Italian soprano, whose

picture appears above whose life was saved because her mother who
was pregnant then did not agree to the doctor’s advice to abort him.
Accordingly, in his testimony, he was narrating about a pregnant
mother who became sad and confused because it was predicted that
her pregnancy will be complicated and that if the baby will be
allowed to be born, he will be blind the whole of his life. And in the
end, Bocelli said it beautifully, “That pregnant woman was my
mother and I was the child.”
2. Carol Everett from Dallas, Texas is modern-day
protegé of Sanger, owner of abortion clinic. She attested in an
interview in 2011, “We had it all planned. How to sell abortion. It
was called Sex Education. Break down their natural modesty, separate
them from their parents & their values & they become the sex experts
in their lives. Our goal was 3-5 abortions from girls between ages 13
& 18. We get them young, get them sexually active. If we could get
a young girl to have abortion, we got her 3 or 5 more because she
remains sexually active, knowing she can get away with it.”
Moreover, Everett said frankly that behind the abortion ideology and
its consequent surgical procedure is a governing motivation that it is
nothing but al about money. It is a very lucrative business. It is the
largest unregulated industry in our nation. Most of the clinics are run
in chains because it is so profitable.
Moreover, she tells that women who want to have abortion have
two questions, namely: "Is it a baby?" and Does it hurt?" The
abortionist must answer "NO." He/she must lie to secure the consent
of the woman and the collection of the clinic's fee. The women were
told that we were dealing with a "product of conception" or a "glob of
tissue." They were told that there would be only slight cramping,
whereas, in reality, an abortion is excruciatingly painful.
In the end, Everett had a parting shot saying that she stopped
being associated with abortion because she had two things that came
into play at the same time. I experienced a profoundly religious
transformation -- a conversion. At about the time I was having second
thoughts, a Dallas television station did an expose disclosing the
abortions performed at my clinic on non-pregnant women -- all for
money! I finally realized, "We weren't helping women -- we were
destroying them -- and their children." By then my transformation
was complete and I knew that I not only had to stop being involved
with abortions, but I had to help promote the truth.
3. Dr. Bernard Nathanson, MD, was once a pioneer and a
leader in the "abortion industry." Dr. Nathanson presided over 60,000
abortions before undergoing a radical transformation. After realizing
how wrong he was about abortion – not only did he quit the abortion
business, but now he admits that abortion is murder as he speaks
around the world against abortion. Dr. Nathanson has written an
autobiography titled, THE HAND OF GOD – A JOURNEY FROM
DEATH TO LIFE BY THE ABORTION DOCTOR WHO
CHANGED HIS MIND. Abortion doesn't look the same after you
view it through the eyes of former abortionist like Dr. Nathanson. A
review of Dr. Nathanson's powerful book and confessions is available
in the web.
4. Ms. Abby Johnson is a nurse in a Planned Parenthood
clinic started by its founder Ms. Margaret Sanger who was an
abortionist and eugenicist. In many of her daily chores, one day she
experienced that while she was assisting in an abortion procedure, she
noticed that when she was trying to detach the growing baby in the
womb, the baby put a gallant stand using his hand to ward-off in a
tough resistance the instrument she was using to expel it. It was at that
point when she realized that the baby is indeed a human being like
hers and wants to tell her that it was in great pain. And she
understood it. Later, in the US Senate, she testified that all these
babies would indeed put a fight and that they want to remain in their
mother’s womb. Her life as an abortionist and later as having
dissociated herself from it, has been made into a black buster movie
entitled, “Uplanned,” obviously a sarcastic reference to the Planned
Parenthood. As pro-life advocate, she made a very powerful speech
at Pres. Trump Republican Convention 2020 and had made strong

impact upon the world’s society.

5. Dr. Anthony Levatino was an Obstetrics and
Gynecology specialist who practiced OB-GYN in Florida, New York
and New Mexico with 40 years of medical experience. In the early
part of his career, Dr. Levatino performed over 1,200 abortions in the
first and second trimesters. In his testimony in the US Senate, Dr.
Levatino said that he had performed more than 20,000 abortions.
Later, he said that abortion is a gruesome act against the life of the
powerless baby in the womb of the mother. He later dissociated
himself from performing abortion procedures and has now become a
promoter of human life.

These are some of the known stories of abortion promoters

who later have realized the ghastly practice of abortion procedures
and have now been passionate advocates of human life beginning
from the moment of conception. And these are what is called the
redemption stories in the midst of this unspeakable crime of abortion
as aptly described by the St. Pope John Paul II.
Some Famous Abortion Cases/Issues in Modern History. The
following below are some of the most controversial instances about
the issue of abortion and its morality:
1. The Infamous Case of Roe vs. Wade
(1973). (www.Findlaw.com, retrieved 2008). The Supreme Court of
the United States-Jane Roe report found that in 1970 at the
Pennsylvania State House, attorneys Linda Coffee and Sarah
Weddingdon filed suit in a U.S. District Court in Texas on behalf of
Norma L. McCorvey (pseudonym, "Jane Roe"). McCorvey claimed
her pregnancy was allegedly the result of rape, although this has not
been proven. The defendant in the case was Dallas County District
Attorney Henry Wade, representing the State of Texas.
“Jane Roe,” a single woman who was residing in Dallas
County, Texas, initiated a federal action in March 1970 against the
District Attorney of the county, Henry Wade. She sought a
declaratory judgment that the Texas criminal abortion statutes were
unconstitutional on their face, and an injunction restraining the
defendant from enforcing the statutes.
Roe alleged that she was unmarried and pregnant; that she
wished to terminate her pregnancy by an abortion "performed by a
competent, licensed physician, under safe, clinical conditions"; that
she was unable to get a "legal" abortion in Texas because her life did
not appear to be threatened by the continuation of her pregnancy; and
that she could not afford to travel to another jurisdiction in order to
secure a legal abortion under safe conditions. She claimed that the
Texas statutes were unconstitutionally vague and that they abridged
her right of personal privacy, protected by the First, Fourth, Fifth,
Ninth, and Fourteenth Amendments. By an amendment to her
complaint Roe purported to sue "on behalf of herself and all other
women" similarly situated.
James Hubert Hallford, a licensed physician, intervened in
Roe's favor. In his complaint he alleged that he had been arrested
previously for violations of the Texas abortion statutes. He described
conditions of patients who came to him seeking abortions, and he
claimed that for many cases he, as a physician, was unable to
determine whether they fell within or outside the exception
recognized by Article 1196 of the US constitutions. He alleged that,
as a consequence, the statutes were vague and uncertain, and that they
violated his own and his patients' rights to privacy in the doctor-
patient relationship and his own right to practice medicine, rights
which he claimed were guaranteed by the First, Fourth, Fifth, Ninth,
and Fourteenth Amendments.
Roe vs. Wade ultimately reached the U.S. Supreme Court on
appeal. Following a first round of arguments, Justice Harry Blackmun
drafted a preliminary opinion that emphasized what he saw as the
Texas law's vagueness Justices William Rehnquist and Lewis F.
Powell, Jr. joined the Supreme Court too late to hear the first round of
arguments. Therefore, Chief Justice Warren Burger proposed that the
case be reargued and this took place on October 11, 1972.
Weddington continued to represent Roe, and Texas Assistant
Attorney General Robert C. Flowers stepped in to replace Wade.
Justice William O. Douglas threatened to write a dissent from the re-
argument order, but was coaxed out of the action by his colleagues,
and his dissent was merely mentioned in the re-argument order
without further statement or opinion.
The following have been the bases for the granting of abortion
rights to Roe by the US Supreme Court, namely:

a. The historic but

infamous US Supreme Court decision overturning a Texas
interpretation of abortion law and making abortion legal in the United
States through the Roe vs. Wade case held that a woman, with her
doctor, could choose abortion in earlier months of pregnancy without
restriction, and with restrictions in later months, based on the right to
privacy. Roe v. Wade was decided primarily on the Ninth
Amendment to the United States Constitution, a part of the Bill of
Rights. The Court's decision in this case was that the Ninth
Amendment, in stating that "the enumeration in the Constitution, of
certain rights, shall not be construed to deny or disparage others
retained by the people," protected a person's right to privacy.
 b. The Court majority determined that the original intent of the
Constitution (up to the enactment of the Fourteenth Amendment in
1868) did not include the unborn. However, the Court did not
specifically determine the question of whether or not a fetus is a
person, noting that the matter remains undecided. The Court's
determination of whether a fetus can enjoy constitutional protection
was separate from the notion of when life begins: "We need not
resolve the difficult question of when life begins. When those trained
in the respective disciplines of medicine, philosophy, and theology
are unable to arrive at any consensus, the judiciary, at this point in the
development of man's knowledge, is not in a position to speculate as
to the answer." The Court only believed itself to resolve the question
of when a right to abortion begins.
c. The decision established a system of trimesters that
attempted to balance the state's legitimate interests against the
abortion right. The Court ruled that the state cannot restrict a
woman's right to an abortion during the first trimester, the state can
regulate the abortion procedure during the second trimester "in ways
that are reasonably related to maternal health", and the state can
choose to restrict or proscribe abortion as it sees fit during the third
trimester when the fetus is viable.
It is noteworthy to provide here Associate Justices Byron R.
White’s and William H. Rehnquist’s emphatic dissenting opinions of
the case. Justice White wrote:
1. I find nothing in the language or history of the Constitution
to support the Court's judgment. The Court simply fashions and
announces a new constitutional right for pregnant mothers and, with
scarcely any reason or authority for its action, invests that right with
sufficient substance to override most existing state abortion statutes.
The upshot is that the people and the legislatures of the 50 States are
constitutionally disentitled to weigh the relative importance of the
continued existence and development of the fetus, on the one hand,
against a spectrum of possible impacts on the mother, on the other
hand. As an exercise of raw judicial power, the Court perhaps has
authority to do what it does today; but, in my view, its judgment is an
improvident and extravagant exercise of the power of judicial review
that the Constitution extends to this Court.
2. White asserted that the Court "values the convenience of
the pregnant mother more than the continued existence and
development of the life or potential life that she carries." Despite
White suggesting he "might agree" with the Court's values and
priorities, he wrote that he saw "no constitutional warrant for
imposing such an order of priorities on the people and legislatures of
the States." White criticized the Court for involving itself in this issue
by creating "a constitutional barrier to state efforts to protect human
life and by investing mothers and doctors with the constitutionally
protected right to exterminate it." He would have left this issue, for
the most part, "with the people and to the political processes the
people have devised to govern their affairs."
3. There apparently was no question concerning the validity of
this provision or of any of the other state statutes when the Fourteenth
Amendment was adopted." Therefore, in his view, "the drafters did
not intend to have the Fourteenth Amendment withdraw from the
States the power to legislate with respect to this matter."
An Ethical Assessment of the US Supreme Court Decision. A
pandemonium of criticism erupted around the world when the
decision of the US Supreme Court was handed down and
promulgated. The following may be of value:
a. The majority opinion failed to adequately recognize the
inviolability and personhood of embryonic/fetal human life. Pro-life
supporters argue that life begins at conception (a.k.a "fertilization",
ensoulment and loosely, quickening), and thus the fetus should be
entitled to legal protection. Other pro-life supporters argue that, in
the absence of definite knowledge of when life begins, it is best to
avoid the risk of doing harm.
b. The right to privacy can never supersede the right to life as
the latter is of a higher value than the former. While the former is
considered a right, the right of the fetus, as a person, is inviolable, and
no legal maneuverings or ambiguous interpretations should be above
it. The right to privacy exists because it inheres dependently in the
right to life.
 According to Tandy Alcorn (2000) in Pro-life Answers to Pro-
choice Arguments, “there is nothing constitutional about the right to
privacy, because that right is nowhere to be found in the US
Constitution. It was declared by the Supreme Court in 1973 as a right
higher than an unborn child’s right to live. Those who wrote the
constitution would be turning on their graves and would be shocked
to learn that their document, which was dedicated to ensure justice
and compassion for all people, has been claimed by some to guarantee
a right to kill children.
c. Pregnancy is not a disease to be cured through medical
treatment. It is a natural consequence of a sexual act that must be
nurtured and not subject it to destructive acts.
d. Any constitution must above all promote and protect the
right to life of its citizens, especially the most vulnerable members, as
it is the backbone of any sovereign nation. Abortion does disservice
to the constitution and therefore to the very people it has to defend.
Abortion deprives a society of a new member that must secure its
future existence.
The Aftermath: Who is Roe in Roe vs. Wade? Norma McCorvey is
the real “Jane Roe” a pseudonym she assumed in the historic Roe vs.
Wade case that led to the decision that legalized abortion in USA.
She wanted to remain anonymous in order to protect her right to
privacy.
The following has been reported and lifted heavily on
international televisions and general references about her interview in
the aftermath of the passionately charged abortion case.
Once an abortion-rights supporter, the 50-year-old McCorvey
has switched sides. She is now a vocal anti-abortion activist. She has
started a ministry called Roe No More to fight against abortion rights
with the aim of creating a mobile counseling center for pregnant
women in Dallas, Texas.
Roe began her association with one of the United States' most
contentious and volatile sociopolitical issues in 1970, when she
became the lead plaintiff in the class-action lawsuit filed to challenge
the strict anti-abortion laws in Texas.
 The case was appealed to the Supreme Court, which handed
down its controversial ruling on January 22, 1973. The decision
legalized the right to an abortion in all 50 states and sparked a
political debate that remains charged to this day.
However, McCorvey, who was 21 when the case was filed and
was on her third pregnancy, never had an abortion and gave birth to
a girl, who was given up for adoption.
McCorvey went public with her identity in the 1980’s and
wrote a book about her life entitled, "I Am Roe: My Life, Roe v.
Wade, and Freedom of Choice."
In the book, McCorvey, a ninth-grade dropout, describes a
tough life, explaining that she suffered physical and emotional abuse
as a child, spent some time in reform school in Gainesville, Texas,
and was raped as a teen-ager. A husband whom she married at age
16 later beat her. She also tells of her alcohol and drug abuse, and
experiences with lovers of both sexes.
Her first child, Melissa, was raised by her mother; her second
child was raised by the father, and the couple agreed that McCorvey
would never contact her and the child.
She drifted through a series of dead-end jobs, including work
as a bartender and a carnival barker. Once she went public with her
story, she worked in several clinics where abortions were performed
and did some public speaking, garnering publicity and a little bit of
celebrity.
But in 1995, it all changed. McCorvey was working at a
Dallas women's clinic when the anti-abortion group Operation
Rescue moved its offices next door. Initially, McCorvey hurled insults
at the protesters.
The Rev. Phillip Benham, Operation Rescue's national
director, described her as being "super hard-core" in her support of
abortion rights. "She couldn't stand us. She hated us."
But then she and Benham struck up a relationship across the
protest lines, when she would go outside to smoke, a habit she still
has.
"They couldn't understand this strange relationship with the
 head of Operation Rescue and the poster child of the pro-abortion
movement," Benham said.
Benham, an evangelical preacher, began discussing
Christianity with McCorvey. She became friendly with some of
Operation Rescue's office staff, and then she accepted an invitation
from the daughter of the group's office manager to attend church.
That night, she converted to Christianity.
She was baptized by Benham on August 8, 1995, in a
swimming pool at a Dallas home. The baptism was filmed for
national television.
Anti-abortion activists immediately heralded her conversion.
McCorvey publicly committed her life to "serving the Lord and
helping women save babies." She took a job at Operation Rescue as
a computer operator and was welcomed into the anti- abortion fold.
McCorvey rued and blamed violence at women's clinics on the
abortion-rights camp. She said: "I personally think it's the pro-
abortion people who are doing this to collect on their insurance, so
they can go out and build bigger and better killing centers."
A book McCorvey co-wrote about her religious conversion
titled "Won By Love" was published. "I think everyone should sit
down and write a book," she said. "It's a lot like therapy but a lot less
expensive."
Abortion-rights advocates were not so happy about
the change of heart by the woman who symbolized a woman's
right to have an abortion.
Sarah Weddington, the attorney who along with Linda Coffee
represented the plaintiffs, now says she would have picked a different
plaintiff, who might have better represented the case.
Coffee said she and Weddington met McCorvey via another
attorney who specialized in adoptions. Coffee doesn't remember
McCorvey having any hesitancy about wanting an abortion.
"She didn't appear to be equivocal," she said. "At the time,
she preferred a safe and legal abortion."
Weddington says it is the result that matters because the class-
action case affected millions of women.
"Frankly, no one ever said, “I believe what Norma McCorvey
said, or I believe what Sarah Weddington said," the lawyer
explained. “People,” she said, “make up their own minds about
abortion.”
Asked why she thought McCorvey changed her mind,
Weddington said, "She's the only one who can answer that," then
refused to comment further about McCorvey.
But McCorvey says that attitude validates her belief that
abortion is wrong. "If they don't care about me, how can they
possibly care about anyone else?" she said.
McCorvey has criticized Weddington in the past for not
helping her get an abortion, because the case needed a pregnant
plaintiff. "I had to be pregnant," she said.

McCorvey had made one trip to an illegal abortion clinic in

Dallas that had been shut down. But now, McCorvey says she
wouldn't have had an abortion, anyway, because she was too far
along in her pregnancy. "I can honestly say no, I wouldn't have," she
said.
When McCorvey announced her change of heart on the issue,
Kate Michelman, president of the National Abortion and
Reproductive Rights Action League, said in a statement: The Roe vs.
Wade decision "isn't about any single individual. It is about the
freedom of all women to make reproductive decisions free from
government intrusion."
Michelman, through a spokesman, declined to be interviewed
for this story.
Coffee said she last saw McCorvey when the television movie
about the case was made in the late 1980’s.
"Perhaps she may have felt left out by some of the pro-choice
groups in connection with the ongoing debate," she said.
That is exactly what McCorvey says about the pro-choice
leaders. "They could have been nice to me instead of treating me like
an idiot," she said. She said that she now prays for pro-choice
leaders.
"I don't hate them any more like I used to," she said. "I just
don't like them very much."
McCorvey also has faced charges that the anti-abortion
movement is using her to further its cause. But now with her own
ministry, McCorvey has a quick answer to that accusation. "How can
I use myself?" she asked.
Advocates of banning abortion point to McCorvey as a
compelling symbol of hope. "Norma McCorvey’s conversion gave us
hope that the pro-life movement can and will be successful," said the
Rev. Robert Schenck, general secretary of the National Clergy
Council, a multidenominational group of conservative ministers.
But no matter what either side says, more than three decades
after Roe vs. Wade, Americans remain divided over the issue of
abortion. Norma McCorvey may have changed her mind, but the
political debate over abortion continues and change seems elusive.
Another famous case is the in abortion controversy is the Doe
vs. Bolton. The Supreme Court of the United States was a landmark
decision that overturned the abortion law of Georgia in Doe vs. Bolton
(Kaiser Daily Reproductive Health Report, 2003). The case of Doe
vs. Bolton is referred to as the companion case to Roe vs. Wade. (see
Supreme Court of the United States, argued December, 1971, re-
argued October, 1971 and Decided January, 1973. Links
www.Findlaw.com).
According to writer, Bryan Lash, it was 1965, Sandra Race,
the seventeen-year-old daughter of an Atlanta City sanitation worker,
was growing up in a poor neighborhood when her life was about to
be changed forever. She had already dropped out of school; poor
grades, the taunts of classmates about her weight and the disfiguring
smile from Bell's Palsy were too much for her to face each day. Her
mother tried forcing her and once nearly broke a broomstick across
her back in the process. Like most adolescents, Sandra dreamed of
romantic encounters with some "knight in shining armor" who would
provide her with affection and attention. Adolescent insecurity and
vulnerability would soon blind her senses and dull her better
judgment. In her fragile emotional state, Sandra was a willing pawn
for anyone who showed her the slightest favor.
Around this time, Sandra met Joel Lee Bensing, a gas station
attendant and occasional day laborer from Hugo, Oklahoma. Sandra
was smitten by the smile of this 22-year-old man. Her emotions
soared. Having known him for only 2 days yet reeling from Joel's
attention and affection, Sandra readily accepted an invitation to
Stone Mountain Park, a popular recreational area 25 miles away.
Somewhere along the way, he convinced her that a trip to visit his
family was in order. Thirteen hours later they pulled into Hugo,
Oklahoma. When she called her panic-stricken parents, her father
threatened to have Joel arrested for kidnapping. Upon their return to
Atlanta, her father beat her with a belt. The couple was then driven
to Alabama where Joel was forced to marry Sandra in a civil
ceremony.
A week after they were married, Sandra found out that her
husband was serving probation for molesting two different 5-year-old
children. Over the next several years Joel was charged again with
molestation and kidnapping. He would appear only a few days out of
the month and was in and out of jail during their entire marriage.
Sandra's other relationships were also tenuous. Sandra's father died,
her mother remarried only weeks after his death, and Sandra's
stepfather proved to be a very demanding and many times an abusive
man. He resented the presence of another man's six children and was
not inhibited in releasing his frustration with verbal tirades and
physical assaults.
In March 1970, at her wits end, barely 22 years-old, Sandra
was married to a convicted child molester with her children in foster
care and pregnant with her fourth child; Sandra Race Bensing went
to Atlanta Legal aid for help. Poverty-stricken, this was her only
avenue for legal assistance. She was seeking a divorce from Joel and
legal help in getting her children returned to her from foster care.
The friendly faces and willing ears were a welcome "oasis" to
Sandra, who had seen little of either her entire adult life. Her new
"friends" there soon introduced her to an attorney named Margie
Pitts Hames who was eager to help with her situation. Sandra saw
Margie as the "life preserver thrown to a drowning man." The only
problem was that Ms. Hames' unstated solution to Sandra's
predicament was not what Sandra had in mind. Margie's plan was
abortion first, and then divorce and freeing the children from foster
care. Sandra was kept in the dark and told only that her case had
something to do with "Women's Rights." When asked once about the
subject of abortion she responded "she did not believe in it, for
herself, but could not speak for anyone else."
Sandra began the murky legal journey through which Ms.
Hames dragged her virtually blindfolded client. Court documents
presented by Hames show that Sandra applied for an abortion at
Grady Memorial Hospital, the only place where the poor could obtain
an abortion. Hames ignored the fact that Sandra had already stated
her opposition to abortion; in fact, extensive searches done at both
Sandra's request and that of Georgia State Senator Pam Glanton had
turned up no evidence of such an application. Next Ms. Hames, in
partnership with Sandra's mother, arranged an abortion for Sandra
at Georgia Baptist Hospital; Sandra had no knowledge of this plan.
When Sandra finally found out about it, she fled to Oklahoma alone.
She had never traveled alone before. Sandra had avoided the
abortion others had arranged for her. Hames filed a class action suit
in U. S. District Court naming Sandra Race Bensing as Mary Doe:
the only pregnant woman in the action. Allegedly, the pregnant
Bensing was denied an abortion at Grady Memorial Hospital by the
abortion review panel; her case was then taken, reviewed and
approved by another review panel at Georgia Baptist Hospital. The
case was presented to liberalize the Georgia abortion law so a
woman could abort her baby at any point through the ninth month of
pregnancy without the interference of a panel of doctors as the statute
directed.
No evidence has ever been found to verify the claim that
Sandra was either seen or rejected by Grady Hospital. Hames named
Sandra as the plaintiff, even though Sandra did not want or seek an
abortion. She only wanted a divorce from a convicted child molester
and help in getting her children back. Grady Hospital officials neither
saw nor rejected her alleged abortion request. So Sandra was
presented as a pregnant woman seeking an abortion, to which she
was adamantly opposed, whose non-existent request for an abortion
was therefore never heard or discussed by hospital officials. While
she was on a turbulent emotional roller coaster, her emotional state
was no cause for her to seek an abortion as alleged by Hames. Her
actions demonstrated the opposite: when she found out an abortion
had been scheduled for her at Georgia Baptist Hospital, she fled and
only agreed to return if she did not have to have an abortion. Sandra
was never asked to testify before any court official and convey her
supposed ardent desire to have an abortion. Sandra was a pawn in
the hands of a feminist ideologue. Her attorney, Margie Pitts Hames
was after abortion on demand and believed she was doing something
great for women's rights, all the while ignoring the rights and wishes
of her client.
When her suit failed to achieve her goals in Georgia, Hames
continued to press her agenda on to the U.S. Supreme Court. On
December 13, 1971, Doe v. Bolton went before the Supreme Court.
Hames represented her side and Dorothy T. Beasley represented the
State of Georgia. Mrs. Beasley was skeptical. There were just too
little facts. The transcript’s document recorded her amazement as
follows:
"The Attorney General, Arthur K. Bolton-Georgia has no idea
what the abortion committee in this particular case did or how much
it knew. And that again is one of the great problems with this case.
We know of no facts, there are no facts, in this case, no established
facts . . . there is no case or controversy. Not with these defendants . .
. It is not a complete divulgence of the facts surrounding her
(Sandra's) circumstances."
On a couple of occasion, the justices wanted to know if Mary
Doe (Sandra Race Bensing) really existed, to which Hames replied in
the affirmative. What she never pointed out was that while there was
a real woman who was pregnant named in the original suit, Mary
Doe never wanted or sought an abortion. Hames presented an
affidavit from her mystery woman, Mary Doe, which contained the
signature of Sandra Race Bensing. The document stated that she was
pregnant with her fourth child and that she could not possibly care
for the child properly, she was not emotionally capable of bringing
the baby into the world, and that she wanted an abortion. Sandra did
not recall reading or signing this paper. The signature is similar to
her own but the contents of it are in direct conflict with Sandra's
beliefs and actions. Her only explanation was either the signature
was a forgery or that she signed the document in a legal setting with
Hames at which time she signed a number of documents relating to
her divorce and the regaining of her children. Sandra trusted her
attorney to be representing her best interests; however, the motive in
this case was ideology over facts.
The judicial system of the United States was established to
insure the rights and freedoms of citizens who are innocent until
proven guilty in a court of law. The outcome of this U. S. Supreme
Court decision was determined without a complete inspection of the
facts. Clearly, Mary Doe was not Sandra Race Bensing. She was just
who Margie Pitts Hames portrayed her to be. Statements Hames
made before the Justices of the Supreme Court were lies and her
motives were clear deception.
The high court's justices were not insistent in their questions.
Members of that court who sided with Hames trampled the U. S.
Constitution under foot. Abortion was legalized by a handful of men
who were not in command of all the facts. This is precisely why the
framers of the Constitution formed the legislative branch of
government. Justices of the Supreme Court are supposed to rule on
the constitutionality of the laws of the land, not author them.
In his dissenting opinion Justice Byron R. White said the ff.:
Nothing in the language or history of the Constitution
supported the court's judgment, and the Court had simply fashioned
and announced a new constitutional right for pregnant mothers and,
with scarcely any reason or authority for its action, had invested the
right with sufficient substance to override most existing state abortion
statutes, whereas the issue of abortion should actually have been left
with the people and the political process they have devised to govern
their own affairs.
An assessment had been made that after the whole
controversy, it was known that Sandra Race Bensing, the "Mary Doe"
of the 1973 Supreme Court case Doe v. Bolton---the companion case
to (in)famous Roe v. Wade that legalized abortion through all nine
months of pregnancy. What was not well-known was that Sandra
never had wanted or believed in abortion.
Sandra Race Bensing is pro-life and has stated her opposition
to abortion from the beginning. The paperwork she thought was
related to a divorce she sought from an abusive husband and the
liberation of her children from foster care turned into one of the most
(in)famous cases in US history. The American Civil Liberties Union
attorney that Sandra Bensing believed was helping to reunite her with
her children and to obtain a divorce claimed that her client applied for
an abortion but was turned down. Sandra Bensing said she was lied
to and that the lawyers handling the case did not explain to her what
was happening and why.

The Malthusian
Theory: The Culprit of it All. This theory has been fiercely
promoted by British economist, Thomas Robert Malthus (1766-
1834) and many of his modern-day staunch followers, like the pro-
choice advocates. In his view, An Essay on the Principle of
Population, during the end of the 18th century, he argued that
population increases geometrically or exponentially while food
production only increases arithmetically. This simply means that
human population tends to increase faster than food supply, with
inevitable disastrous results, unless population growth is checked and
restricted by moral (or immoral) restraints (through contraception or
abortion) or by war, famine and disease. This disharmony would lead
to widespread mass poverty and chaos.
The Malthusian theory has long been dismissed as a purely
speculative thinking for its pessimism and failure to take into account
the technological advances in agriculture and food production which
has been a remarkable characteristic of the 20th century civilization.
Systematic and scientific food management, processing, preservation
and even distribution have increased tremendously for the past
centuries and are hoped to increase even more with countless and new
discoveries that are waiting to be harnessed. Mechanisms have been
appropriately put in place in order to check unabated predation and
depletion of resources that are sources of nutrition, vitamins, minerals
and other needs for human consumptions. This includes also those
sea foods that are almost scarcely untapped. Human creativity, as
modern society has known, has more than overcome the problems of
land use and food production. The only places where starvation
occurs are where there are massive political problems, wars and
sometimes natural calamities that make food distribution difficult. In
sum, resorting to moral restraints, like contraception and abortion, are
untrue since fears about lack of food, space and energy resources are
not founded and are only inventions of the imperialists out to preserve
geopolitical interests.
Setting the Value of the Human Person vs. Abortion. The cartoon
below is highly and deeply incisive. This caricature best depicts the great
injustice done to an unborn child. It does not need so much explanation as it is obviously
self-explanatory. Nevertheless, it is worth noting that in the world’s obsession for rights to
privacy, women’s rights, right to abortion and sexual revolution advocated by Margaret
Sanger and her cohorts, the right of the child to be born and to have a birthday has been
disposed of like rubbish and superseded with the culture of death with such impunity.
Unfortunately, the babies have been thrown indiscriminately as trash that can easily be
disposed of.

This hilarious but very insightful cartoon below captures

the ideology of the pro-choice and how it views the status of unborn
babies vis-à-vis the value of pet animals. It tells very clearly that the
pro-choice just strongly resent to see unborn children and ironically
treat pets to be more secure than humans. In the depiction by the
(anonymous) author of the cartoon, the pets dog and cat clearly
express their shock in a very poignant tone on why humans are not
safe in an environment that is supposed to be the most secured place
for them on earth. Disgusting as it is, the dog and the cat seem to
express nevertheless their empathy for the unborn child and the
overwhelming reaction of the baby as it engages a conversation with

both the cat

and dog.
Finally, in the funny yet incisive sketched cartoon sets a final
verdict on how the world of pro-choice has placed the value of the
human person in the midst of the wickedness of abortion. What better
rendition of such repugnance in the cartoon?
Postscript to the Moral Repugnance of Abortion. Since the
legalization of abortion in USA through the infamous Roe vs. Wade
legal battle, millions of unborn have lost their lives to abortion at the
rate of 1.5 million annually, not to mention those in Europe and Asia.
Millions of women have suffered the destructive and untold physical
and emotional pain of such a procedure. About 70 million babies
have had 30 years of life denied and for the same number of years
have seen societies devalued women and infants.
Abortionists and their cohorts need no words to see how their
warped and distorted values have deformed many nations. The so-
called “reproductive rights” or right to abortion has produced the
worst enemies on earth that pitted mothers against their very own
children and women against their husbands. It has sown violence and
discord at the heart of the most intimate human relationships. It has
aggravated the derogation of the father’s role in an increasingly
fatherless society. It has condoned a promiscuous generation in
pleasure-seeking ultra-liberals. It has portrayed the greatest gift of a
child as a competitor, an intruder, and an inconvenient burden. It has
normally accorded mothers unfettered dominion over the independent
lives of their physically dependent sons and daughters. This right has
given women “access to murder” the very children they should be
cradling in their arms.
Further, in granting this unconscionable power, it has exposed
many women to unjust and selfish demands from their husbands or
other sexual partners. Sadly, human rights are not mere privileges
conferred by government on its constituents. They are every human
being’s natural entitlements by virtue of their humanity. The right to
life of the unborn does not depend, and must not be declared to be
contingent on the pleasure of anyone else, not even a parent or a
sovereign nation.
The culture of death developed by the proponents of abortion
makes the world come face to face with a dismally depressing cultural
epidemic. It has been forcing the world to live a kind of self-
destruction, an absence of a desire to grow. Ironically, this culture
has been euphemistically called progress and development. Others
would even call it an ‘enlightenment.’ Now, it can be told that this
culture also makes convoluted minds. While we know that our verbal
and written language is the appropriate vessel of the innermost
thoughts, the abortion advocates have distorted it by using
euphemistic language to make it more attractive to unsuspecting
victims. They too, use it as a vessel, but on a deeper look, it has big
holes at the bottom and its utilization is empty and meaningless, and
cannot therefore hold its real meaning.
In 1970, the so-called economic intelligentsia of the UN, with
the support of the IMF and WB, had predicted that the population of
the world will reach 6.5 billion by year 2000. But in 2008, as
demographers and statisticians had declared, there were only 6.15
billion people in the world – far too great a surplus of 300 plus
million – and this is less than the population of USA of 329 million in
the year 2020. This is too big a number to inhabit the moon.
In 1974 and the succeeding years thereafter, the international
population conferences in Bucharest, Cairo and Beijing,
recommended universal contraception and hundreds of billions of
dollars had been spent by the rich countries and institutions trying to
curb childbearing among married women. That money could have
changed the lives of millions in the third world without homes and
safe drinking water. But nothing of this sort happened. So the poor
just begot poorer children.
The culture of death carried out through abortion procedures
has wrought havoc upon the most hapless, most vulnerable and
defenseless population in any society. Because of the magnitude of
its victims, it has earned a reputation of being the modern-day “ethnic
cleansing” of the most devilish kind, worse than that of Hitler and of
the murderous emperors that walked this earth. Abortion has indeed
surrendered to Satan whatever sanity was left among men.
Mother Teresa has succinctly put it, “if we accept that a
mother can kill her own child, how can we tell other people and even
those who promise to provide health care (italics author’s) not to kill
one another?” It is now uncomfortably felt that the womb, which
should be the safest place on earth, has become a tomb for countless
number of children.”
The moral repugnance of abortion lies in its contemptible
disregard for the innocent life of the baby who is deprived of even
crying for the first time and seeing the light of day. It violates even
the parents, especially the mother, who has to violate themselves of
their privilege to be fathers and mothers. It violates the health care
providers by betraying themselves and the nobility of their profession
as one that should promote life rather than death. It violates the
siblings or the would-be siblings of the unborn child who are deprived
of having relatives to call as their own. It reduces the members of the
human society as helpless and hapless witnesses to a horrible crime.
Lastly, it violates the sacredness of life and its Author who
painstakingly carves the unborn child in His palm and is
contemptuously deprived to be called by his name. These violations
make abortion morally repugnant and obscene.
Lest we forget to note that the pro-abortion Presidents of the
USA are Jimmy Carter, Bill Clinton and Barack Obama and the
whole Democratic Party. Those who were against were Richard
Nixon, Gerald Ford, Ronald Reagan, George W. H. Bush and George
W. Bush and now Donald J. Trump.

Case Studies:
A. An OB-Gyn’s Sham Expertise
An OB-Gyn doctor, a former senator, a priest and a movie star
have been invited for a TV talk show to discuss and tackle the issue
of abortion. The discussion centered on what should be the best
decision to take if a mother was found to be pregnant but was
discovered to have a heart condition that aggravated the pregnancy.
The mother is three (3) months pregnant and has consulted for the
first time an OB-Gyn. This is the OB-Gyn in the TV talk show. She
said that the condition of the mother indicates termination of
pregnancy for better medial management. The former senator
unabashedly told the host that in this case, the best decision was really
to terminate the pregnancy while the baby was still very young in the
womb. The priest echoing the former guests said that in this case one
could use the principle of double-effect so much so that even if we
decide to terminate the pregnancy, such procedure would be ethically
valid and defensible. The movie star, without second thoughts spoke
out that since there was a right to freedom, she could exercise it for
what was good in the situation. “For me,” she asserted, “since the
case is rather a dilemma, I would favor the life of the mother more
than the baby.”
1. What is the common denominator in the opinions
demonstrated by the guests in the TV Talk Show? Justify.
2. Were the answers of the TV guests all ethically tenable?
Why?
 3. In your opinion, what could be the best ethical decision that
can be made in the case being discussed by the TV guests? Why?
4. What should have been done by the TV channel before
guests are interviewed as the ones above, in order to avoid exposing
the public to unethical pronouncements?
B. Abortion or Adoption?
Lhea P. is a 25-year-old housewife and married to an OFW in
Dubai without children. Her husband although regularly
communicating to her, had not gone home for three years. Being
alone and bored at home, she went out with friends and got involved
with a married man. She was impregnated by him and upon knowing
it, she wanted to abort the baby as the pregnancy, according to her
would break her family as her husband would not accept her in her
current circumstance. Lhea goes to you, as nurse, and she wants to
get your advice because she is planning to go to a doctor who knows
how to do the abortion procedure unless the baby is adopted right
after her delivery in a hospital where no one knows her. The baby is
due for delivery in five more months.
1. What are the ethical issues in the case?
2. Afraid of breaking the marriage relationship with her
husband, Lhea decides to have the baby aborted. Is this decision
ethically tenable? In this dilemma, is termination of pregnancy more
important than breakage of a marriage relationship as in the case of
Lhea?
3. Would adoption be a better solution than abortion? Why?
4. Rhea knows that her pregnancy is not her husband’s but of
her married boyfriend. She is afraid that her husband will discover it.
Is secret delivery the solution to her predicament? Should adoption
be the solution to her problem? Why?
C. A Woman, a Priest and a Bishop?
One day, Bernadette P., a 22-year old fashion model came to
the parish office and wanted to talk to the Parish Priest for advice.
She had a very promising career that could insure her long term
economic stability. But, she was eight-week pregnant by her
boyfriend. But the boyfriend did not want to marry her and this
greatly disappointed her. They broke up, hence her going to the
Parish Priest. She told the latter that if no one adopts the child she
would have it aborted. After all, she was not prepared for
motherhood. She further asked the priest to adopt her baby. The
Parish Priest being pro-life readily accepted. A couple of days after,
the Parish Priest went to the Bishop to ask if it was legitimate to adopt
the baby since he had been a pro-life crusader and wanted to show an
example about his advocacy. The bishop candidly told him that his
decision might create a scandal that can seriously put a question on
his priesthood inasmuch as the baby’s presence might be a source of
gossip and rumors by parishioners. This would gravely disrupt his
ministry. So the bishop said that it was not practical to do so. The
Parish Priest was in a quandary as he had already made his promise to
adopt the baby.
1. What ethical issues can be drawn from the case of
Bernadette?
2. Should the Parish Priest, a pro-life advocate, proceed with
his plan to adopt the baby as a concrete example of his advocacy?
3. Which is more important, the Parish Priest’s adoption of the
baby or obedience to the Bishop? Justify your choice.
4. If you were Bernadette, would you continue pregnancy in
spite of losing a long and fruitful fashion career which you know will
emancipate your family from a long-standing poverty? Explain.
D. To Take Another Chance or Not
Charlene A. is a 28-year-old wife and is pregnant for the third
time. She has previously had two still-born children in succession.
After consultation with her OB-Gyn, the latter advised her that there
was a strong reason to fear that the present baby would also be born
dead. She was depressed as it had always been her wish to have a
baby after seven years of marriage without any offspring. She was
confused if it was wise or ethical for her to ask the doctor to terminate
her pregnancy in order to avoid the inconvenience of uselessly
bearing the fetus for some months. Her husband told her that it is up
to her to make the decision and he did not have any objection for
whatever action she would make.
1. Should Charlene A. ask the doctor to terminate pregnancy
based on her previous experience? Is taking another chance at birth
prospect a wise decision to make? Elaborate.
2. Is it truly useless to bear the fetus for some months as
alleged in the case? Will the third pregnancy lead into still-birth? Is
this an ethically- based medicine? Explain.
3. Is the position of the husband about giving her the freedom
to make a decision all by herself and that he will just allow whatever
actions she will make ethically tenable? Why? Why not?
4. What can be done to insure an ethically-based decision on
the case?
 Chapter 24
Your adornment should not be an external one:
…but rather the hidden character of the heart,
expressed in the imperishable beauty
of a gentle and calm disposition,
which is precious in the sight of God.
1Pet. 3:3-4

THE PRINCIPLE OF HUMAN AND CREATIVE SEXUALITY

good distinction of concepts at the beginning of this chapter is
A important and is imperative to use in the principle of human and
creative sexuality. It will provide clarification and understanding to
avoid misconception in the progress of this chapter’s discussion.
Distinction and Clarification of Concepts. An understanding of
important concepts in sexuality will help enlighten towards the
resolution of the confusion that usually accompanies their sometimes
uncontrolled misuse, or worse, abuse. There are good ethical
implications that can be learned here as the distinction of these
concepts will help clarify some mental-sets or paradigms that
confound everyone no end.
1. Sex refers to a specific nature and implies two possibilities
(man or woman, male or female, or boy or girl). It is the biological
rendition of a character of being distinctively a male or female. For
Filipinos, sex is kasarian, a ‘distinct possession’, and it certainly tells
about one’s possession of biological sex. This specific nature is
usually determined at birth because by or in birth, one’s sex is
immediately known. Of course, with the current advances in
imaging procedure technology, biological sex can already be
determined.
2. Sexuality is a characteristic attribute of man and woman
not only in the physical level, but also in the psychological and
spiritual, making its mark on each of the expressions in the mode of
being, of communicating with others, of feeling, of expression and of
living human love. Sexuality is an attribute of man’s nature as having
a capacity to act in a manner that distinctly belongs either to a man or
woman. Although there are many similarities in the behavior of man
or woman, there are also dissimilarities that truly characterize them as
distinct from either or each of them. This attribute becomes the over-
reaching quality that manifests itself in the expression or
manifestation of a person as belonging to either male or female. Any
deviation may be open to various interpretation or understanding.
 3. Gender is
understood under the field of linguistics and culture and includes
three varieties: masculine, feminine and neuter. While sex is the
biological principle, gender is the cultural expression. They are not
identical, but neither are they completely unrelated. Gender is a
sexual orientation. Nowadays, with the current development in the
political and even in legal domain, gender has multiplied in its
orientation or manifestation and now accounts for around sixty-five
(65) kinds of genders and counting.
4. Genitality comes from the Latin term, genus, like gender,
that literally means to generate or produce or breed and it refers to the
physical sexual attribute of the reproductive structure usually
associated with the male and female sexual organ. It is therefore the
generating principle used to carry out the sexual act. Genitality is
primarily physical or biological.
5. Sensuality. It is the quality or state that indicates a
devotion to pleasure of the sense and appetite, especially of the sexual
act and those contributing to its consummation. Hedonism is another
name for it in ancient Greek philosophy. Shankara philosophy is its
Indian equivalent.
The above distinctions should not be considered under a strict
definition of terms. It is an attempt “to clear, so to speak, the air of
dust.” And when this dust settles down, it is easier to discuss the
principles and truths beneath the real principles of sexuality.
Fundamental, Divine and Anthropological Truths about Sexuality
in Genesis. The genesis story about man and woman is heavily
replete with profound basics, anthropological and divine truths about
sexuality.
1. God created man in his own image . . . male and female, He
created them. (Gen. 1:27) The woman is taken from man . . . bone of
man’s bones and flesh of man’s flesh. (Gen. 2:23)
2. Man is the highpoint of the whole order of creation in the
visible world. He was created on the last day and was to have
dominion over all creation. (Gen 1:26)
3. Both man and woman are human beings to an equal degree
as both are images and likeness of God. They are blessed and
commanded to be fertile and multiply, fill the earth and subdue it.
(Gen. 1:27)
4. Man and woman are rational and moral, and are able to
dominate the other creatures of the visible world. (Gen1:20)
5. The man and woman are a “unity of the two”, hence,
marriage arose and is an indispensable condition for the transmission
of life to which conjugal love is naturally ordered. That is why, a
man leaves his father and mother and clings to his wife, and the two
of them become one body. (Gen. 2:24).
6. Both are of weak nature. The woman saw that the fruit was
good for food, pleasing to the eyes, and desirable for gaining wisdom
and she also gave some to her husband, who was with her and ate it.
Their eyes were opened and they realized they were naked. So they
sewed fig leaves together and made loincloth for themselves. (Gen.
3:6:7.)
A sufficient understanding of the truth revealed in the book of
Genesis is necessary if one is to understand the nature and purpose of
sexuality. No manuscript is more patently lucid and unambiguous
than the rendition of Genesis scripture. Many other ancient literatures
also speak about this truth.
The truth revealed in the sacred writing has been the basis of
many moral teachings about sexuality. It is not vulgar nor sensual nor
pornographic. Although sexuality does not preclude the sexual act
between the man and woman and its attendant pleasure or sensuality,
it is presumed that the possession and use of reproductive organs or
capacities (through the use of genitalia) are necessary to carry out the
purpose for which sex was given as gift. Shame was nowhere found
in the original state, but only after man’s falling out of grace from the
Creator. Hence, we see the reason why they were ashamed when they
saw themselves naked after their fall. Gender distinction did not
matter nor was it given focus since sexuality is not understood as an
orientation but as a nature of one’s humanity and its corresponding
social duty. In Genesis sexuality, sexual specificity is more God-
made than man-made. None has been known to be identified as
neither neuter nor homosexual (or gay or any other distinction).
Moreover, man was meant for the woman and vice-versa, and
never was it directed to the beasts. “It is not good for man to be
alone. I will make a suitable partner for him.” (Gen. 2:18). Nor was
it directed to the same sex. For when God brought the woman to the
man, the man said: “This one, at last, is bone of my bones and the
flesh of my flesh; this one shall be called ‘woman’ for out of ‘her
man’ this one has been taken. Gender dysphoria syndrome was
completely unknown in the creation story of Genesis. Gender is a
mere one of a kind among the three since it belongs to an orientation
that is distinctly different as it is perverted, like homosexuality.
Sexuality is one of two kinds which are naturally complementary.
Here is where the wisdom and truth about sexuality in man and
woman are seen, since man and woman are created to insure the
generation of posterity. It is sad to note that the modern medical
books do not anymore identify homosexuality as a perversion but a
normal behavior or condition. But the American psychology still
identifies it to be so.
 Sex, a Natural
and Supernatural Desire for Intimacy. According so some writers,
men and women are naturally attracted to one another; they engage in
sexual activities not only because of the attendant pleasure that they
can derive from the sexual act, but because it is a natural attribute that
they can engage in like eating or drinking to cope with the certainty of
death or biological extinction. The pleasure cannot only be limited to
the physical realm, but extends to the psychological and even the
spiritual domain of man. It can elevate the couple’s relationship to
high levels of intimacy under right conditions, timing, feeling,
mutuality and above all, love. And each sexual act is always a
learning experience that may lead the couple to new discoveries,
realizations and thinking. It can always transcend the mere
concupiscence of the flesh towards a spiritual fulfillment. This is so
because God made sex not only something that belongs to the animal
nature/instinct of man and woman, but also to their spiritual nature
especially when done for a noble purpose.
On a profane level, sexual love involves the elements of
romance, desire and concupiscence. Many ancient literatures, like the
Indian classic erotic book, “Kamasutra” teach men and women
various things about desiring and engaging the beloved in the sexual
act and pursuing the optimum pleasure attendant to it. The desire of
men and women for each other though belonging to their lower
instinct is consummated through all possible avenues of
communication from the bodily to the emotional and spiritual
dimensions. With this, sex takes a plurality of understanding and
satisfaction. Sexual love therefore becomes a passion that is found in
all aspects of the human being. Under the auspices of this passion,
men and women become attracted to each other, thus making sexual
love a uniting factor that can bind a human relationship to mutual and
creative collaboration.
This passion turns a man and a woman on and leads to self-
surrender. They let go of their control of each other’s separateness
and liberate their inhibitions that lead them into self-abandonment. It
gives their body, mind and spirit a high level of ecstasy and intimacy
that only man and woman can understand and feel. This level is
simply called an intimacy of both sense and spirit. It is therefore not
only an experience in terms of sexual orgasm but of intimate spiritual
union. It can even be described as divine and transcendental. It is for
this reason that even spiritual writers believe and understand sexual
love as a human expression of divine love. It is therefore a
“sacrament” symbolic of God’s deepest love for man. Incidentally,
Catholic morals teach therefore that the locus of sex is the institution
of marriage because this symbolic element is deeply grounded on the
love of God and men. It is for this reason why marriage has become
 a channel of divine grace and
it is just fitting that it be one of the sacraments where the reality of
redemption can be experienced. It should not come as a surprise that
marriage has been consecrated by Christ as truly a sacrament that
confers a grace deserving of supernatural life.
Basic Values Recognized in Human Sexuality. Aside from the
truths that can be gleaned from the Genesis story, there are also other
values universally recognized as part of the understanding of human
sexuality, namely: (see also Ashley and O’Rourke, 2002)
1. Personally, sex is a search for sensual pleasure and
satisfaction, releasing physical and psychic tensions. Sex, as many
psychologists understand, is also a therapeutic means that releases
stress and can relax an otherwise anxious person. Accordingly, some
psychologists believe that lack of sexual act can lead to some
depression. Consequently, its sexual exercise is relaxing especially
when done in an atmosphere of legitimate relationship. It was made
to be naturally pleasurable so that men and women will engage in it
and thus the insure the future of humanity.
 2. Interpersonally, sex is a search for the completion of the
human person through an intimate personal union of love expressed
by bodily union of man and woman. Hence, it is also ordinarily
conceived as the complementation of the male and female by one
another so that each achieves a more complete humanity. Their
biological presence in the offspring makes them more interpersonally
connected.
3. Socially, sex has an essentially social dimension. It 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 members. This makes sexuality
a means to the insurance of the future human community.

4. Simply, it
is a gift that comes from a generous God and constitutes a nature that
must be taken care of under the notion of stewardship. It brings with
it accountability because as a gift, it must be utilized under the view
of the intentio dantis (intention of the giver) principle.
5. Ultimately, sex is a symbolic mystery (a sacrament for
Christians), revealing the cosmic order of man and nature. The
cosmic order is characteristically productive and fertile. Hence, as a
sacrament, it means participation and cooperation in the creative
power of God, as a Creator. When there is no more productivity (or
fertility) there is no more growth. When there is absence of growth,
there is no more fruit and when there is no fruit there is only death.
Therefore, sex is a living testament to the power of God as a
productive God revealed in the dynamic world of the living and
where man and woman are dynamic and willing co-creators in the act
of creation by God.
The Principle of Human and Creative Sexuality. The Principle of
Human and Creative Sexuality subsumes the understanding of the
nature and functions of human sexuality and the ethical consequence
attendant to its use. Human sexuality, although sometimes
understood to be part of the principle of the privacy of the human
person, is not always understood nor practiced according to its nature
and purpose because it is regarded as a personal right which men
and women can use at will and according to their caprice and whims.
It is for this reason that normal people demand privacy and secrecy
when they engage in the sexual act. Thus, the principle should not be
called a personalized sexuality because its very nature is never
(solely) personal but is characterized by an attribute of interpersonal
creativity and co-creativity with the Creator. Once human sexuality is
deemed personal then it takes away the attendant obligation towards
God and human community. The personalized sexuality is the view
of the sexual revolutionaries and women’s liberationists which has
been a-priori and a-posteriori condition condemned by Humanae
Vitae (1968) and succeeding teachings of the Church.
Moreover, when sexuality is bereft of the attribute of creativity
and co-creativity, then sensuality, genitality and gender-oriented sex
become an easy and straightforward substitute. When this happens
then, sexuality becomes only a personal necessity to satisfy one’s
need for pleasure. Therefore, the proper term for this principle is
human and creative sexuality.
The following is the Principle of Human and Creative
Sexuality (called Personalized Sexuality acc. to O’Rourke and
Ashley, 2002 under a different line of thought):
The gift of sexuality must be used in keeping
with its intrinsic, indivisible, specifically human
 teleology. It must be a loving, bodily, pleasurable
expression of the complementary, 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
responsibly beget and educate.
To understand more clearly the principle, the ideas below with
help as Humane Vitae has clearly delineated them:
1. Sexuality is human. It belongs to both senses and spirit,
not only to instinct and sentiment. It has its source in one’s human
internal principle and therefore an act of free will intended to endure
and grow. It is nurtured by the richness of human attributes,
enlightened by higher truths and values revealed through the divine
truths. If it is only brought by natural instinct, then human sexuality
is no different from the dogs, cats, birds and bees.
2. Sexuality is total. Engaging in sex should reveal a very
special form of integral personal friendship. The man and woman or
the husband and wife generously share everything, without undue
reservations or selfish motivations. This includes whatever
potentialities that are expected to occur like motherhood or
fatherhood. Sexuality is far-reaching because it is not only limited to
the sexual act but to the consequences of where man and woman
become father or mother and so also benefit the human society.
3. Sexuality is faithful and exclusive. Genuine sexuality is
meant to endure a lasting relationship until death that binds a man and
woman since it is meant to serve a higher purpose beyond the sexual
satisfaction of the persons engaging in it. Hence, the locus and place
of sexuality is a stable union between man and woman consummated
in marriage and never in a perverted union between same sexes or in
unstable relationship. Sexuality lived in marital union becomes
conjugal love in its true form and nature.
 4. Sexuality is fecund or fruitful. It is destined to continue
raising up new lives as it is possible. It is ordained to begetting and
educating children in a stable society. The children are the supreme
gift of God to the family and to the world, and the parents are
privileged to be procreators and co-creators of God. If this element is
absent in sexuality and its use, the world would have become extinct a
long time ago. Here is seen the necessary nexus or connection
between eros and ethos in sexuality. Inferentially, love-making is for
life-making.
The Destructive Views and Perverted Practices of the Gift of
Sexuality. Any opposite view of sexuality from what has been
expressed above can lead to the destruction of the beautiful gift of
sexuality. More so, when it leads to perverted and dissonant
practices. The following can be mentioned here:
1. Gay Marriage. It is the union (legal or illegal) of two
persons of the same sex to live in some semblance of domestic life.
In some states/places in Canada, Europe and USA, this union has
been recognized to be legitimate and is allegedly allowed by their
constitution. Nevertheless, ethically this union is a testament to the
perverted understanding of what sexuality and union of sexes is all
about. It is the very height of a convoluted mind and arrogant
behavior, and is every inch contradictory to common sense. When
this view and practice is allowed to thrive, it is not too remote that
human beings will be marrying creatures other than their own
counterparts – man or woman. We should dread the moment when
humans will uncontrollably have sex with animals. This is ethically
repugnant.
2. Casual or “one-night stand” Sex. This is the favorite
practice of the young aggressive and reckless men and women, done
usually in liberal societies globally. It is called casual because it is
done by way of current agreement and in a hurried and temporary
manner without the intention of establishing a long relationship. It is
sometimes called “one-night-stand” because as the term suggests, it is
done usually once for the purpose of temporary sexual satisfaction
(para makaraos, to say it in Pilipino). Anyone can do it usually in a
very surreptitious and secret fashion. There are no commitments or
responsibilities that perpetrators of this practice should bear, only the
temporary relief from sexual need. Pre-marital sex can also be
included for casual sex. But sex here is between people who have
some romantic relationships.
3. Prostitution. This refers to sex service for a fee. It is
giving sexual gratification to anyone who pays for sexual favor either
from a man or a woman. The solicitor engages a prostitute or
prostituted person in a casually agreed sexual act usually for a pre-
agreed fee.
4. Surrogate Motherhood. Various practices of surrogate
motherhood have been reported and are familiar among many western
countries. The following terminologies according to general
references are important to understand this concept.
A surrogate mother is the woman who is pregnant with the
child and intends to relinquish it after birth. The word surrogate, from
Latin subrogare (to substitute), means appointed to act in the place
of. The intended parent(s) is the individual or couple who intend/s to
rear the child after its birth.
In traditional surrogacy (a.k.a. the Straight method) the
surrogate is pregnant with her own biological child, but this child was
conceived with the intention of relinquishing the child to be raised by
others; by the biological father and possibly his spouse or partner,
either male or female. The child may be conceived via home artificial
insemination using fresh or frozen sperm or impregnated via IUI
(intrauterine insemination) or ICI (intra cervical insemination) which
is performed at a fertility clinic.

In gestational surrogacy (a.k.a. the Host method) the surrogate

becomes pregnant via embryo transfer with a child of which she is not
the biological mother. She may have made an arrangement to
relinquish it to the biological mother or father for them to raise the
child or to parents who are themselves unrelated to the child (e. g.
because the child is conceived and sperm donation or is the result of a
donated embryo). The surrogate mother may be called the gestational
carrier.
Altruistic surrogacy is a situation where the surrogate receives
no financial reward for her pregnancy or the relinquishment of the
child (although usually all expenses related to the pregnancy and birth
are paid by the intended parents such as medical expenses, maternity
clothing, and other related expenses).
Commercial surrogacy is a form of surrogacy in which a
gestational carrier is paid to carry a child to maturity in her womb and
is usually resorted to by well off infertile couples who can afford the
cost involved or people who save and borrow in order to complete
their dream of being parents. This procedure is legal in several
countries including India where due to excellent medical
infrastructure, high international demand and ready availability of
poor surrogates, it is reaching industry proportions. Commercial
surrogacy is sometimes referred to by the emotionally charged and
potentially offensive terms "wombs for rent", "outsourced
pregnancies" or "baby farms".
The Celebrated Case of Baby M. (in google web) It was reported in the
news media that Mary Beth Whitehead, the genetic mother, was
artificially inseminated with William Stern's sperm, becoming the
surrogate mother of the child. Despite what was stated in the
surrogacy contract, Mr. Stern's wife, Elizabeth, was not infertile, but
rather she had multiple sclerosis and was concerned about potential
health implications of carrying a child. A medical colleague warned
her that his own wife, who also had multiple sclerosis, suffered
temporary paralysis during pregnancy.
On March 27, 1986, Whitehead gave birth to a daughter,
whom she named "Sara Elizabeth Whitehead." Within 24 hours of
transferring custody to the Sterns, Whitehead returned to ask for the
baby back, threatening suicide. Whitehead then refused to return the
baby to the Sterns and left the state, taking the infant with her. A
New Jersey court awarded custody of Melissa (as the Sterns had
named her and later became Baby M.) to the Sterns in 1987, under a
best interest of the child analysis and thereby implicitly validated the
surrogacy contract. On February 2, 1988, the Supreme Court of New
Jersey, led by Chief Justice Robert Wilentz, invalidated surrogacy
contracts as against public policy, but in dicta affirmed the trial courts
best interest of the child analysis. The Supreme Court remanded the
case to a family court. On remand, the lower court awarded William
Stern custody and Mary Beth Whitehead visitation rights.
The case attracted much attention as it demonstrated that the
possibilities of third party reproduction had novel legal and societal
ramifications. The case exposed the dilemma of a birth mother
created by contractual agreements and biological bonding. The case
also split feminists who on one side argued that a woman has a right
over her body but were also sensitive to the issue of exploitation. The
surrogacy arrangement was heavily criticized.
There is now a book that Mary Beth Whitehead later wrote
about her experience.
A Brief Legal and Ethical Assessment of Surrogacy. There are
certainly legal and ethical implications of surrogate motherhood.
Legally, there is a legal question as to the parents of the child, the
surrogate or the contracting couple or person. There is a default legal
assumption in most countries that the woman giving birth to a child is
that child's legal mother. In some jurisdictions, the possibility of
surrogacy has been allowed and the intended parents may be
recognized as the legal parents from birth. In the Philippines, the
woman who gives birth is the mother of the child. Many states now
issue pre-birth orders through the courts placing the name(s) of the
intended parent(s) on the birth certificate from the start. In others, the
possibility of surrogacy is either not recognized (all contracts
specifying different legal parents are void), or is prohibited.
The ethical question that arises here is the element of
exclusivity of one’s body as belonging to the couple since marriage is
meant to be exclusive and they are supposed to be faithful with each
other in the use of one’s reproductive organs. The concept of
surrogacy breaks this element. It even treats the womb like a
commodity (or an apartment) available for rent. And it is of sound
ethics that one’s body is never a subject for trade/sale. This is what
happens to prostitution.
Artificial Birth Control (ABC) or Contraceptive Methods.
Artificial methods of contraception are means to prohibit or obstruct
the union of sperm and egg before or after the sexual act and thereby
exclude the occurrence of pregnancy. They may be in the form of
mechanical, pharmacological, surgical, chemical, thermal or the like,
that may either be temporary or permanent. Thus, a sexual act can be
done and yet the methods make it impossible for the sperm and the
egg to unite. Wikipedia observed that it is a regimen of one or more
actions followed or devices used in order to deliberately prevent or
reduce the likelihood of pregnancy or childbirth. It is intended to
reduce the likelihood of the fertilization of an ovum by a
spermatozoon. This birth control is commonly used as part of family
planning. It is the belief and practice of contraception.
Contraception or artificial birth control practices are neither a
novelty nor monopoly of the twentieth century. It began way back
during the Egyptian civilization and was later picked up by
succeeding generations.
Accordingly, probably the oldest methods of contraception
(aside from sexual abstinence) are coitus interrupts, lactation, certain
barrier methods, and herbal methods (emmenagogues).
Coitus interruptus (withdrawal of the penis from the vagina
prior to ejaculation or vice-versa) probably predates any other form of
birth control. Once the relationship between the emission of semen
into the vagina and pregnancy was known or suspected, some men
began to use this technique. This is not a particularly reliable method
of contraception, as few men have the self-control to correctly
practice the method at every single act of sexual intercourse.
Although it is commonly believed that pre-ejaculate fluid can cause
pregnancy, modern research has shown that pre-ejaculate fluid does
not contain viable sperm.
Moreover, there are historic records of Egyptian women using
a pessary (a vaginal suppository) made of various acidic substances
lubricated with honey or oil, which may have been somewhat
effective at killing sperm. However, it is important to note that the
sperm cell was not discovered until Anton van Leeuwenhoek invented
the microscope in the late 17th century, so barrier methods employed
prior to that time could not know of the details of conception. Asian
women may have used oiled paper as a cervical cap, and Europeans
may have used beeswax for this purpose. The condom appeared
sometime in the 17th century, initially made of a length of animal
intestine. It was not particularly popular, nor as effective as modern
latex condoms, but was employed both as a means of contraception
and in the hope of avoiding syphilis or other sexually transmitted
diseases (STD) which was greatly feared as devastating prior to the
discovery of antibiotic drugs. The modern condom is believed to
prevent the spread of AIDS during the sexual act, but it has been
proven not to be 100% effective. This is due to the fact that latex
condoms are not perfect blockers and they have holes that are 5,000
much bigger than the AIDS virus. Hence, there is real danger in their
use.
The other modern methods of contraception are surgical, like
vasectomy and tubal ligation, spermicides or gels to kill the sperm,
Intra Uterine Device (IUD, which is actually an abortifacient),
heating of scrotum before sex, Patch (Norplant), diaphragm,
injectables (Depo-provera) and the morning after pills like the
RHU-486.
The RU-486 Morning-after Pill and How it Works. RU means
Roussel Uclaf. It is French Company and a subsidiary of Germany’s
Hoechst, originally I.G. Farben, which is responsible for the
manufacturing of Zyklon-B gas used by the Nazi at the gas chamber
to eliminate the Jews.
Etienne-Emile Balieu is a Jew and the inventor of this
morning-after pill. He changed his name to Leon Blum to avoid
being killed by the gas invented by a company he now works for.
RU-486 imitates progesterone that signals the uterus to
become receptive to the fertilized ovum. It is used with prostaglandin.
It contains progesterone analogue and is anti-hormone. RU 486 is
actually a poison and its role is to deny the blastocyst of attachment to
the uterus and starves it for want of nutrients and oxygen. It kills
babies of less than 5 weeks in the womb. Thus, the RU 486 is not a
contraceptive but an abortifacient, for why should it be used after the
sexual act when it can well be used before it, if indeed it is a
contraceptive?
Why Artificial Birth Control Methods are Frowned upon as
Immoral. There are basically four reasons why contraceptives are
frowned upon as immoral by the Church. These are the following:
1. Anti-Sexuality. As discussed above, sexuality is for the
begetting of offspring. Its nature is not essentially personal but goes
beyond the individual freedom to use it. This is due to the fact that it
has a social dimension, i.e., it is for the preservation of humanity.
2. Anti-Love. Sexual act is not only for pleasure. It is
genuinely meant as an expression of one’s love for the partner,
including the acceptance of the partner’s potentiality to be a mother or
father. Contraception negates this purpose as it makes impossible the
procreation of children.
3. Anti-Health. Many of these contraceptive methods bring
some ill-effects or risks that are both physical and psychological. The
contraceptive pills, tubal ligation and other methods may lead to
cancer. Others bring with it recurrent pain in the back especially the
IUD. The gels and spermicides can cause allergy. “Coitus
interruptus” becomes worrisome for the couple as interrupting the
ejaculation in the vagina is difficult to do. Heating the scrotum can
make the male infertile. Injectables, Patches and RU 486 are poison
and can adversely affect the blood. Hence, these contraceptive
means are risk to human health.
4. Anti-Person. A person is meant to be loved and treated
not solely as an object of leisure and pleasure. When the purpose is to
have pleasure alone without the responsibility of having an offspring,
the woman is treated as a plaything, as well as, the man. Since there
is no intention of having a baby, those who engage in sex with the use
of artificial contraceptives do so only because of the pleasurable
orgasmic feeling they want to experience. When this happens men
and women violate themselves by acting against their persons and
sometimes they are not even aware of it.
 The
Natural Family Planning, the Ethical Alternative to
Contraceptives. The most natural among birth methods that follows
the natural law is the Natural Family Planning (NFP Method. The
natural method of family planning is also the most effective way to
plan a family, both by controlling the number of offspring or by
having offspring. It employs knowledge of the pattern and behavior
of human nature and uses it to either produce or control the number of
offspring without the use of artificial methods. It also uses the power
of the will by way of periodic abstinence from sexual intercourse on
days in which the woman is fertile and also the engagement in sex
even when the woman is infertile. There are various ways to use the
NFP and there are three main types: a. the symptoms-based method,
b. the calendar-based method, and c. the lactational amenorrhea
method. The symptoms-based methods rely on biological signs of
fertility. The three primary signs of a woman's fertility are her basal
body temperature, her cervical mucus, and her cervical condition.
Computerized fertility monitors may track basal body temperatures,
hormonal levels in urine, or changes in electrical resistance of a
woman's saliva.
From these symptoms, a woman can learn to assess her
fertility without use of a computerized device. Some systems use
only cervical mucus to determine fertility. Two well-known mucus-
only methods are the Billings Ovulation Method and the Creighton
Model Fertility Care System. If two or more signs are tracked, the
method is referred to as a symptom-thermal method. Two popular
symptom-thermal systems are taught by the Couple to Couple League
and the Fertility Awareness Method (FAM) taught by Toni Weschler
(though not connected with the Catholic Church, www, 2000). The
Calendar-based methods estimate the likelihood of fertility based on
the length of past menstrual cycles. They include the Rhythm
Method and the Standard Days Method. They can be used even if
the woman has irregular menstrual period.
The Calendar-based methods estimate the likelihood of
fertility based on the length of past menstrual cycles. They include the
Rhythm Method and the Standard Days Method. They can be
used even if the woman has irregular menstrual period. The
Lactational Amenorrhea Method (LAM) is a method of avoiding
pregnancy based on the natural post-partum infertility when a woman
is amenorrheic and fully breastfeeding. The rules of the method help
women identify and possibly lengthen their infertile period.
Therefore, a longer period for sexual intercourse can be done without
fear of having an offspring. A strict version of LAM is known as
ecological breastfeeding.

The Case of
Transgender and Transsexual Persons. This section does not
follow a politically correct narrative as the ethical principle behind
human and creative sexuality is immune from political steering.
What is ethically right or right wrong does not always follow the path
of politics because the latter usually take the path of convenience as it
pays into the gallery of what is popular or practical and not what is
right or wrong. Ethics is toes the line of what is based on Natural
Law Principles.
Whereupon, giving a simple description of the term
transgender and transsexual is in place. A transgender person is
one who according to medical science experts have gender
dysphoria. It is that condition in which a person feels or believes that
he has the wrong biological sex because he (wants to) thinks, acts,
dresses or loves in the likes of the other gender or sex. So a
biologically born male believes or thinks he is female or the same is
true with the biologically born female who believes or thinks she is
male. A transsexual person is one who undergoes sex or gender
changing surgery to become ‘physically’ the sex or gender he or she
wants to be. So, a biologically born male, for example, undergoes
surgery to remove his penile attribute and the surgeon subsequently
supplants to make it into an attribute in the shape or form of the
female vagina. Now, he is not only a transgender but a transsexual
person.
The Reverend Nicolas Austraco, a Dominican cleric and a
molecular biologist who works in the UN says, “The human person is
biologically made up of millions of molecules specific to his
biological sex.” Thus, these molecules function in united
coordination like an orchestra that works in unison in order that the
human person act in a way that is specific to his male or female
sexuality, as the case may be. When these molecules are distracted or
destructed, these molecules are unnecessarily disturbed that in the end
they become confused and move wildly into different directions. So,
even the biology of the whole human body is substantially affected.
Hence, there will be a different biological behavior that will occur in
the person. Lastly, Austraco continued saying that human dignity is
never extrinsic. It is intrinsic and will never be different from what it
was biologically determined at conception.
Moreover, another expert, Dr. Jordan Peterson, a clinical
therapist with over thirty years of practice, had said it absolutely clear
that “a person who is born with a male or female sex can never
become female or male respectively, no matter how he or she may
want to.” So, from the scientific accounts of these experts, one can
say that indeed a biologically born person is one who he is
specifically either male or female and will never belong to another
sex (or gender). The feelings of a person do not make one belong to a
gender that he chooses (or wants) to be. Doing so is unnatural and
impossible. This is usually the argument of those who believe that
they are only imprisoned in a body they do not belong into. What
they feel is what they are. The argument by well-meaning people
tells that this is untenable. This is so because when a person who is
already 60 years old and still thinks that he is 30-years old, does not
really make him actually 30-years old. Feelings do not a person
make, more so a transgender or transsexual (as when he or she does
transsexual sex changing surgery).
The Catholic Church’s Stand and the Humane Vitae Encyclical.
The encyclical, Humane Vitae (# 1) recognizes so solemnly that:
. . . the most serious duty of transmitting human
life, for which married couples are the free and
responsible collaborators of God the Creator, has
always been a source of great joys to them. Even if
sometimes accompanied by not a few difficulties and
distress.
At all times the fulfillment of this duty has
posed grave problems to the conscience of married
persons, but, with the recent evolution of society,
changes have taken place that give rise to new
questions which the Church could not ignore, having
to do with matter which so closely touches upon the
life and happiness of men.
Taking cue from the above and in view of what
the nature of sexuality is, the Catholic morality holds
that God created sexual intercourse to be both unitive
and procreative. Thus, artificial birth control
methods are forbidden as acts intended to end in
orgasm outside the context of intercourse under the
 unitive and procreative purpose of sex (e.g. oral sex
that is not part of foreplay). At the same time, not
having sex at all (abstinence) is considered morally
acceptable.
Having sex at an infertile time in a woman's life (such as
pregnancy or post-menopause) is also considered acceptable, since
the infertile condition is considered to be created by God, rather than
as an act by the couple. Similarly, under Catholic theology, it may be
morally acceptable to abstain during the fertile part of the woman's
menstrual cycle as an act of freedom of choice. Increasing the post-partum
infertile period through particular breastfeeding practices ---the
lactational amenorrhea method---is also considered a natural and
morally unobjectionable way to space children.
The Catholic Church acknowledges a potential benefit of
spacing children and the use of NFP for this reason is encouraged.
Humanae Vitae (1968) cites "physical, economic, psychological and
social conditions" as possibly compelling reasons to avoid pregnancy.
Couples are warned, however, against using NFP for selfish, immoral,
or insincere reasons. A few Catholic theologians argue that couples
with several children may morally choose to avoid pregnancy, even if
their circumstances (emotional, physical and economic) would allow
for more children. An act of conscience is not repugnant in this case.
More commonly, Catholic sources extol the benefits children bring to
their parents, their siblings, and society in general, and encourage
couples to have as many children as their circumstances make
practical.
In addition, what should be said about the charge that while
artificial birth control is about avoiding children the NFP is also about
avoiding children? What is the difference between the two? The
Humane Vitae (#15) has the following answer:
To this teaching of the Church on conjugal
morals, the objection is made today, as we observed
earlier that it is the prerogative of the human intellect
to dominate the energies offered by irrational nature
and to orientate them towards an end conformable to
 the good of man. Others ask on the same point
whether it is not reasonable in so many cases to use
artificial birth control if by so doing the harmony and
peace of a family are better served and more suitable
conditions are provided for the education of children
already born.
Neither the Church nor her doctrine is
inconsistent when she considers it lawful for married
people to take advantage of the infertile period but
condemns as always unlawful the use of means which
directly prevent conception, even when the reasons
given for the later practice may appear to be upright
and serious. In reality, these two cases are completely
different. In the former the married couple rightly use
a faculty provided them by nature. In the later they
obstruct the natural development of the generative
process. It cannot be denied that in each case the
married couple, for acceptable reasons, are both
perfectly clear in their intention to avoid children and
wish to make sure that none will result. But it is
equally true that it is exclusively in the former case
that husband and wife are ready to abstain from
intercourse during the fertile period as often as for
reasonable motives the birth of another child is not
desirable. And when the infertile period recurs, they
use their married intimacy to express their mutual love
and safeguard their fidelity toward one another. In
doing this they certainly give proof of a true and
authentic love. (#15)
Thus, the NFP cannot be branded as contraceptive because it
can both be used to produce or not produce offspring by using the
natural patterns of the fertile and infertile period of the woman. The
artificial birth control (ABC) method has for its sole purpose the
contraception of any birth and can never be used to have it. This is
the basic difference between the NFP and ABC.
 Sex Education
with or without Values. Worldwide, there has been serious clamor
for sex education not only for adults but more so for minor and small
children. The question is what is the appropriate age by which sex
education can be initiated? A common judgment is when the children
reach the age of reason. More properly designated by psychologists
to be at the age of seven (7) (and should be a continuing process even
until death). It is at this stage of the children’s developmental age
that they begin to know and distinguish (though initially in very
ingenuous childlike manner) right from wrong; or good from bad.
Sex education can benefit the learners when they are done in a
way that leads to maturity, responsibility and not malice. The
psychological development education of the learners must not be
taken for granted. Sex education, as in other educative endeavors,
must cultivate first and foremost the mental development of the
person including their attitude and not only their skills in doing good
at the sexual act. Sex education program therefore must always
include values since sexuality is a deeply value-laden subject matter.
Values (moral values) are essential themes that give meaning to sex
education, otherwise it will only lead to pointless curiosity and
irresponsible sexual activity. Values are the saving graces of sex
education. Without them as inherent parts in the process, sex
education becomes a course in sexology and anatomy of the
reproductive system, a psychology module of the Freudian type, and
an attractive invitation to curiosity of the bizarre and prying mind.
The first sections of this Chapter should be considered well to be able
to imbue a genuine sex education to the educands.
 The following construct may well clarify the distinction of sex
education with and without values:
Table 3.
With values: Without values:
Genuine sexuality Sensuality
Responsible Exercise in mutual
complementation of both pleasurable genitality
sexes
Well-formed Conscience Lust
Socially responsible act Social permissiveness
Noble gift and act of Pornography and
generosity commercialization
Selflessness Licentiousness
Sacredness of sexuality Reproductive anatomy
The table illustrates the contrast between the understanding of
true human and creative sexuality and on the other hand, the idea of
liberal and irresponsible sexuality. When the practice of true
sexuality goes beyond the red line limitations, it leads to
consequences that are ethically deplorable. In the second column
above, it is feared that humans will become uncontrollably
irresponsible which is hedonism. The events in Sodom and
Gomorrah should remind humans of the consequences of this
irresponsible behavior.
 The How of Sex
Education. This is a follow through of the above idea about sex
education. Herein is the basis on what sex education is all about. It is
noteworthy that the concept of education is that it is kind of formation which
is a preparation for life. It is intended to help the individual to realize
the fullness of his or her capacity and to help him live up to his
responsibilities. It is meant to help him live a happy & contented life,
in harmony with his fellowmen & environment.
Now, sex education is part of this education. Similarly,
preparation of men and women to fulfill their specific functions in the
family and to a larger extent, in the society. It is meant to help them
understand the function and role of sex in their lives and is meant to
help them utilize their sexual capacities adequately and with a sense
of responsibility.
It is good to note that the following elements in sex education
should always be considered. These have been articulated well by a
well-known physician, Dr. Vicente Rosales. Below are these
elements, namely:
1. Involves more than biological, physiological and technical
aspects of reproduction – not only about anatomy and physiology of
genitals, of sexual intercourse and of the process of birth. It is
concerned with human values, ethical principles, attitudes and modes
of behavior that identify one as male or female as discussed
thoroughly above.
 2. It is different from simple sex instruction. Instruction deals
with providing information about facts of reproduction. Education
deals with giving information and formation of attitudes or outlook of
the young. It guides their emotional growth to have healthy attitudes
about sex to guide behavior in sexual matters.
3. It does not consist only of prohibitions meant to control
excessive desires. It should provide guides towards the best
development of genuine maturity. It means avoiding and correcting
abnormalities that can delay or arrest the process of sexual
maturation.
4. It means overcoming inhibition and embarrassment about
sex developed in childhood and adolescence. Persons who will
impart sex education must have the needed factual knowledge, and
must have the correct attitudes so that they may give correct guides to
various occasions concerning sexual matters.
Whereupon, by the time the child becomes an adult, he should
take as the following aims of sex education, namely:
1. He should feel complete biological and physiological maturity.
2. He should have the normal tendencies, drives, and impulses
towards sexual fulfillment.
3. He should be physically able to carry out his sexual functions.
It good to note that a frustration at this point may lead to
perversions and problems of impotence and frigidity.
The Case of the Sexual Revolution of 1820’s. This section is
included in order to introduce the reader to the so-called sexual
revolution that has made great and influential inroads in the way the
world thinks sexuality should be in the 19th century as advocated by
the so-called extreme liberals and feminists that started in the west.
Moreover, this will orient readers about the complex problems that
the revolution has brought to the contemporary society.
John F. Kippley (2001) claimed that the sexual revolution
started in 1820’s. In 1798, an economist and Anglican clergyman,
Thomas Malthus, started the population scare with this gloomy
prediction that population would outstrip the food supply. (See Chap.
22, ad supra). Malthus recommended late marriage and sexual self-
control, i.e., total abstinence, once the desired family size is reached.
In the early 1820s, however, an article appeared in the Encyclopedia
Britannica that transmitted the population scare but inferred that
contraceptive behaviors could be used for family limitation. Soon
everybody was talking about the article. This introduced the
philosophy of the neo-Malthusians who promoted contraception as
the answer to the dire population predictions. They probably got a
technological boost when Charles Goodyear accidentally discovered
the vulcanization of rubber in 1839 because that made it easier to
manufacture condoms.
This so-called neo-Malthusian advocacy of contraception in
the 1820’s has started the sexual revolution as it was the first time in
history when socially respectable people in Christian culture openly
and systematically recommended forms of birth control condemned as
immoral by all the churches. For the first time in Christian history
some people were saying that it was morally permissible for married
couples to take apart what God Himself has put together in the
marriage act.
American Protestantism strongly resisted the inroads of the
neo-Malthusians when they attempted to spread their doctrines in the
USA.
Margaret Sanger, acknowledged as the foundress and direction
setter of Planned Parenthood, established her first organization, the
National Birth Control League, just before the WW I and became the
leading proponent of the sexual revolution in the USA. Since then all
efforts about sexual revolution and contraceptives were tied to her.
The sexual revolution flourished, but in 1929 the national
writers were one in condemning it as contrary to human nature. Had
the churches maintained their universal stand against contraception, it
would not have been engraved into the mind of the people. When this
has been sown in the popular mind, and with married couples publicly
welcoming the pill when first marketed in 1960, the flames of the
sexual revolution roared out of control.
What is called the sexual revolution of the 1960’s was the
widespread acting out of the basic premise by single and married men
and women who got into spouse-swapping and very easy going
adultery. The more rebellious even charged that the Bible was and is
out of date.
Homosexuals also joined their voices to the sexual revolution.
No longer did they and others say their orientation was a disease,
perversion or a weakness. In the 60s they were linking their behavior
to the population scare and were saying that sodomy was not only an
acceptable behavior but a progressive way of life because it did not
result in babies, ‘only HIV infection’.
It was during these tumultuous times that the encyclical
Humanae Vitae (1968) was declared to respond to new questions
raised by the use of contraceptive and abortifacient pills and
reaffirmed the Christian tradition against all unnatural forms of birth
control. This encyclical did not proceed smoothly without
tremendous opposition. In fact, groups organized by a handful of
priests called for dissent before anyone had the chance to read the
encyclical. Up until now, there is opposition among the clerics and
it has been alleged that the encyclical has failed many around the
world as it was very unrealistic to practice its provisions.
Accordingly, the poor families have always been the unwilling
victims of the strictures and restrictions of the Humanae Vitae. This
of course remains to be proven and a good research is highly
imperative to prove the conflicting positions especially in the present
dispensation.
The Predictive Nexus/Link between Contraception and Abortion.
What has contraception got to do with abortion? Is there a predictive
nexus/link between contraception and abortion? asks the well-
meaning public. The pro-lifers do not mince any word when they
say a categorical “yes”. They say that when contraception fails,
couples resort logically to abortion as this will be the final means to
get rid of delivering offspring. This is predictive as contraceptive
practices are preponderant of the practice of abortion. This is one of
the reasons why there is great fear that the proliferations of the use of
contraceptives will eventually lead to the use of abortifacient means.
This has been proven in many medical and social studies and cannot
be dismissed so easily. The following can give us enlightenment.
A. J. Montalvan II (PDI, 2008) writes candidly regarding the
uncomfortable truth about the predictive connection and essential
inseparability and identity between contraception and abortion. In the
Philippine Congress, several congressmen have shown a facade that
they want us to see. Representatives in previous Congress, Edcel
Lagman, Janette Garin, Narciso Santiago III, Mark Leandro Mendoza,
Eleandro J. Madrona and Ana Teresa Hontiveros-Baraquel would like
us to believe that their bill respects religious convictions and is not
pro-abortion. The house bill that goes under the lengthy title: “An
Act Providing for a National Policy on Reproductive Health,
Responsible Parenthood and Population Development, and for other
Purposes” and referred to in brief as the Consolidated Reproductive
Health Bill, has passed through an unprecedented time of two minutes
without any discussion. It is expected to proceed to the plenary
session without dragging more controversies.
In a bill that avows a “full range” of family planning methods,
both natural and modern, this stance remains much of a lame
proposition. We can hardly believe that the bill’s authors are
ignorant of the inarguable fact that many contraceptives are within the
full range of abortifacients. And nowhere does the bill denounce
abortifacients, at the very least. However, as a matter of fact, the
intra-uterine device (IUD) prevents a fertilized egg from being
implanted into the uterine wall, or if it does, prevents it from
growing. Its purpose is to abort. The pill does not always stop
ovulation but sometimes prevents implantation of the growing
embryo into the uterus. The new RU-486 (morning-after) pill works
by aborting the fetus, hence, it is an abortifacient.
Further, Montalvan continued that there is a grave
contradiction there. Not only is it a contradiction, it is a grievous
mistake. By its failure to address abortion as an odious and
repugnant (italics author’s) reality in our society, how can our elected
representatives claim that they labor for the progress of that society
where even a new life cannot have the privilege of safety, much less
of the light of day?

Quoting Janet Smith, a professor of

philosophy at the University of Dallas, Montalvan asserts that: “We
need to realize that a society in which contraceptives are widely used
is going to have a very difficult time keeping free of abortions since
the lifestyles and attitudes that contraception fosters create an alleged
“need” for abortion.

Abortion is often the result of sexual relationship

in which there is no real “intimacy and love”, but only lust.
Contraception enables those who are not prepared to care for babies
to still engage in sexual intercourse; when they become pregnant, they
resent the unborn child for intruding upon their lives, and they turn to
the solution of abortion.
The argument against the concept, often misused by many of
our legislators, that contraception is the antidote to abortions and
unwanted pregnancies, is a simple one. Contraception has been
highly practiced in the world for ages. Within this time frame,
unwanted pregnancies and abortions have not gone down. The
argument is clearly fallacious. Thus, where contraception is
pervasive, so is abortion. For failure of contraception leads to
abortion.
 Lagman et al. define “full range” as “hormonal contraceptives,
intrauterine devices, injectables and other allied reproductive health
products and supplies shall be considered under the category of
essential medicines and supplies that shall form part of the National
Drug Formulary and the same shall be included in the regular
purchase of essential medicines and supplies of all national and local
hospitals and other government health units. This certainly is a
travesty of what medicine and essential drugs are concerned. For
medicines are meant to promote and prolong life, not to prevent or
even destroy it. These legislators could have known better.
Notice the term “essential medicines”. There is here at once a
pharmacological and social meaning. This is a classic American
contraceptive mentality that Montalvan observes. But this has been
unmasked by the realities of demographic truth. Babies are no
accident of pregnancy. There are no pregnancies by accident.
Babies, not contraceptives, are the fuel to our understanding of a
healthy society. Contraceptives are a sign of a degenerate humanity
who are unable to recognize the gift of sexuality and the gift of
children.
Sexuality and Responsibility. Sexuality as a gift to human beings
always brings with it an attendant responsibility just like any wealth
that is acquired or received. While humans enjoy the attendant
pleasures that accompany it, human beings are responsible for the
concomitant fruit or fruits that may result from its practice. Like
wealth, human beings are expected to use it wisely and be responsible
for whatever may result from its use. Therefore, aside from the
responsible use of this gift of sexuality, there is responsibility that
extends to its attendant result. The irresponsible use of this gift
happens when human beings are only after the pleasure but not the
concomitant responsibility, like the offspring that may result from it.
The Church, however, does not prohibit the use of
human sexuality as a right and natural act of a sexual being. This
should not be understood that it cannot be controlled by the will since
any human act should be under the direction of one’s freewill. The
Church only tries to promote discipline and responsibility. It simply
means that when couples can afford then by all means they can go for
it. If not, then discipline should be applied.
A Church shepherd has candidly expressed his insight about
the so-called Philippine congressional “Reproductive Health Bill” as
understood by the lawmakers. He said, “In the Roman times,
wealthy families were known for their love for feasting, eating,
drinking and merrymaking. In their houses, there was a thing called
vomitorium. The practice was then when they were filled up, they
would go to the vomitorium, tickle their throat to vomit what they had
eaten or drunk. So they were hungry again and would eat again.”
(Inquirer, Sept. 17, 2008). Reproductive health bill therefore is
similar to the use of vomitorium – couples have sex, put it in, spit it
out, have sex again and again without regard for the attendant
responsibility beyond copulating.

Case Studies:
A. The Daughter of my Mother is my Daughter
The couple Ryan and Judy have lived their marital life for
eight years, but have not been blessed with a child. They have
consulted various specialists and underwent many procedures both
physical and psychological with the hope that Judy will eventually
conceive. Everything turned out to be unsuccessful. The doctor
suggested that the only way left for them to have a child is to have
Judy’s mother, who was still of productive age to donate her egg and
have it fertilized by the sperm of her husband. It was done through an
In-Vitro Fertilization (IVF) and was successfully placed in her uterus
through artificial insemination (AI). Judy conceived and eventually
delivered the child.
1. What are the ethical sexual issues in the case?
2. Is the procedure of IVF and Artificial insemination ethical
or not? Why?
 3. Are there legal implications to the procedure? What are
they?
B. “He is my Baby, I Delivered Him”
The couple Cesar and Shine, both 34 years-old have been
married for nine years but have not been blessed with even a single
child. They have always desired to have one because according to
them, they are not getting any younger and it is time to have a baby
because they are now economically stable. They have consulted
various doctors and were advised to do many sorts of things for the
purpose of having a naturally conceived child. Cesar has a low sperm
count. Shine though does not have any problem with her
reproductive system. Unfortunately, none is forthcoming. Finally,
they decided to borrow the womb of their friend, Rufina, single and
28-years-old. The latter agreed for free and was even excited about
the idea. After doing the necessary work ups, Rufina was pronounced
“serviceable”. After fertilizing the couple’s sperm and egg in a petri
dish, the doctor inseminated it into the uterus of Rufina. It was
successful and pregnancy occurred. The baby was delivered but a
deep emotional attachment had bound Rufina and the baby that she
decided not to give the baby to Cesar and Shine. In the ensuing
conflict, Rufina said that it is her baby because she delivered him
from her womb. According to law, she who delivers the baby
belongs to her as a mother.
1. What can you say about the agreement between the couple
Cesar and Shine and their friend Rufina in terms of public policy?
2. What is the ethical dimension of surrogate motherhood?
3. What can you say about the law on delivery of babies?
What are its legal and social implications?
4. If you were Rufina, would you give the baby to the couple
in spite of the sacrifice you will make in terms of emotional
attachment?
C. The Foreplay that She Enjoys but later does not Like it
 Edmundo and Lilibeth are a couple in their 30’s. As a young
married couple, they engage in foreplays when making love by doing
acts such as fellatio and cunnilingus. They enjoy them as part of their
sexual rituals. Lilibeth is a religious woman who spends time for
mass and prayer everyday. Lilibeth however mentioned the foreplays
to another religious lady who was asked about her opinion on it. Her
friend was shocked about it to the point of being scandalized. She
told Lilibeth to stop it as engaging in them is against sexual morality
and decency. Lilibeth was worried about her sexual practice. Later,
she did not want to do it with her husband who later was furious
about the sudden change in her sexual behavior.
1. What is ethical or unethical in foreplays?
2. Was the lady friend ethically correct in her view about
sexual foreplay?
3. What can be done ethically with regard to sexual foreplay?
4. Do they deserve censure or commendation from the
Church? How?
D. A True and Loving Couple in a Dilemma
Eduardo and Marianne are in their 16 years of marriage and
have five (5) children (ages 5 to 15) who are in school save the
youngest. “Another child,” they said, “will have a toll on their
dwindling family income,” since they have not really earned anything
outside their employment. He is in a construction firm as a technician
and she works as a nurse in a tertiary hospital. They have already felt
the pinch of the economic grind since the third child. To avoid
another baby, both resort to withdrawal and sometimes use
condoms. But Eduardo and Marianne are a conscientious couple
who would go to confession every time they use the above
contraceptive means because they are both Catholics. Further, they
believe that confession and going to mass and receiving communion
are sources of their spiritual comfort. The priest whom they consult
about their situation said that he understands well their predicament
and told them to come every time they need confession. The priest
also believes that the couple really love each other.
1. What do you say about the couple’s practice of
contraception? Is this a vicious immoral practice?
2. The couple is understandably conscientious as they take to
their heart the seriousness of the consequences of their actions. What
do you say about their religious practice? Do you think it is ethically
objectionable to use these contraceptive methods? What if they
invoke the principle of conscience? Explain.
3. What can you do ethically to help the couple in such a
dilemma?
4. Do they deserve censure or commendation from the
Church? How?
5. What can you say about their going to confession then
doing it again (and again)?
E. The Gay Love
Rey and Roy are gay lovers. They have endured their mutual
relationship for nine years and are about to celebrate their tenth
anniversary. They are both Filipinos, but went to California to marry
each other in a civil ceremony. They are now back in the Philippines
and live as a couple in a house they rent. They introduce themselves
to friends as a couple and even petition the court to avail of social
services just like the other citizens. They have adopted a male baby
boy to complete their being a family even without legal papers. In
filling up bio-data, they indicate their civil status as married to each
other. Those who criticize them are not enlightened, they say.
Further, they say that even Anglican priests have already allowed gay
marriages. What is there to stop their love and making it legitimate
before the eyes of the society? Accordingly, they charge that
criticism against their union belongs to a primitive myth and taboo
which in the modern age are obsolete. They continue by saying that
their love does not hurt them, neither does it harm others.
1. What can you say about the marriage of Rey and Roy? Do
you believe that their union hurts neither them nor others?
 2. What can you say about their having adopted a baby? What
if they just take care of pets like their own children?
3. What ethical principles can be applied to the union of Rey
and Roy?
4. Do you think that they cannot fulfill the task of parenting
over the adopted child? How?
F. The Gay Parenthood
Since gay marriage has been legalized in California, other
countries like Spain and some states Canada, many gays, like Tramey
and Fronsi have trooped to the city hall to contract marriage with each
other. Since they believe that marriage should lead to a family, they
are convinced that they have a legal right to have children. But since
this is impossible through the natural mode and neither through the
“back door” or the “labial frontage”, they now can adopt children and
raise them as children of their own. Now, their wish can come true.
They have applied for adoption of a little baby who was offered for
adoption by an unwed mother. They are upbeat about it.
1. What do you think about adoption by gay couple? Is it
ethical for them to do it?
2. Do you think that they can fulfill their responsibilities as
parents of the baby given their sexual orientation and function?
3. What obstacles can you think of about gay parenthood?
4. Can adoptees have an ethical argument (when they are of
the major age) to disengage themselves from their gay parents in case
they dislike such arrangement?
 Chapter 25
I willingly boast of my weakness,
that the power of God may rest upon me. . .
for when I am powerless, it is then that I am strong.
2Cor. 12:9-10

BIOETHICS OF DEATH AND DYING

nother controversy-laden issue in Bioethics is about death and dying.
A This chapter will delve on the concepts and controversies and
how bioethical principles can be applied in and over the many
issues regarding death and dying. This will also include related
topics of interest.

The Controversies
in the Care of the Terminally-ill. A multi-faceted view in the care
of the terminally-ill is to be expected when such care reaches a point
in which some radical decisions have to be necessarily made within a
certain and limited period of time, and not indefinitely. The
moralists, the lawyers, the judges of the courts of law, the physicians,
allied health professionals and the family join the fray when making a
collective solution in view of the interest of the patient. This scenario
becomes indeed difficult to face or solve when the patient is
irreversibly-ill or is unconscious. The solution to it, more often than
not becomes elusive. Medicine has its limits just as life has its own.
God’s will has to be considered for it is not within the power of
human beings to end life or is it? Hence, the concept of playing God
crops up into the scene. Many ask, “Who plays God?” The answer
depends on which point of view is presented. When this happens,
then indeed there would be serious ethical issues about the concept
and reality of death and dying. Unless health care professionals have
a good grasp of the concepts and principles related to the issues and
apply them accordingly, it would be almost impossible to arrive at a
good ethical decision. The tendency to relegate ethical decisions
concerning death and dying to the courts of law adds even more
controversies to the already controversy-laden situation. Many well-
meaning people do not want the courts of law to make solution or
decision concerning death and dying because they do not want the
judges to preside over the life and health of patients. The doctors and
families should. Unfortunately, this situation will not disappear so
long as the important questions in death and dying are not
satisfactorily answered.
The following questions have to be reckoned with in order
to facilitate the process of arriving at a good ethical decision when
faced with the prospect of death and dying, namely:
1. When the patient is terminally-ill, is it ethical to remove
LSD (Life Sustaining Device) or other interventions which are the
only means that could keep him alive? In the first place, when is a
patient considered terminally-ill?
2. When we remove these interventions, and the patient
dies, don’t we kill him? Or do we just allow him to die? Are these
concepts only semantics or is there an objective distinction between
killing or letting die?
3. If the interventions just prolong the dying process, is it
ethical to continue applying them? Are there limits to the
prolongation process?
4. Can the family ask the AMD (Admitting Medical
Doctor) to withhold or remove LSD on a terminally-ill patient? Or
should it be the doctor who should ask the former?
5. When are interventions considered ordinary or
extraordinary? Are food, drink and oxygen always considered
ordinary?
6. When the decision to remove LSD has been agreed
upon, who will do it?
7. Who should give consent for the removal of LSD? Who
can withdraw LSD?
8. Should health care givers honor advanced directives of
patients? (Wills, Living Wills, Durable Power of Attorney (DPA) or
health care proxies)
9. Is the removal of LSD whose utilization has been
considered useless a failure of medicine?
10. What about patients who have been pronounced to be
under irreversible coma for months, but one day just wake up?
The Need for Clarification of Values in the Face of Death and
Dying. A laudable way by which health professionals (doctors,
nurses, etc.), bioethicists, chaplains and families can facilitate
decisions in the face of death and dying is for them to be certain of
the values they hold dear or which they are comfortable believing.
When they are found wanting in these, they would also be
uncomfortable about viewing the scenario of death and dying. Hence,
there is good reason to be initiated into the various values that are
recognized to be important in the discharge of bioethical knowledge.
That is why, for those in health care, including the families, they must
first be very sure about their cultural, moral and religious values of
the society in which they live and should not only rely on what they
currently hold or believe. It is imperative then that they possess
objective valuation of the things they hold dear, and not only rely on
their emotions. There would be a strong possibility that one will
misjudge events if emotions will be the basis for one’s decision.
Truth about medicine and ethics must be at the forefront of such
judgment so that in the assessment of the case as a whole, objectivity
will prevail. Of course, one’s religious and cultural beliefs are
important values that can be used as bases for ethical decision-
making.
 Moreover, everyone must be sure about his view of human
life, which includes the earthly and beyond. Furthermore, how are the
young, the adult and the aged who are sick valued? Are they of
import when making decisions for or against utilization of medical
interventions? In addition, what is the medicine’s role with regard to
treatment of the sick? What happens if medical interventions do not
offer any benefit except making the patient dependent on them?

It
is paramount that the view of health professionals and patient’s
families on pain and suffering must be understood clearly and in no
uncertain terms and must have depth so that the stakeholders would
be able to accept whatever consequences or saving graces are
attendant to them. Lastly, they have to accept the inevitable
consequence that death may deal them and the values that this event
can offer. Facing the inevitability of death and dying will not be
easy, unless a clear understanding of foregoing concepts by the
stakeholders is accessible.
The next sections will attempt at explicating these concepts
and must help pave the way to a better understanding of the issues in
death and dying which will eventually enable the stakeholders to
make better and ethically decisive actions.
Goals Assigned to Medicine. It is to be understood that medicine as
an art has for its goal the preservation of life, prevention of disease,
maintenance of health and the relief of pain and suffering. In
addition, it is the duty of the medical practitioners to seek, within
moral means a decent and peaceful death for the patient which entails
the assurance of the most comfortable condition possible for the
patient until death puts everything to a close.
Medicine, although primarily concerned with the technical
aspect of the medical process (diagnosis and treatment), is not in
anyway constrained in technical practice to include the values of
compassionate caring in the most ethical way possible. This is so
because, as has been mentioned in the Chapter 1, “medical practice is
ethical practice.” In the end the goal of medicine is the over-all well-
being of the patient which necessarily includes his physical, mental
and spiritual well-being. The patient is never a dichotomized being
but a substantial whole of both matter and spirit. Thus, it should not
come as a surprise if medicine’s goal is to comfort an embodied spirit
of the patient. It is therefore not contradictory to include the well-
being of the spiritual soul with the well-being of the physical body.
As a matter of fact, it is not a good medical practice to separate the
things of the body from that of the spirit, since the pain and suffering
of the body also affects the spirit. The body and the spirit are so
intertwined that they interact and influence the workings of each
other. If the body is weak, the spirit can also be dragged downward.
A drooping spirit, in turn, can worsen bodily afflictions. Thus,
medical processes must link these diagnostic and therapeutic claims
within these parameters.
In the end, medicine’s duty is to protect, defend and
preserve life within its own limits. Such duty springs from the truism
that life is sacred and inviolable. It is a gift from God who is a
generous giver. Hence just as its origin is divine, it is destined to a
divine state. Through the principle of stewardship, we are given a
shared, not an absolute dominion over human life. Hence, care must
be deemed a duty to promote the good and prevent harm for it. A
human being must be treated as a creature gifted with a noble dignity.
The Concepts of Euthanasia, Dysthanasia and Orthothanasia. In
the discussion and analysis of the topic on death and dying, it is best
to come to dwell on the following concepts, namely:
 1. Euthanasia. This word is derived from two Greek
words, namely: eu and thanatos, which means “good death” or
“pleasant death.” In modern usage, this term was equated to “mercy-
killing,” or “death with dignity” that is, it refers to an action by which
a person is assisted or induced to die painlessly, usually to avoid
further suffering from an incurable disease or end an irreversible
comatose condition. Many years ago, this term was traditionally
understood as the act of putting someone to death with or without his
prior permission. However, the traditional view of the Christian ethic
is that, when this is done without prior permission of the patient, it is
simply killing or murder. The term, euthanasia is of two kinds,
namely:
a. Active Euthanasia. This refers to a commission of an
act to render the patient dead and so end his suffering through the
administration of overdose of drugs or injection of a lethal drug or
any means that would slowly lead the patient to death. This patient-
assisted suicide is advocated by the infamous Dr. Jack Kevorkian, a
pathologist, who is also known as “Dr. Death”.
b. Passive Euthanasia. This refers to an omission of some
treatment with the intent of rendering the patient to die even if these
would prolong his life, like the denial of nutrition, respiratory or
oxygen support, non-administration of necessary drugs and
medicines, starvation, etc.
Whether the euthanasia is active or passive, both are not
ethically tenable since they are characterized by a willful intent to
ensure the death of the patient in order to end his suffering.
2. Dysthanasia. Etymologically, the terms dys and
thanatos means faulty, imperfect, abnormal or unnatural death. It is a
medical process with the intent of prolonging the dying process by all
means available. Usually, it ends in ‘undignified death’ after
excessive and sometimes abusive use of disproportionate or
extraordinary means, provoked by technological imperative or fear of
malpractice lawsuits. Sometimes it refers to the effort of postponing
an impending death through the use of interventions like ventilators,
respirators or any medical equipment usually regarded as life
sustaining devices (LSD).
3. Orthothanasia. Etymologically, ortho and thanatos are
two Greek words which mean “right death” or “pleasant death.” It
first appeared in the 1950’s. This refers to an act of withdrawing or
withholding a supposedly useless intervention/treatment from a
terminally-ill patient who has no more hope to reverse his condition.
By doing so, the intent of this act is to “let the patient die” in the
natural course. This is considered as an ethical intervention in the
dying process.
Observably, several cases worldwide revolve around the
above three concepts and issues when such are litigated in the courts
of law more than they are decided in the circle of bioethics.
A Historical Brief about Euthanasia. The practice of euthanasia is
not of recent origin. It dates back to ancient Greek civilization that
has numerous indications of this well accepted and prevalent practice
affair given the religious and secular medical acceptance that time. It
is for this reason that the name is Greek in origin. The Greek concept
about the value and purpose of human life includes the view that the
deformed, the mentally handicapped and the terminally-ill are of no
use to the society. This view has been the barometer for the accepted
practice centuries upon centuries. Infanticide, too, was enforced as a
crude form of eugenics for the sake of a superior race based on
healthy and vigorous individuals. This can be seen in the regulations
in Ceos, Greece, which required those who reach the age of sixty to
commit suicide as an approved practice to release oneself from pain
and suffering. But Hippocrates (400 BC), the father of modern
medicine and the first recorded believer in Bioethics stated in his
time-honored Oath which is still recited by today’s newly licensed
doctors thus, “I will give no deadly medicine to anyone, if asked, nor
suggest any such counsel.”

Another great civilization is the Roman

civilization in which many of the Greek ideas and customs about
euthanasia and suicide were also practised. Although patients have
the right to reject a treatment by doctors their families must never
deprive them of life. In the meantime, the advancement of the
modern technical medical capabilities came about in the 1950’s. Dr.
Jack Kevorkian, a pathologist unfortunately does not walk alone in
the battle to legalize euthanasia/Patient-Assisted-Suicide (PAS). Dr.
Kevorkian, the modern euthanasia advocate believes in euthanasia
and said that we must eliminate the “defective” in order to strengthen
the gene pool or that we should eliminate the “surplus” because the
world is “over-populated”. The aim of euthanasia and PAS is to spare
the patients from additional pain, to save them from depression, and
to avoid increasing the financial and emotional burdens on their
family.
Aside from a few states in the USA, like Oregon and
Washington, the Netherlands has also legalized Euthanasia.
Australia’s northern territory wanted to have euthanasia legalized but
it was struck out later by the people. In the Philippines, there had
been attempts to legalize it but the strong pro-life activists lobbied
against it, and it was relegated to the sidelines. Up until now,
euthanasia is never a popular practice around the world, as the
majority of people still view this practice as solely for the intention of
killing the patient. Many ethicists believe that every human being has
a natural inclination to continue living. The risk of the practice of
euthanasia is that people do harmful things to both individuals and
society. Historically the role of doctors has been to save lives and
ease pain and never to cause death.

Categories of Terminal Illness. The following distinctions will lead

us to a better understanding of what terminal illness is, and will help
us appreciate their meaning and use. The following concepts are well
recognized in medical circles as well as among bioethicists.
1. Patients with terminal illness are those whose death is
imminent (probably within one month).

2. Patients with terminal illness are those whose

death may not be imminent but who are currently in a state of acute
life threatening crisis (massive stroke, cardiogenic shock, or
septicemic shock).
3. Patients on a PVS (persistent vegetative state) are those
whose conditions are irreversible (no cerebral cortical function or the
irreversible cessation of all brain function, including brain stem).
It is immensely an overriding concern that PVS are those
whose diagnosis is an opinion as all other diagnoses are. A false
diagnosis of a person in a persistent unconscious, vegetative state, or
brain resting state may unnecessarily result in the death of a person
who could achieve consciousness. What is detestable is that this may
open to organ removal from patients which results in severely
disabling conditions or death of patients.

The Concept of
Fatal Pathology. The concept of fatal (deadly) pathology refers to
any disease, illness or injury which will cause death if allowed to run
its course. Therefore, those who are under the condition of terminal
illness are afflicted with fatal pathology and if such is not duly
treated, it may lead to death. Fatal pathology is a condition where
death is likely to happen when treatments are not anymore effective in
reversing the condition, but can only prolong the current terminal
condition. This condition must be analyzed and determined properly
under the light of current medical practice to prevent any ethical
conflicts.
 In the presence of fatal pathology, the duty to protect and
preserve life is necessarily assessed. That is why the health care
team, including the health professionals, bioethicists and families
should be briefed about the following inquiries:
• Will the intervention be effective?
• Will the intervention cause serious burdens?
- Suffering (or pain)
- Effort
- Psychological/emotional burden
- Financial burden
• Will the burden imposed by intervention seriously
impede achieving life’s purpose?

In view of the above, if the treatment to cure/alleviate

pathology is:
1. Effective and does not entail a grave burden – it must be
utilized.
2. Ineffective or non-beneficial – it must not be used.
3. Effective but entails grave burden – it may be withheld
or withdrawn. Herein, there are calculated options.
The above propositions are not as easy as they appear.
They certainly need a lot of reflection and consideration.
Achieving life’s purpose must be factored in as part of the
decision. The purpose of life is to serve. When a patient is
constrained with gadgets and medical limiting procedures
(unnecessarily), he is impeded from achieving life’s purpose. They
unduly break his relational nature and the burdens make him live
under an inhumane condition. This reduces his dignity and diminishes
the quality of life substantially in a manner that is not appropriate for
him as a human being. Therefore, when all else fails, the decision is
to withdraw or withhold any medical intervention and let the patient
die a natural death. The release from the technical and human
trappings will set his spirit free. This is the truth that every
reasonable human being must adhere to.
The Concept of Ordinary and Extraordinary Means of Sustaining
Life. According to O’Rourke and Ashley (2002), many physicians
use the term Ordinary means to prolong life as referring to standard
and accepted treatment, while Extraordinary means refers to
experimental and unproved treatment. The Bioethicists on the other
hand, look at the way therapy will adversely affect the person’s ability
to function at the higher level of human potential, e.g., reasoning. If
the therapy is useless or a severe burden insofar as the higher
functions are concerned, then it is extraordinary. Accordingly, one
might reject brain surgery to prolong life for a few weeks but which
will render one comatose for the remainder of one’s life.
Further, while the physicians have the expertise and the
right to make decisions concerning the usefulness or medical
effectiveness of some medical procedures, the patient (or the family
with a proxy consent power) has the right to determine whether a
particular medical procedure is ordinary or extraordinary from an
ethical viewpoint. There is therefore necessity to consult experts in
this case.
Lastly, even if the extraordinary means in question is
determined from an ethical view, the decision being made by the
patient (or the family) in consultation with the physician has to be
respected, the ordinary care should still continue.
It is important to know that a particular patient care may
initially be ordinary, but later it can become extraordinary when it
becomes useless and ineffective. A pacemaker may be initially
ordinary, but when it does not render its usefulness, it becomes
extraordinary. Here lies the wisdom behind the so-called DNR (do
not resuscitate).
From the above, discussion we now can make some generic
determination of what ordinary or extraordinary means is, namely:
An extraordinary means refers to any intervention that
does not offer any reasonable hope of recovery, or that which makes
care unreasonably burdensome. While an ordinary means refers not
only to nutrition, hydration or respiratory or oxygen support but also
to any treatment or intervention that offers reasonable hope of
recovery, or any means that does not make care unreasonably
burdensome.
In sum, the ethical principle in the use of ordinary or
extraordinary means of prolonging life is that “We are not normally
bound to use extraordinary means based on the duty to promote
good and avoid evil or harm as it is possible in the situation. But we
are always obliged to use the ordinary means for as long as it
remains to be non-extraordinary.”
The following thought of Pope Pius XII, which has been
accepted by both Catholics and non-Catholics, offers valuable
insights for patients, their families and the health practitioners:
“. . .normally one is held to use only ordinary means---
according to the circumstances of persons, places, times and cultures-
--that is to say, means that do not involve any grave burdens for
oneself or another. A stricter obligation would be too burdensome for
most men and would render a higher, more important good too
difficult to attain. Life, death, and temporal activities are in fact
subordinated to spiritual ends. On the other hand, one is not
forbidden to take more than the strictly necessary steps to preserve
life and death, as long as he does not fail in some more serious duty.”
Medically, the extraordinariness of treatment is understood
to refer to futile intervention. The American Thoracic Society defines
it as “if reasoning and experience indicate that the intervention
would be highly unlikely to result in a meaningful survival for
that patient.” There are therefore important elements that have to be
considered to conclude that indeed an intervention is extraordinary,
namely: 1. evidence-based medical experience, 2. the unlikelihood of
a better result, and 3. the level of quality of life that should result after
the intervention. The elements above should also ethically guide the
decision-makers in withdrawing or withholding any treatment or
intervention other than those that have been mentioned already.
The “Ordinariness” of Nutrition, Hydration and Oxygen. It has
been asked many times whether food (nutrition), water (hydration)
and oxygen (respiration) are always considered ordinary means of
sustaining life even if they take an artificial route like naso-gastric
feeding tubes which are essentially medically assisted. This seems to
be a very innocent question but its precise answer is rather elusive.
The answer, more often than not is, whether or not such means is
really useful or does not offer reasonable hope of recovery as far as
the patient is concerned. In case the patient’s digestive or respiratory
system does not function as it should, but uselessly assimilates food
or oxygen into his system, then by all means, they should be
considered extraordinary. But what if the terminally-ill patient (who
is in irreversible coma) could still assimilate them and prolong his life
in the process, should they be utilized? Again such condition should
lead us to the same answer as above. Their use may now be
considered extraordinary and can be withdrawn without ethical
drawback. More so, when such use and route application renders
physical difficulty and disproportionate pain to the patient. This is
also true with regard to the use of respirators or ventilators or any life
prolonging devices. Therefore, the use of nutrition, hydration or
oxygen is not always absolute. It can be used though if they bring
about the needed benefit to the patient. Of course, for as long as the
patient breathes, no one can put a stop to it. But when the patient has
become edematous, i.e., the bodily organs cannot anymore process
liquid or food to the point of becoming uncontrollably swollen, then
there is no reason why one has to give him or her hydration or
nutrition. These become extraordinary.
In the above case, the intention is not to kill the patient but
simply to avoid doing something useless or futile. This is good
medicine! It does not play God nor take away from God His
dominion over life and death. Loeb’s Law in medicine states that 1.
If what you do, works – continue doing it. 2. If what you do doesn’t
work - stop doing it. 3. If you do not know what you’re doing -
don’t do anything at all. This is in consonance with the physician’s
eminent duty to emulate the Principle of Beneficence: “Always do
good” and the Principle of Non-maleficence: “Do no harm.”
 Moreover, with the withdrawal of LSD, one does not say
that life has already been useless. Life is intrinsically valuable and can
never be useless despite whatever circumstances or condition it may
find itself in. What is pointed out here is that the LSD has become
useless, thus it must already be withdrawn as it all the more harms the
patient. The impersonal connection of the patient to the tubes and
technological gadgets that only prolong his life is against his
relational nature (as pointed to above) as the useless LSD poses
obstacles to his natural drive to connect with his loved ones and only
renders him as a mere object of medical treatment. One must
remember that any useless device when administered to a patient will
only harm him, because such administration is certainly not good
medicine.
The withdrawal of LSD from a terminally-ill patient whose
condition is irreversible does not mean killing the patient but only
allowing death to follow its natural course. There is a tremendous
difference between the two acts. The former necessarily includes a
direct motivation to do the act of killing or abandonment of the
patient, while in the latter, the act merely removes the LSD because it
has become useless. We will still take care of the patient in case he
survives. No element of abandonment is present. For the sake of
argument, the following below is provided for.
Suppose one withdraws the LSD that has been rendered
useless, and the patient dies? What does this imply? Simply, the
LSD is indeed useless because its only use is to prolong the dying
process and not really to treat. Suppose the LSD is withdrawn and
the patient is able to survive? What does this imply? Simply, the
LSD is useless because even with its withdrawal, the patient is still
able to survive. In both cases, there is wisdom in the withdrawal of
the LSD. There is no motive here to kill the patient.
The Patient’s Living Will and Advance Directives. The so-called
living will or advance directive of patients who are terminally-ill are
usually practiced in developed countries. They are not so common
in the Philippines. Only a few would want to use them. The family
is usually given the authority to make decisions when they fall into
terminal condition. They are usually done when they have the
decisional capacity to make it. It means that they are competent and
can exercise free and informed consent related to medical care in case
of a terminal condition. These living wills or advance directives are
usually written for swift and clear decision-making with regard to
withholding or withdrawing life sustaining devices. There are no
fixed formulas written about them, but only statements regarding
future decisions related to treatment when a patient falls into terminal
illness and signed by the person making the living will or advance
directives.
Some of these living wills are formally done through a
Durable Power of Attorney (DPA). The maker of the living will or
advanced directives must be of major age who will assign adults who
will make representations with regard to decision-making over the
maker’s health especially in terminal illness. This DPA has a usually
binding force of the law, although not necessarily ethical. It must be
noted that in the enforcement of the living will or advance directives
through the DPA, the best interest of the patient reigns supreme.
The Case of the Cardio Pulmonary Resuscitation (CPR) and Do
Not (Attempt) Resuscitate (DNR/DNAR) Order. The University of
Sto. Tomas Faculty of Medicine and Surgery (UST FMS) has
articulated some policies when faced with the use or non-use of life-
saving procedures or usefulness or non-usefulness of medical orders.
The policies are:
1. Cardio Pulmonary Resuscitation (CPR), medically
speaking, refers to an emergency medical procedure to prevent
sudden and unexpected death in the life-threatening situation of
cardio pulmonary arrest. Accordingly, successful resuscitation will
establish effective cardiovascular functions and lead to complete
neurological recovery.
2. Do Not Resuscitate (DNR) order (or DNAR, Do Not
Attempt Resuscitation) is a standing order not to initiate cardio
pulmonary resuscitation in the event of cardiac or respiratory arrest.
The purpose of the two orders is to ensure that every CPR
and DNR decision is made through a medically responsible and
ethical principle that should ultimately protect the rights of patients
and families from undue and invasive procedures. Adequate
communication must be secured among the health care team. This
will certainly educate the health professionals in caring for the
terminally-ill while considering the ethical, legal and emotional
elements involved.
Initiation of CPR is based on the fundamental presumption
that the brain may still be viable even though the heart has stopped
beating. When this possibility exists and there are no compelling
medical or legal considerations, resuscitation should be initiated.
The DNR as viewed by good medical practice is consistent
with sound medical practice not to initiate CPR in certain situations,
such as in cases of irreversible illness where death is expected or
where prolonged cardiac arrest implies futility of resuscitation efforts.
3. Indications of DNR/DNAR. Accordingly, health
professionals have no obligation to offer, start or maintain a treatment
in the following situations:
a. When a patient’s condition is terminal and death is
imminent so that life-sustaining measures only unduly prolong the
dying process;
b. When the patient is irreversibly comatose so that life-
sustaining measures only maintain his/her present condition, and there
is no hope of recovery or improvement;
c. When the burden of treatment far outweighs the benefits;
and
Nevertheless, when potential benefit is uncertain, CPR
should provide for a specific period of time and for a monitoring of
responses for effectiveness.
All of the above are in consonance with the provisions for
decision making in the previous topic on the treatment of fatal
pathology.
 4. Procedural Guidelines for DNR/DNAR Order.
Guidelines are not absolute rules that one must always follow. They
should rather be used as references for the proper disposition of
actions rather than rules that cannot be bent or improved. The
following procedural guidelines (UST FMS) may be important to
consider:
a. Who decides?
The attending physician or the staff physician primarily
responsible for the care of the patient and thus has appropriate
knowledge of the patient’s clinical condition should make the
decision that “CPR is not indicated.”
This decision may be based on consultation with other
professionals and is finalized only upon proper consent.
b. Consent
b.1. The attending physician has the responsibility to
coordinate communication among all those involved in the DNR
order;
b.2. When a patient is competent, the decision not to
resuscitate should be reached consensually by the patient and
physician. Advanced directives should be solicited;
b.3. When there is evidence that the patient’s physical
and/or emotional well-being would be jeopardized by discussion of
the DNR order, the decision not to resuscitate should be reached
consensually by the physician and the patient’s family members in the
following order of priority: spouse, adult children, parent(s), sibling
and legally appointed guardian;
b.4. When the patient is incompetent.
b.4.1. If an advance directive made while the patient was
competent is available, this, in general, must be respected;
b.4.2. If no advance directive has been made, the decision
not to resuscitate should be reached consensually by the physician
and the patient’s family in the same order of priority as in b.3., ad
supra;
b.4.3. If the patient is abandoned by relatives or appears to
have no relatives, the decision has to be referred to the proper medical
authorities, i.e., medico-legal officer and hospital director; and
b.4.4. If the patient does not satisfy the criteria for DNR
order as enumerated above, the DNR order may not be given even if
the legal guardian or family members request for it.
5. In Case of Disagreement with DNR/DNAR. When
there are disagreements on the DNR order, the following may be
considered.
a. In case a member of the team disagrees with the decision
and in conscience cannot follow the orders, he may beg off or
withdraw and the attending physician should respect his conviction;
b. Moreover, in medico-legal cases, a DNR order must be
approved by the medico-legal counsel in coordination with
the Bioethics Committee; and
c. In medico-legal cases, a DNR order may be cleared by
the hospital authorities.
6. Physician’s Order. The attending physician shall
communicate the decision for DNR in a written order in the doctor’s
order sheet, in the progress notes, and in the official hospital DNR
form.
a. The attending physician should write specifically what is
to be withheld on the doctor’s order. It may read: “routine CPR
procedures are not to be performed on (name of patient), until further
orders.” This should be followed by a reference to the physician’s
progress notes related to the order. The order should then be
countersigned by the patient (if competent) or the surrogate, the
responsible family member or legal guardian;
b. The attending physician should write in the physician’s
progress notes the reason/s for the DNR and the consent procedure
performed;
c. The official hospital form should be filled up and signed;
and
d. All hospital staff attending to the patient is required to
notify the attending physician immediately of changes in the patient’s
condition. If these changes make a DNR order no longer applicable,
the attending physician should revoke the DNR order and
immediately communicate the revocation to all concerned.
e. Care and Comfort Orders. A DNR/DNAR order is not an
abandonment of the patient. It is a redirection of health care towards
alleviating suffering and ensuring maintenance hygiene and dignity.
Ordinary supportive measures, palliative and comfort care should be
given until the patient expires.
f. Organ Donation. If the dying patient is a suitable
candidate for organ donation, the attending physician may encourage
relatives to donate the patient’s organs. (1997)
The Three Celebrated Cases of Quinlan, Cruzan and Schiavo (see
links with General References. Also www. healthsystem. virginia.edu.com).

The purpose of this section is to introduce the beginner into

the world of often controversial discipline of Bioethics of death and
dying.
1. Karen Ann Quinlan Case On April 15, 1975, Karen
Ann Quinlan, then seventeen years old, presumably ingested
barbiturates and alcohol at a party. She became comatose and
experienced two periods of apnea (absence of breathing) of about
fifteen minutes each that resulted in irreversible brain damage. She
was placed on a respirator and was fed nutrition and fluids by a
gastrostomy tube. Her parents were told that she was in a persistent
vegetative state from which there was no hope of recovery. Her
physician, Robert Morse, considered the ventilator medically
appropriate. He claimed that allowing a person in a persistent
vegetative state to die was in violation of the professional standard of
the time. Quinlan was still in a vegetative state five months later. The
electroencephalogram (EEG) showed no signs of brain function, and
she did not respond to verbal, visual, or even painful stimuli.
The Quinlan family priest told the parents that they had no moral
obligation to continue extraordinary means (the respirator) to support
their daughter's life, but that artificial feeding and fluids were
"ordinary means" and should be maintained. Quinlan's father said he
did not want to kill his daughter but merely wanted the respirator
removed so that she had the option of dying a natural death. The
Quinlans petitioned the New Jersey Superior Court for permission to
remove the respirator. On November 10, 1975, that court denied the
parents' request based on its contention that people have a
constitutional right to life but do not have a parallel constitutional
right to death. The lower court decision was appealed to the New
Jersey Supreme Court, which in 1976 decided that "refusal of life-
saving treatment" fell under the constitutional "right to privacy."
They ruled that Quinlan could be removed from the respirator.
However, hospital staff had already weaned her from the respirator,
so the court decision was moot. She lived for ten years with the aid
of artificial nutrition and hydration. She finally died in December
1985 of pneumonia. Since the Quinlan decision, a number of other
states have permitted families to withdraw life support from comatose
or terminally ill patients.
The Quinlan case is significant for several reasons. The
definition of death, once linked to brain damage and the cessation of
heart and lung functioning, had to be modified to accommodate
technological advances in life support systems. Patients who
formerly would have died can now be maintained indefinitely on life
support. Further, considerations to maintain or withdraw life support
raised moral and legal issues involved in the nationwide debate on
abortion rights, patient's rights, and as well as organ and tissue
retrieval for the burgeoning field of organ transplantation. The
Quinlan case provided a focus for energetic and productive discussion
of the complex and interrelated moral, ethical, and legal issues related
to the definitions of life and death, the right to die, and the freedom of
choice. The Quinlan case stimulated intensive and productive
national debate, discussion, and research on the related subjects of
physician-assisted suicide, the quality of life, and the quality of dying.
2. Nancy Cruzan Case. On January 11, 1983, Nancy Beth
Cruzan, then twenty-five years old, was involved in an automobile
accident. Her body was thrown thirty-five feet beyond her overturned
car. Paramedics estimated she was without oxygen for fifteen to
twenty minutes before resuscitation was started. As a result, she
experienced massive, irreversible brain damage. However, she could
breathe on her own. Attending doctors said she could live indefinitely
if she received artificial nutrition and hydration, but they agreed she
could never return to a normal life. Cruzan had not left advance
directives—instructions how she wished to be treated should such a
physical and mental state occur. A feeding tube enabled her to receive
food and fluids. Over the ensuing months, Cruzan became less
recognizable to her parents. They began to feel strongly that if she
had the opportunity she would choose to discontinue the life-
supporting food and fluids. After five years of artificial feeding and
hydration at the annual cost of $130,000, and with increasing physical
deterioration, Cruzan's parents requested that the feeding tube be
removed so that their daughter could die a "natural death." In early
1988 their request was granted by Judge Charles E. Teel of the
Probate Division of Jaspar County, Missouri.
Judge Teel's decision was met by a very strong reaction
from persons who expressed concern that removal of the feeding tube
would not be in accord with Cruzan's wishes under the doctrine of
"informed consent." Others argued that removal of the life-support
feeding tube would constitute an act of homicide. The state of
Missouri appealed Judge Teel's decision. In November of the same
year, the Missouri Supreme Court overruled Judge Peel's decision and
therefore refused the Cruzan petition to make a decision on behalf of
their daughter by stating that the family's quality-of-life arguments
did not have as much substance as the state's interest in the sanctity of
life. The Cruzan family appealed the Missouri Supreme Court
decision to the U.S. Supreme Court. In their pleading to the U.S.
Supreme Court, the state of Missouri asked that they be provided
clear and convincing evidence of a patient's wishes regarding a will to
die before granting the request to discontinue life support for persons
in a persistent vegetative state. On June 25, 1990, the U.S. Supreme
Court recognized the right to die as a constitutionally protected civil
liberties interest. At the same time, the U.S. Supreme Court
supported the interests of Missouri by declaring that it was entirely
appropriate for the state to set reasonable standards to guide the
exercise of that right. Thus, the U.S. Supreme Court sided with the
state and returned the case to the Missouri courts.
Following the Supreme Court hearing, several of Cruzan's
friends testified before Judge Teel, recalling that she stated
preferences for care if she should become disabled. In addition, the
doctor who was initially opposed to removing her feeding tube was
less adamant than he had been five years previously. On December
14, 1988, the Jaspar County Court determined that there was
sufficient evidence to suggest that Cruzan would not wish to be
maintained in a vegetative state. The following day the feeding tube
was removed and she died before the end of the year.
3. Terri Schiavo Case (cf. Tampa Tribune). On Feb. 25,
1990, 26 year-old Terri Schiavo suffered cardiac arrest. Because her
brain was deprived of oxygen, she lapsed into what doctors called a
persistent vegetative state.
In 1990-1992, her husband, Michael Schiavo, and her
parents, Bob and Mary Schindler, worked together to find therapy
that would help her improve, but she remained in a coma-like state.
In November 1992, Michael Schiavo successfully sued the physician
who treated his wife before her cardiac arrest. A jury awarded the
couple $1 million, with $700,000 of that designated for her perpetual
care. While care was ongoing, Michael had already a fiancée and
two children with her.
In May 1998, Michael Schiavo filed a petition to end his
wife's life support. In April 2001, Terri Schiavo's feeding tube was
removed. Two days later, a judge ordered her feeding resumed in
view of a new lawsuit filed by the Schindlers. In November 2001-
January 2002, Michael Schiavo and the Schindlers tried to resolve the
case through mediation, but failed to come to an agreement.
In October 2002, a second trial began to decide if new
therapies might help Terri Schiavo recover. Each side presented
conflicting testimonies. A doctor chosen by the court testified that
Terri Schiavo's recovery was unlikely. In November, 2002, a judge
again ordered Terri Schiavo's feeding tube removed. The Schindlers
appealed again.
In September 2003, with appeals running out, the
Schindlers asked a federal court to intervene. Gov. Jeb Bush filed a
brief in the case supporting the Schindlers. So on October 10, 2003,
the federal court judge said he had no jurisdiction in the Florida
case. Then on October 15, 2003, the doctors removed the feeding
tube.
On October 21, 2003, Bush successfully pushed for an
emergency act of the state legislature to restore the feeding tube. The
law became known as “Terri's Law.” A lawsuit challenging its
constitutionality was immediately filed. On September 23, 2004, the
Florida Supreme Court struck down Terri's Law. And on January 24,
2005, the U.S. Supreme Court refused to hear arguments for Terri's
Law.
On February 23, 2005, a hearing was scheduled. The
Schindlers asked for more time to file appeals. The appeals would
address whether new therapies would help their daughter and whether
their daughter's religious beliefs prohibited withholding nutrition.
In compliance with the court’s order, in March, 2005,
Terri’s feeding tubes were removed and she died.
Controversies about Terri Schiavo’s case continue to this
day. There had been questions about the propriety of the husband in
asking for the removal of Terri’s feeding tube when all the while he
already had a new family, though that time, he was not legally to her
new wife yet. Another was the issue about the dwindling funds that
should be spent for Terri’s care, as ordered by the court and the
husband allegedly did not want said fund to vanish. Lastly, the issue
about the on-and-off removal and resumption of the feeding tube, thus
leaving Terri like an object to be worked on or not worked on was
seen as an undue encroachment into her human dignity.
The Case of the Patient-Assisted Suicide (PAS). The Bioethics of
death and dying is not complete unless a discussion about the topic on
patient-assisted suicide (PAS) is presented for the information of the
readers. This procedure has become a very contentious issue in death
and dying theme because some states in US, as in Oregon, and
elsewhere in Europe, like Holland have made it legal. In UK,
legislation in the House of Lords is in the offing. The name of Dr.
Jack Kevorkian, otherwise known as “Dr. Death,” an advocate of
patient-assisted suicide comes immediately as a popular or unpopular
character due to his brave stance and dedication in its favor. He had
already performed one hundred thirty procedures in the USA with
variations of his suicide machine. He raised his stakes when he
directly injected a series of lethal drugs into a 52-year old man who
had amyotrophic lateral schlerosis (ALS), sometimes called Lou
Gehrig’s disease. A video tape he provided to CBS television aired
on “60 minutes” program and was seen by 15 million households. “I
want a showdown,” the pathologist said. Thereafter, he scoffed at the
government and challenged the US judiciary to imprison him for his
advocacy for the procedure. Fortunately or unfortunately, he got what
he wished for. He was convicted of second degree murder.
Currently, he is in the prison awaiting final conviction or acquittal by
the US Supreme Court.
The patient assisted-suicide occurs when a doctor provides
a patient a lethal overdose of medication for self-administration with
the explicit goal of enabling the patient to commit suicide. The
doctor prepares the lethal injection, connects the syringe into his vein,
like the IV fluid so that the poison gets into the blood stream. There
is the control plug through which the patient has to press into the
“ON” setting when he is ready for the procedure. Once pressed, the
patient has only to wait until he expires. In the syringe is the poison
called hydrochloride ready for disposal. Once it enters the
bloodstream, the patient is relaxed, gets into sleep and finally dies.
This process is done to ensure that the patient does not struggle
agonizingly with the pain that might accompany the dying process.
This procedure is ethically and legally distinct from prescribing
 medication with the
expressed goal of pain relief while understanding that death could
occur earlier as a secondary effect (the double-effect principle).
General practitioners deal with most assisted suicide
requests in the UK, as they do in Oregon and the Netherlands. (see
Human Rights Watch, US, 2008)
In Oregon, doctors’ practice of assisted suicide is through a
prescription of an overdose of barbiturates that the patient takes orally
with several ounces of liquid. In 2005, the prescribing doctor was
present at 23% of PAS deaths. The complication of vomiting
occurred in 5% of cases. After taking the overdose, patients became
unconscious in 2–15 minutes (median 5 minutes) and died within 5
minutes-9.5 hours (median 26 minutes). One patient took the
overdose, lost consciousness in 25 minutes, and then regained
consciousness 65 hours later. This individual did not obtain another
PAS prescription and died 14 days later of the underlying illness.
(see Human Rights Watch, US, 2008)
In the Netherlands, the doctors prescribe an antiemetic and
an overdose of barbiturates in liquid or crushed tablet form. It is
through an intravenous barbiturate followed by a muscle relaxant to
paralyze breathing. It is similar to lethal injection administered as
capital punishment to criminals, like the administration of anesthetic,
sodium thiopental, which is a fast-acting barbiturate that depresses
the activity of the central nervous system. This initial shot doesn’t
serve as an analgesic (pain killer) that numbs pain nerves, but instead
rapidly puts a person into a state of unconsciousness that is
theoretically deep enough to make pain undetectable. (see Human
Rights Watch, US, 2008)
After the initial injection, the intravenous line is quickly
flushed with saline, a neutral substance commonly used to push a
drug into the bloodstream more quickly. Subsequently, pancuronium
bromide is administered. It acts as a neuromuscular blocker,
preventing a nerve messenger, acetylcholine, from communicating
with muscles. The result is a complete muscle paralysis, which
causes respiratory arrest since the diaphragm—a muscle imperative to
pulling air into the lungs—stops working. (see Human Rights Watch,
US, 2008).
Following another saline flush is the final injection of
potassium chloride. This chemical floods the heart with charged
particles that interrupt its electrical signaling, stopping it from
beating. According to a 2002 study in Forensic Science, the average
length of time from the first injection to death is 8.4 minutes. (see
Human Rights Watch, US, 2008)

Hereupon, despite acknowledging this to be euthanasia, Dutch

researchers have not counted these cases in reported numbers of
voluntary, involuntary, and unreported euthanasia in their
publications or in evidence to the House of Lords. Complications
occur in 7% of assisted suicides. Doctors proceed to carry out
euthanasia in 18% of initial PAS cases, usually because death took
longer than expected, coma did not occur or the patient awoke from
the coma. (see Human Rights Watch, US, 2008)
The Ethical Dimension of Patient-Assisted Suicide. Aside from the
many arguments against patient-assisted suicide, the one that can be
gleaned crystal clear is that this procedure has no moral or ethical
requirement to provide therapy which is not medically indicated or
which is futile or unduly burdensome to the patient. All that is
actually required by good medicine is what is necessary, as judged by
a conscientious physician for the patient’s best interest. When this is
detached altogether then such procedure leads to the commission of
the crime of murder, as in PAS. In the first place, the purpose of the
administration of these drugs is to kill the patient, what with the
overdose of these drugs which has already been claimed by doctors to
be redundant? This means that the amount of chemical contained in
each shot itself is lethal. PAS, therefore, is murder, pure and simple.
Important Notes to Ponder. The well-revered Hippocrates said that
in the face of the issues in death and dying one has to be reminded
that good medicine advocated by Hippocrates cures sometimes,
relieves often and comforts always. Thus, medicine is not the be all
and end all of human maladies. Neither is its technological support
absolute and should thus not compel people to blindly submit to the
so-called technological imperative.
Furthermore, we have to be assured that we are never
obliged to keep everyone alive. For while life is God’s prerogative,
so is death and never of mortal beings. Death of a patient is neither a
failure of medicine nor of the doctor (unless proven that negligence
or malpractice is present). Death can occur even in the best of hands
or with the best medicine. What is important is doing what is best for
the interest of the patient (whether he dies or not). This is Bioethics
and good medicine at their noblest and greatest.
Further notes to remember when faced with death and dying
issues are the following: When medical care fails, not everything
ends or fails. There is palliative care (the relief of pain and suffering
and includes medical, humane and spiritual care) that is still very
much available. There is comfort care that everyone can do. Again,
what is important is: never abandon the patient in his most crucial
moments. St. Peter 5:7 said, “Cast all your cares on God because He
cares for you.” This advice sits well with terminally-ill and dying
patients.
Brief Answers to the Questions Posed Above (pp. 458-459). The
following below are legitimate questions to ask, namely:
1. When the patient is terminally-ill, is it ethical to remove
LSD (Life Sustaining Device) or other interventions even when this is
the only means that keep him alive? In the first place, when is a
patient considered terminally-ill? Yes, as has been explained above.
It is not to kill the patient, it is only saying that the LSD has been
considered useless and therefore its use can be terminated. The
definition of the terminally-ill is one who has a fatal pathology and
that there is currently no cure available and that death is imminent.
2. When we remove these interventions, and the patient
dies, don’t we kill him? Or do we just allow him to die? Are these
questions a matter of semantics or is there an objective distinction
between killing or letting die? We don’t kill the patient, we only
allow the patient to die through a natural course. There is no
semantics here as the means and ends are different from killing and
allowing to die.
3. If the interventions just prolong the dying process, is it
ethical to continue applying them? Are there limits as to time to the
prolongation? It is not ethical as this is against the principle of
justice. There must be limits to the prolongation process. When it
has been concluded by the health care team that withdrawal is the best
ethical option, then it can be done.
4. Can the family ask the AMD (Admitting Medical
Doctor) to withhold or remove LSD on a terminally-ill patient? Or
should it be the doctor who should ask the former? Yes, this must be
subjected to a time frame. The doctor or the family members of the
patient may request that LSD be removed or withdrawn.
 5. When are interventions considered ordinary or
extraordinary? Are food, drink and oxygen considered always
ordinary? Food, drink and oxygen are normally ordinary means.
When the biological processes however become onerous or
burdensome, they may become extraordinary. This concept has
already been explained above.
6. When the decision to remove LSD has been agreed
upon, who will do it? Only the doctors or those whose job includes
the removal of LSD like the occupational therapist. No member of
the family should do it, more so the minors. Neither can the janitors
or orderlies do it or be requested to do it. Only medical practitioners
and those given due authority can do medical procedures, like the
removal of LSD. If the doctors do believe that there is nothing
ethically wrong in the withdrawal of LSD, why should they be afraid
to do it? For practicality, if there is no one health professional who
wants to do it, then “the one who connected it should disconnect it.”
7. Who should give consent for the removal of LSD? The
patient himself if he is still competent, or the one who has proxy
consent authority or anyone who has been given the Durable Power of
Attorney (DPA). Normally, it is the closest kin who can do so,
especially the one of majority age following the principle of queuing
among the kin.
8. Should health care givers honor advance directives of
patients? (Wills, Living Wills, DPA or health care proxies). Yes, for
as long as they are ethically guaranteed or for the best interest of the
patient.
9. Should suffering and death be considered a failure with
the removal of LSD that has been considered useless? Suffering and
death are part and parcel of human existence. They speak of values
that even Christ upheld.
10. How do you consider patients who have been
pronounced to be in irreversible coma for months, but one day just
wake up? This is a welcome event for them. It only means that they
were not truly dead but only in temporary coma. They belong
however to exceptional events in medical history. But in Bioethics,
we do not make the exception as the normal standard upon which we
base our ethical decisions.
The Stages in the Dying Process or Grief. When man is afflicted
with terminal illness, he undergoes palpable manifestations that,
unwittingly, he may not even be aware of. According to Dr.
Elizabeth Kübler-Ross (1926-2004), who was born in Zurich, in the
book she wrote, Death and Dying (1969), every person basically goes
through a five-stage process through which he copes with the process
of dying. This experience may take various degrees of manifestations
and external behaviors. Some are intensely profound and some are
mildly manifested. But there are always marked manifestations. The
role of the doctors and other health professionals is highly crucial in
the process because any sign of incompetence in one’s response to
them will create confusion and disorder, and even send chills into the
whole therapeutic process and the healing centers. Fortunately, this
process is recognizable and rational. The following are the stages:
1. Denial. The first and foremost manifestation of a person
who learns of his terminal illness is that of denial. He believes that
the diagnosis is wrong and that the diagnostic instruments used did
not function well, and therefore were not correct even if, objectively,
there was no indication of a good and normal diagnosis. The patient
would swear that he is strong and that he can do any normal task as
any healthy person can. In spite of the general bodily malaise that he
experiences, he believes that this is just a temporary setback. He is
afraid to even talk about the matter of death to avoid fear of its
inevitability. It is terrifying and daunting for him because it is
characterized by a refusal to accept facts.
 2.
Anger. This emotion is one of the most natural phases that the
terminally-ill undergoes. When normal diagnosis is neither
forthcoming nor indicated, he becomes angry with just about
everyone including the doctor, nurses or even the family. Included
here is the chaplain who visits him. He is also angry with God to
whom he swears he has not done anything gravely bad. He swears
God is not fair and he is not given a chance to live longer in order to
perform unfulfilled goals and aspirations. He considers his illness as
punishment from God for whatever wrongdoings he might have done.
3. Bargaining. The patient comes to his senses and is
opened to strike a deal with anyone who can make his condition
better. He believes that he can return to his original state and so he
wants to bargain. To bargain is to make a humble appeal with those
who may contribute to his health. He appeals to the doctors and
sometimes makes promises to offer half of his wealth if he is made
better. He promises to his chaplain to build him a cathedral in case he
recovers. He promises to be a better father or husband if his/her
health is restored. He promises to God that he will go to mass and
confession regularly, and devote himself to serving Him throughout
his life. This stage is one that is characterized as full of bargains and
promises.
4. Depression. Depression is most likely to happen when
anger is not resolved or a bargain is not forthcoming. There is the
feeling of low self-esteem and inadequacy. He feels abandoned by
God, the family and even by the doctor. He feels useless. He
becomes suicidal and believes he is not worth his condition. He
reaches a point where he wants to question further diagnostic
management for him. Sometimes he does not want to see anyone and
he wants to be alone. He feels that speaking to anyone is useless.
Depression is absolute frustration and that his case is hopeless.
5. Acceptance (or Hope). This is the last of the series of
stages that a terminally-ill patient undergoes. This is the most
positive phase that everyone in the health care team would like to see
in the patient. To accept his condition is to bring hope to a beautiful
dying process. The patient is drawn to some religious interests. He
places premium on his faith and there is great evidence of a positive
attitude to submit himself under the power of a compassionate and
caring God. He becomes grateful to everyone who has shown
concern and love for him in his moments

of ordeal, pain and suffering. He

is most open and receptive to his doctors and the family. Suddenly,
he wants to smile.
 There are no definite timeframes about the
duration of these five fundamental stages that a terminally-ill patient
undergoes. It depends solely on how personally he copes with his
psychological state and the effective response accorded by the health
care team and his family to him. What is important throughout this
process is the empathetic and patient attitude that his significant
others show him. Such attitude is paramount in order to hasten the
coping process towards an impending death. In this stage, he wants
to talk to his chaplain or religious adviser on how best to prepare
himself to die.

Case Studies:
A. A Drama in the Life of a Family
Mrs. Lilia Montes was a 72-year-old widow with three
adult children and ten grandchildren. She was rushed to the hospital
due to cardiac arrest. Eventually, she was hooked onto a ventilator
and fell into a coma. Dr. Lab informed the children that Mrs. Montes
was in critical condition and he could not do anything about it. He
explained further that hers was a terminal case. The ventilator would
only prolong her life and suffering. The eldest daughter signed a
waiver in favor of DNR on occurrence of another arrest. They
decided to bring their mother home. But before they could have done
that, Dr. Lab asked, “Who among you could pull out the ventilator?”
The three children looked at each other and said, “We’ll think about
it.” After a couple of minutes, they returned bringing Angelica, a
four-year-old daughter of one of Mrs. Montes’ children to the Doctor
with the view to letting her pull out the ventilator’s plug. The doctor
concurred. It was done. Mrs. Montes was pronounced dead ten
minutes later.
1. Was the decision by the doctor to pull out the ventilator
ethical? Explain.
2. Was the actuation of Doctor Lab ethical in asking the
family to remove the ventilator? Why?
 3. Was the decision to let Angelica pull out the ventilator
ethical or not? Justify.
4. What should be done if nobody volunteers to remove the
ventilator? Is it ethical to request the nurse or the janitor or the
orderlies since they do not know the patient’s real medical condition?
Explain.
5. Should non-knowledge of the nurse, janitor or orderlies
be a good reason for their non-culpability? How should the doctor
fare before the bar of ethics or even of law in his action?
B. To Withdraw or not to Withdraw
Aunt Tina R. is in an irreversible coma. But she has been
given nourishment and hydration through intravenous (IV) devices.
She is also hooked to a respirator which is the only device that
sustains her breathing. The physician suggests that the respirator be
removed, allowing her to die of natural causes. The family members
object because they believe that that would be tantamount to killing
her. They need clarity of thought and intention in the suggested
removal of the respirator.
1. If you were the physician of Aunt Tina R., how would
you convince the family with your plan? Explain.
2. Should the condition of Aunt Tina R. warrant the
removal of the respirator even if doing so would cause her immediate
death? Is this not killing her? Explain.
3. Is it necessary to consult a neurologist to ascertain the
real condition of Aunt Tina R. before any radical procedure can be
done? Justify.
4. Is it necessary to bring the case of Aunt Tina to the
Ethics Committee of the Hospital? Justify.
C. AIDS Patient Going Suicidal
A Florida Circuit Judge Joseph Davis rules that Charles
Hall who is dying of acquired immuno-deficiency syndrome (AIDS)
has the legal right to commit suicide with the aid of a doctor. The
ruling, still rare in the US jurisprudence, applies only to Hall who is
the only survivor in a lawsuit seeking the right to have a doctor
prescribe him a lethal dose of drugs without interference.
1. Can you impugn or hold the Circuit judge and Hall
ethically responsible for the decision to commit suicide with the aid
of a doctor? Are there ethical principles violated in the case? What
are they?
2. Suppose Mr. Hall charges that if in the case of
terminally-ill patients whose conditions are irreversible their LSD can
be withdrawn, why can’t it be ethically tenable to allow him to die
since his condition is also irreversible? Is it justified that the family
or the State should spend for his medication when his illness does not
have any hope of recovery? How would you answer him?
3. What can be done ethically to help Mr. Hall in his
predicament? Is life still worth living in the case of Mr. Hall?
D. Enough is Enough
Julius B., 64-years-old, is in a terminal stage of illness. He
has been admitted into the hospital and was diagnosed to have
advanced cancer, stage 4. Within three to four days, he was expected
to die. Now, a certain stimulating drug is available and can be
administered to the patient to prolong his life for a week. The family
can easily afford it, but they request the doctor not to give it as the
patient has already suffered enough.
1. What can be said about the wish of the family of Julius
B.?
2. Suppose the family accedes to the administration of
stimulating drug, are they clearly equipped with an ethical
soundness? Explain.
3. Does it matter if the patient has insurance claims that can
run into million pesos and the beneficiaries are the members of the
family? Which decision is better, the administration of the drug or
withholding it? Explain.
E. Persistent Vegetative State (PVS)
Sixty-year-old Mrs. Gloria R. has been in a PVS for ten
months and is hooked to an artificial feeding machine. As far as her
condition is concerned, the doctors say that she has lost all conscious
and cognitive function inasmuch as her brain cortex has shut down.
Only the brain stem, which maintains some involuntary responses and
reflexes and response to stimuli, is functioning. After a certain length
of time in the Intensive Care Unit (ICU), recovery is virtually nil.
Mrs. Gloria’s family is confused as to what to do and how to feel
about her.
1. Would discontinuing her artificial feeding constitute
active or passive euthanasia?
2. Will there be reason that will help you decide whether it
is ethically acceptable?
3. Should the family be given full power to decide on her
medical fate?
4. If the family can well afford the medical bills, is
continuance of the artificial feeding machine ethically tenable?
Justify.
 sigeneration

Chapter 26
For in this earthly dwelling we groan,
longing to be further clothed with our heavenly habitation,
if indeed, when we have taken it off,
we shall not be found naked.
2Cor. 5:2-3

BIOETHICS OF SUFFERING
AND THE MYSTERY OF DEATH
his chapter could have been a part of Chapter 25. But due to its
T distinct significance, it deserves a chapter of its own. It can be
considered a corollary to Chapter 25. For indeed, one cannot
easily speak of the Bioethics of death and dying unless one also
speaks of suffering.

The
Nature of Pain and Suffering. Pain is commonly understood as an
acute or chronic physical, mental or emotional distress associated
with some disorder or abnormality (like injury or disease) or other
unpleasant stimulus characterized by discomfort which the mind
perceives as in itself an injury or a threat to one portion of the self or
to the self as a whole. Pain is also considered as kind of malady, an
unpleasant feeling, a sensory or emotional condition an individual
experience. It is caused by abnormal functioning of bodily and
emotional stimuli. Pain does not necessarily translate to suffering as
one may be feeling some pain but is not really suffering.
There are four kinds of pain, namely: 1. Nociceptive pain
(typically the result of tissue injury, like arthritis, mechanical back or
postsurgical pain). 2. Inflammatory pain (it is caused by an
inappropriate response by the body’s immune system). 3.
Neuroceptive pain (it is cause by nerve irritation). And, 4.
Functional pain (usually without obvious origin like fibromyalgia,
caused by stress, and irritable bowel syndrome). Emotional or mental
pain can be included here.
 Suffering is a state of a person undergoing a painful or
distressing feeling. This may at first begin with a physical or mental
pain. Later it becomes a generically borne human condition or state
when the pain is neither resolved nor alleviated and it becomes
protracted and state of life. Suffering is a sign of human helplessness
due to the inability of the sufferers, experts or knowledgeable
professionals to find available and cogent human means to counteract
the effects of pain. Man suffers when there is continuous distressful
condition that leads to bodily and mental malaise. It is actually a
psychosomatic feeling of anguish and misery.
On a human physical level, suffering is agonizing as it is an
experience of concrete awareness of a threat to our bodily composure,
integrity or totality. On a deeper level, it is a feeling of frustration
arising from the realization of the dearth or absence of meaning of our
existence that causes anguish and the deterioration of our personal
well-being.
Nevertheless, from the above, many claim that pain is not
an option but suffering is.
The Necessity of Suffering and its Value. It has been argued that
by the time man is born into the world, he is impetuously shoved to
suffer. His finite being is an invitation and a necessity to suffer.
Infinitude is a sign of immunity to suffer. God is the pre-eminent
being who does not suffer because of this attribute.

It was
not too long ago that the existentialist philosopher, Albert Camus
claimed that men are creatures condemned to absurdity. For whatever
he has accomplished, man is condemned to suffer and stop living.
Hence, his life is an absurdity.

So why does man suffer? Medically, man

suffers because there is imbalance in his physical and mental system.
The oriental medicine based on the yin and yang principles is very
clear about this. There is defect or excess in the way organs function
and how they are supposed to positively relate to the proper
functioning of the whole bodily and mental system of the human
person. When that happens, man experiences pain. When that pain
continuously bothers him and he is unable to function as he should be
productive, then he is thrown into a state of suffering. That happens
for instance among those afflicted with cancer or life threatening
conditions.
 Man
suffers because his nature is limited, imperfect and weak. Without
these negative factors, there is no reason why he should suffer.
Suffering is a state of a person undergoing painful or distressing
feeling. It is an indication and sign of human helplessness and
inadequacy. And why should man suffer? It reminds him of his self-
insufficiency and dependence on the higher power of his Creator. For
man cannot claim self-sufficiency as prospect of needing healing
beyond the confines of medical therapy. Herein, he realizes the great
value that suffering teaches him. In fact, through suffering man
realizes his sinfulness and its consequences and is able to see the real
value of things. Moreover, it makes one empathetic to others and
realize the temporality of the world. In addition, it highlights the
frailty of each human being that should enable man to distinguish the
temporary from the permanent values. Through suffering man diverts
his attention to the true God which consequently makes him
prayerful. In other words, suffering makes man develop values like,
humility, courage and spirituality.
The value of suffering has been clearly demonstrated by
Christ. He accepted suffering and eventual death so that humanity
will be ransomed from sin and the eternal verdict of a death sentence.
Under the purview of the world’s standard, this is foolishness. But St.
Paul has declared that the foolishness of God is wiser than the
wisdom of men. Thus, the suffering of Christ was neither a work of
idiocy nor thoughtlessness, but has shown the wisdom and the deepest
mystery of God.
Why does Man Die? The question above is similar to the question
“Why does man suffer? And although philosophically and
theologically charged, it is a very pertinent question that can be asked
by anyone. The same answer made in response to the question on
suffering, can be made here since death and suffering are closely
related to each other. Simply, man dies because his nature is limited,
imperfect and weak. If man possesses a nature that is unlimited,
perfect and powerful, then death would be a stranger to him.
Unarguably, Vatican II’s Gaudium et Spes, the Pastoral
Constitution on the Church in the Modern World, immediately
recognizes the anguish-filled effect that can overwhelm any human
being in the face of his mortality and finitude vis-à-vis the
vulnerability and temporality of the material world. In a very
poignant and emotive mood, it enunciated:
It is in the face of death that the riddle of
human existence grows most acute. Not only is man
tormented by pain and by the advancing deterioration
of his body, but even more so by a dread of perpetual
extinction. He rightly follows the intuition of his
heart when he abhors and repudiates the absolute
ruin and total disappearance of his own person. Man
rebels against death because he bears in himself an
eternal seed which cannot be reduced to sheer
matter. All the endeavors of technology, though
useful in the extreme, cannot calm his anxiety. For a
prolongation of biological life is unable to satisfy that
desire for a higher life which is inescapably lodged in
his breast.
 Due to the inevitable but unwelcome incursion of death in
the life of man, he can only but sigh in the face of its daunting reality
upon him. He can at times protest and try to fight this mortal
predicament and its demoralizing effects in the already vulnerable
condition. This fight should only be taken though as ephemeral and
temporary. That is why a good understanding of this concept can
help resolve the difficulty and challenge it poses to mortals. The
viewpoints here below should help readers to understand this reality.
What is Death? There are three points of view with regard to the
definition or understanding of death, namely: the medical,
philosophical and theological viewpoints.
Medically, death refers to that event when disease or illness
suppresses the human organism and all life signs succumb to its
destructive effect. This means that the vital organs necessary for life
cease to function permanently, (e.g. entire brain activity in the
cerebrum, cerebellum, including brain stem). This is, according to
medical experts, considered a sign that the individual has lost his
integrative capacity. And finally, death is the irreversible loss of
cardio-respiratory function.
Philosophically, death is the stoppage of self-motion of an
otherwise self-moving individual person. It is when the physical
body reaches and succumbs to its final subjection to physical
corruption and decay. This is to be expected because as all matters
are subject to disintegration and corruption, so is the human being
because he is essentially and characteristically finite. A human being
is a substantial whole of both matter and soul, the separation of both
entities is considered death of the human being. This is because the
separation of the soul from the body deprives the body of a principle
of life called soul. Hence, the absence of this principle renders the
body lifeless and deprived of the properties that characterize life and
everything that indicates life.
 This definition of
death above tells of a highly intellectual language of abstraction based
on the logic of arguments studied under rational psychology. It can
only appeal to the mind capable of a rational construct.

Theologically, death is a concept which uses the

language of a God who is a God of the living and the dead. It is
deeply rooted on the Scriptural construct and on the view of the
Christian, e.g., Paulinian discernment. It is neither medical nor
philosophical, but is understood in a language that is attributed to
Christ who said “I am the resurrection and the life: whoever believes
in me, though he should die, will come to life; and whoever is alive
and believes in me will never die.” (Jn. 11:25-26). In his letter to the
Corinthians, St. Paul expressed with a tone of assurance and
candidness thus:
“I am going to tell you a mystery. Not all of us
shall fall asleep, but all of us are to be changed---in an
 instant, in the twinkling of an eye, at the sound of the
last trumpet. The trumpet will sound and the dead will
be raised incorruptible, and we shall be changed. The
corruptible body must be clothed with incorruptibility,
this mortal body with immortality.” (Cor. 15:51-53).
Death, (as a necessary event and an accepted fact of human
existence) happens because man is not meant for this world, though
he is in this world. He is meant for something greater, fit for his
higher spiritual nature. He is therefore destined for a place beyond
this world. This is what gives life meaning inasmuch as life is not
merely earthly but heavenly. Death puts an end to the limited
perfection of his human form and confers on him the realization of his
divine destiny.
The following will give a better understanding of the concept
of death in a theologically-charged language:
1. Death is a rite of passage. “When the earthly tent in
which we dwell is destroyed, we have dwelling provided for us by
God, a dwelling in the heavens, not made by hands but to last
forever.” (Cor. 5:1).
Thus, death is a passage from one form of life to another. It is
a transformation from the earthly to the heavenly, from humanity to
divinity, from time to eternity, from the limitation of space to the
limitless state of harmony. Death is the passage from the subjection
to the body towards the freedom of the spirit.
Moreover, “death is part of the narrative or story of the life of
every human being, a mortal being.” (cf. Eccl. 8:8.) It is therefore not
the end of everything. It is a part of a seamless cloth.
2. Death has a beautiful message. Death leads the faithful to
the glorious resurrection in which the denial of death becomes the
certainty of the claim to the truth of life in the spirit. When Christ
died and later resurrected, it confirmed the finality of the resurrection
event in the midst of the sadness of death. With the resurrection
event, death was swallowed up in victory. With the truth of
resurrection, it assures the faithful that death is not the end but just a
beginning, not a final separation of loved ones, but an anticipation of
a great union where God is host in the heavenly banquet. Death is not
about saying “goodbye”, but saying: “’till we see each other again.”
3. Death is a great heritage. Death for many is a negative
event and a painful one especially for those who are bereaved. Many
probably would have wished that there was no such thing as death, so
that no one would be encumbered to his limitations. Had there been
no death, no one would be afraid of anything, neither hunger nor
thirst. No one would have to suffer in toil and labor since he does not
die. Had there been no death, people would be forever happy to stay
in this world. Yet, even if there were no death, man cannot avoid
getting old. This world would be full of filth and chaos, as it will be
populated by old people who cannot even be recognized as they will
become so old and yet they cannot die. People may have been
10,000-years-old and are still alive. How would one look when he
reaches that age? Would one still be inspired to look at the mirror
when he is already 10,000-years-old? Probably he may only have
bones with little flesh. Medicine would be irrelevant and human
industry would be obsolete. It is for this reason that death should be
considered a great event. Thank God, there is such a thing as death
and it is a great heritage.
Rebuking those who are unwilling to accept death when it has
reached its final episode, Jorge Manrique insists, “For man to want to
live when God wants him to die is madness.” (Que querer hombre
vivir quando Dios quiere muera es locura).
In his usual show of gentleness brought about by his Hinduist
upbringing, Rabindranath Tagore compellingly intimated, “Death is
extinguishing the light because the dawn has come.”
A Poem about the Mystery of Death. A poem of unknown
authorship tenderly pays tribute to Christ in view of the reality and
mystery of death. The poem is entitled God’s Beautiful Garden. It
runs thus:
God looked around His garden and He found
 an empty place.
He then looked upon this earth, and saw your
tired face.
He put His arms around you and lifted you to
rest.
God’s garden must be beautiful. He always
takes the best.
He knew that you would never get well on earth
again.
That in us you will be absent, but in God you
will certainly be present.
He saw that the road was getting rough and the
hills were hard to climb.
So He closed your weary eyelids and whispered
“Peace be thine.”
It broke our hearts to lose you but you didn’t go
alone.
For part of us went with you, the day God
called you home.
(For more in-depth discussion of the topics of suffering and
death, see Fausto B. Gomez, OP, the Journey Continues: Notes on
Ethics and Bioethics. UST Publishing House, Manila, pp. 235-253,
2009).
 Final but not “Dead”
Remarks. It is worth knowing that in the care of the terminally-ill,
especially when death has already penetrated into the inroads of the
mystery of life, one has to remember that the cost of combating the
human problems of loneliness, infirmity, depression associated with
human death is not self-destruction. Rather it can usher in the
development of a compassionate, caring and generous community.
The doctors and the pastoral carers are necessarily and naturally the
leaders in this privileged task. No amount of medical savvy or
expertise can contain life’s final corruptibility and decay and confer
deeper meaning any more than the acceptance of the better state
beyond earthly life. Certainly, no medical solution could be truly
compassionate if it would violate the natural law and stand in
opposition to the revealed truths of the word of God. “In the end, we
must recall that no doctor, no nurse, no medical technician, indeed no
human being, is the final arbiter of human life, either of one’s own
life or that of another. This realm belongs only to God, the Creator
and Redeemer of us all.” (cf. Pope John Paul II’s Address to
Anesthesiologists, 1988).
 Finally, in the care of the dying, we have to trust that human
life is not the greatest human good. Beatitude with the Creator is the
greatest and the only real good. Beatitude is a state of harmony,
peace, happiness and satisfaction. When that good is not anymore
served due to the intricacies and complexities and unnecessary
difficulties in solving the often “unresolvable” issues in the dying
process, it is of greater interest and meaning to let death finally take
its natural course. And let medicine and ethics tackle another human
life who may be in the same predicament.

Case Studies:
A. A Courageous Decision to Die
Mr. Edmundo Tesuma, 34-years old, married, has three
children aged 9 to 14. While doing an errand for the family, he rode
his motorcycle. As he was about to turn to the main road, he did not
see a speeding car; he was side swept and was thrown into a ditch.
Bystanders helped him in unconscious state and brought him to the
hospital. Findings showed he had a badly damaged spinal cord that
resulted in his paralysis from the neck down. He survived initial
hospitalization. Indication showed that any surgical operation on his
spinal cord would be too great a risk and the likelihood of recovery
would only be 5%. Mr. Tesuma is an average money earner and his
wife is a plain housewife. With his condition, the family would beg
for help from his siblings for their daily survival and the education of
their children and always with difficulty. It has been already three
years that Mr. Tesuma is bed-ridden but remains very mentally
competent and conscious. He could move neither his hands nor his
legs and could not eat by himself and was being taken care of
alternately by his family members.
One day, he just suddenly declared to his family that he had
already suffered long enough and had also seen his family suffer.
Death for him was the only choice as it would free his family from
taking care of him and reduce substantially his financial burdens. He
did not want to eat. He wanted to starve himself to death. He also
said that life had no meaning as he was unable to serve life’s purpose.
 a. What do you say about the wish of Mr. Tesuma and his
decision not to eat?
b. Is this a case of suicide? Or is it just an exercise of one’s
autonomy? Does his condition warrant the decision not to live
anymore?
c. What do you say about his declaration that his life has no
meaning as he is unable to serve life’s purpose?
B. A Magnate who Decides to End it All
Mr. B. Soriano, 60, a wealthy businessman, was playing
his favorite recreation. He mounted a horse to play Polo. As the
game was on its height, he suddenly fell from the horse and
immediately became unconscious. He was rushed to the hospital and
was diagnosed to have several torn spinal cords and was paralyzed
from the neck down. Doctors declared that he would for the rest of
his life be wheelchair bound. Mr. Soriano has been in the wheelchair
for the past seven years. He realized that even with all the money that
he has, he cannot be weaned out of the wheelchair to do the very
things he had been doing. He was being taken care of by a caregiver
who does exceptionally well. Now he wants to die as he believes
that his life is meaningless and his wheelchair presence is already a
burden although not financially.
1. Is Mr. Soriano’s life meaningless given his condition?
2. Is wanting to die unethical? Is this against the will of
God?
3. Had he been poor, is his wish to die ethically
understandable?
C. To Eliminate or not the Excess Mentally Handicapped
A mental institution in Cavite has been erected in the 60’s
and operates on a very limited budget. The once two hundred (200)
bed mental hospital is now operating with seven hundred (700). It is
in its charter that it cannot refuse any patient whoever he may be.
Because of the limited budget and due to the government’s neglect,
patients have not been truly taken care of and a majority of them just
stay there wallowing in dirt and excrements. Their cells are cleaned
only once a week. According to the Director, they would be able to
help the patients especially those who can still be well, if only the
volume of other patients would be reduced. They can just be dumped
outside the compound and left to wander around aimlessly. After all
there is no hope for them to be well again.
1. The other patients can be cured if only the others can be
eliminated. Is this a right way of looking at it? Is this ethically
tenable based on the principle that it is better to choose the lesser
evil?
2. Is dumping other incurable patients outside the
compound a socially responsible act for the hospital? Do you think
that they are useless and the value of suffering is meaningless for
them?
3. What can be done ethically to other patients who are
incurable?
3. Are there other laudable things the government can do to
help mentally-ill patients with such conditions?

Chapter 27
For if a man with gold rings on his fingers
and in fine clothes comes into your assembly,
and a poor person in shabby clothes also comes in,
 and you pay attention to the one wearing the fine clothes and say,
“Sit here, please,”
while you say to the poor one, “Sit at my feet,”
have you not made distinctions among yourselves
and become judges with evil designs?”
Jas. 2:2-4

THE MEDICAL DIMENSIONS

AND THE ATTENDANT VIRTUES
OF HEALTH PROFESSIONALS

The encounter between a patient and a health professional (especially

doctors) is an event characterized by help, assistance and concern.
This encounter immediately creates a legal and ethical contract even
if it is unwritten. It is characterized by a certain closeness or bonding,
because the persons of the doctor and the patient are not based
entirely upon data and statistics provided by machines, gadgets and
computers, nor by any technical necessities or amenities. Patients, as
we know, are not only biological, chemical nor physiological objects
to work or tinker on. They are not mere impersonal and scientific
matters left to the scientific mind to understand and solve. Besides
beings with organs, cells, bones, tissues or immune systems, they are
embodied spirit --- intelligent, free, social, artistic, symbolic beings
who have desires, dreams and plans. Thus, medical treatment has to
be more than scientific and technical because patients have
personalities to care for, privacy to protect, characters to develop,
virtues to emulate, vices to avoid and fears to dispel. And these are
ways beyond the experimentation yet certainly observable facts.
That is why, the patients must be handled with utmost care and
solicitude.
The Medical Dimensions and Corresponding Virtues of the
Health Professional. The following are the technical/medical
dimensions of the health profession and the corresponding virtues that
must be developed and imbibed by the health or medical
professionals if they have to be relevant to the patient in particular
and the society in general:
1. The Medical Dimension of Health Care and the Virtue
of Benevolence. The cognitive element in the diagnostic process and
therapy involves knowing and determining the disease or illness and
the person of the patient, as well and the prospects of cure, including
the eventual prognosis of the diseased person. Good medical process
involves knowledge of the person as it is the focus of the whole
medical endeavor. Diagnosis and therapy are fundamentally an
interpersonal act where the doctor or health professional is linked
with the continuum of the whole spectrum of health care. The health
professional who takes interest and bequeaths time to be
(inter)personally involved with the patient is a better health
practitioner in both the medical and ethical sense. There are patients
who have to travel miles and miles of distance to see their doctor,
even if there are other doctors who are easily within their reach.
Observably, the clamored doctor is one who can fill their needs in a
very special way. The sick does not need a doctor who is interested
only in the disease (and money) and not of the patient as a whole.
Being a patient does not only include his medical need but also his
cultural, emotional, social and spiritual dimensions. These
dimensions below will explain.
When this happens, it results into the development and
intensification of the virtue of benevolence of the doctor or health
professional. Benevolence is nothing but doing and promoting the
good or well-being of the patients with a touch of compassion,
kindness and affection. Benevolence is a Latin term which means
good (bene) and will (volitum), i.e., willingness to do good to others.

2.
The Psychical Dimension of Health Care and the Virtue of
Honesty and Truthfulness. It is of great necessity that the verbal
and symbolic communication between the health professional and the
patient reaches a level that is beyond the purely physical encounter.
The physical need has to be met and satisfied. However, patients
have questions that need to be answered and concerns that need to be
discussed with their health professionals. When they are not
addressed, even if cure is successfully achieved, patients go
dissatisfied. Patients expect answers that are honest and true. Lies are
unacceptable and so are promises of cure that are too good to be true,
unless “miracles” happen. The body may hurt due to illness, but, it
hurts even more when the mind is dissatisfied and suffers from
unsatisfactory responses and cold treatment.
When the above questions and concerns are addressed by the
doctor or health professionals, the resulting virtues are honesty
(honorable allegiance to the standards of one’s profession) and
truthfulness (ability to render facts accurately).
3. The Volitional Dimension and the Virtue of Respect and
Commitment. Unarguably, the sick are expected to make choices
that are related to their illness for their best interest. Sometimes these
choices have to be made even if they are painful and difficult. And
doctors may choose to accept or reject patients under their care
(unless in an emergency case). Patients choose to respect the doctors’
best judgment and doctors trust that their patients will comply with
the necessary medical regimen. But it is a marked truism that the
doctors’ attitude be characterized by a sense of duty to assist and
selfless interest. Instead of walking away, they should elect to stop
and stand close to the patients crying for help. To feel with the
patient, doctors become engaged in the fears and anxiety that patients
endure.
When this happens, the health provider develops and practices
the virtues of respect (worthiness of esteem or honor) and
commitment (a promise or pledge to do well and good).
4. The Affective Dimension and the Virtue of Friendliness
and Charity. This consists of a “feeling bond” between the health
professional and the patient. This bond is called affection and can be
popularly referred to as love, a peculiar love different from the
romantic type. Herein, the health provider develops a distinct desire
to help the patient, and a common human kindness (not usually
motivated by material interest, fame or the desire to dominate nature
by his curing power).
The affection that unfolds between the health professional and
the patient is something different; it is much deeper than the so-called
moral ascendancy. It is a distinct solidarity exemplified by a soulful
relationship. This affection should extend to others who in one way
or another are associated with selfless health promotion and
management.

When this affection

is developed, the health provider develops and practices the virtues of
friendliness (selfless disposition to show affection) and charity (a
disposition to will the good of the patient).

5. The Social Dimension and the Virtue of

Justice. Human life as we know it, requires by nature a social
context because there are interactions that cannot be avoided and
which demand intellectual and volitional functioning. Human beings
need others to survive, to progress and develop. Human beings are
never an island by themselves. The health experts and the patients
need one another for the proper functioning of the society to which
they both belong.
It must be noted that illness has a social dimension since it has
social causes and concomitant disabilities that bring forth social
effects or consequences. No matter how personal an illness is, it takes
its toll on others. This is true especially when there are epidemics or
pandemics. During the time of Hippocrates, both freemen and slaves
were treated as if there were no distinctions between them. Likewise,
the relationship between the health professional and patient should be
based on race, religion, sex, economic status and other discriminating
factors as to regard with low esteem others who are in need of health
care. It must always be borne in mind that each human being is
vested with an inherent human dignity. Everyone is a brother to a
brother doctor.
When this happens to the health practitioner, such possesses
the virtue of justice (by conferring or giving what is due to others).

6. The Religious Dimension and the Virtue of Religion. For

some, this may be a going overboard because some may not believe
in the religious or spiritual aspect in the whole spectrum of medical
care. But history tells that in the past, the medical care has been
replete with religiosity and that the priest (regarded then as a
physician) was both a doctor and spiritual healer. It should be noted
that a human being is structurally religious because he possesses not
only physical body but also a spiritual soul. He is therefore an
embodied spirit. The soul in the patient is a soul crying in need. And
this soul is essentially ethical, social, affective and spiritual. It was
just natural, that patients then (during primitive times), went to the
priest. Moreover, it is noteworthy that all components of the body
function for the sake of the soul.
When illnesses, especially serious ones, afflict people, they are
naturally drawn to religious concerns. People have individual goals
to pursue and are derailed when disease strikes and weakens them.
These goals reflect their self-image and worth. A healthy body
permits the pursuit and attainment of these goals. A serious illness
threatens these self-image and worth and therefore the very meaning
of life is questioned. When this happens, patients rely on doctors and
healers for satisfactory answers. When the healer fails to satisfy
patients about this, life goes berserk and courts disorder. Usually, the
attendant result is untold turmoil. Thus, the healer must always be
prepared to console, comfort, counsel, protect and perhaps help in
deciphering the meaning of pain and suffering or life and death.
When the healer is able to serve the patient in this manner, he
possesses the virtue of religion. This virtue is an attribute or quality
which makes it possible for the doctor even to act like a religious or
priest and is able to muster adequate patience and contain the last
possible patient need. This virtue assists the health professionals to
help the patient feel better through their own faith. Religion is an act
by which a man gives God (the real Healer) His due in the whole
gamut of medical art and science.

Case Studies:
A. The Power of Flowers vs. Insurance
Dr. Senen and Dr. Temio are good friends. They both are
surgeons with contrasting characters and viewpoints. They respect
each other’s opinions even if they have to debate about subject
matters of interest from political to managerial or about anything
under the sun worth discussing. One difference is their assessment
regarding insurance of their medical practice. Dr. Senen is afraid not
to get insurance policies since anything can happen in his surgical
practice and the insurance may just substantially save him from
spending money in case of court litigations. On the other hand, Dr.
Temio does not believe in getting insurance policies for as long as he
is ethical in his practice. He believes that bringing a flower to a
patient every time he goes for a patient visit is enough to tell the
patient that he cares. Dr. Temio spends a thousand pesos for flowers
a month. Dr. Senen spends P300,000 annually for his insurance.
1. Who is the more caring between the two surgeons?
Explain.
2. Who of the two doctors could possibly be charging patients
more? Why?
3. Who do you think is a better doctor between the two
surgeons? Why?
B. Ground Coffee or Grounds for Lawsuit
The following is a parody by an anonymous writer about
doctors and med reps:
If you have to listen to this bunch of well-
groomed med reps, it is well to let them
propagandize.
Listen to them rhapsodize about the merits of
their latest tranquilizers or
vitamins.
But, be careful not to share coffee with them!
Because the first cup of coffee will be in a
restaurant,
There will be lots of laughs and eye contact.
The second cup of coffee will be in her apartment,
There will be fewer laughs and a different kind of
contact.
The third cup of coffee, you will be sitting at the
end of the table.
And you grow cold.
In the end, there will be no ground coffee, but
only grounds for lawsuits.
1. What do you suppose the parody above is all about?
 2. What do you think are the ethical virtues breached by the
doctor in the case?
3. Is there an ethical ground for acts of misdemeanor of the
doctor here? What are they?
C. Segregation of the Charity Patients from the Private Patients
Dr. E. Oreña is a surgeon who treats both paying and charity
patients. He charges paying patients more than the usual fee which to
him is to make up for his loses from the services he gives to charity
patients. When he schedules an operation, he sees to it that paying
patients are scheduled on the most convenient time, while charity
patients are scheduled on the most unholy hours. He usually has the
audacity to postpone scheduled surgery for charity patients but never
for paying patients. He justifies this by saying that anyway, the
charity patients are like beggars who cannot be choosers.
1. What can you say about the attitude of Dr. E. Oreña towards
charity patients? Is it within the call of justice to relegate charity
patients for surgery to unholy hours?
2. Do you think he is ethically accountable for the
postponement of charity patients’ schedule of surgery?
3. What are the virtues that Dr. E. Oreña missed practicing? Is
segregation of paying and charity patients a laudable practice?
Explain.

D. Ghost Surgery in Practice

Dr. S. Ola is a consultant surgeon in a training hospital.
Several resident surgeons are under his ward. As trainees, these
resident surgeons are at the beck and call of Dr. Ola. When busy with
other schedules, he would order senior resident surgeons to do the
surgical procedure on patients and charge them the usual professional
fees, even when he is not around or doing some other surgeries in
other operating rooms. Accordingly, Dr. Ola does not share any part
of the fee with the resident who does the surgery by justifying that the
latter is still under training. Besides, he is the one accountable to the
patient and the hospital for any complication that may arise following
the procedure. In other words, ghost surgeries are abetted and
perpetrated in the hospital because there are resident surgeons who do
them and are pervasively allowed by consultants themselves.
1. What is your opinion about ghost surgery? Is there
something unethical in the practice? How?
2. Through ghost surgeries, resident doctors learn from the
procedures. Is this a good justification for the ghost surgeons to
collect professional fees from patients?
3. The consultant surgeon accepts responsibility if something
goes wrong with the operation, should he be justified therefore to
collect professional fees from patients?
4. Do you favor the banning of ghost surgical procedures on
ethical grounds? Should there be a law prohibiting ghost surgeries?
What if they make resident doctors adept in surgical skills?

Chapter 28
Some people God has designated in the Church to be,
first, apostles; second, prophets; third, teachers;
then, mighty deeds; then gifts of healing, assistance,
administration, and varieties of tongues.
1Cor. 12:28

THE BIOETHICS COMMITTEE IN HEALTH CARE

T

he
Bioethics Committee (BC) or simply Ethics Committee (EC), in
health care facilities is significantly important especially when such
facilities serve a large number of patients approximately a hundred or
above bed capacity. This does not mean that small hospitals do not
need an Ethics Committee. The volume of patients with different
backgrounds, idiosyncrasies and in general, belonging to different
culture augurs well with various ethical problems to resolve, aside
from the cultural and economic problems. Most of the time,
dilemmas and issues cannot just be simply resolved by the attending
doctors or other health professionals because decision-making on
cases with an ethical dimension needs a different kind of applicable
knowledge, specialization or approach. When cases of this nature
happen, it is imperative that a hospital or any health care facility must
have a committee in which the power of analysis and rationalization
is reposed the so-called reasoned judgment that should characterize
every ethical recommendation. The Bioethics or Ethics Committee as
an essential group in a health care facility must be established for the
purpose of discovering, offering wisdom and making judgment and
recommendations to proper authorities from whose office are
expected a rational and timely disposition of cases charged with said
dilemmas or problems. It is to be understood that since ethics
committees are by nature ethical, their decision must be based on
ethical grounds.
 We
properly know that medical decisions are always ethical decisions.
Both of which are consensual and based on adequate, competent, and
conscientious truthful information by the decision makers and
recipients. Current issues must be tackled for purposes of
clarification and understanding. Questions needing answers must be
brought to the fore with candor and nothing should be left out without
exhaustive discussion. This will prevent future complaints and
certainly will educate the people concerned especially the patients or
his family in acquiescing to decisions. Questions, like the following
must be answered on their own merits like: “Doctor, was the choice a
better option than the rest?” “Will the procedure save the life of the
patient?” “What are the risks and benefits involved in the planned
procedure?” “Will the procedure entail heavy financial burden?”
“How about the emotional burden that the family will undergo in case
the procedure is not successful?” “Will the patient recover
completely or just partly?” “Will prognosis be bright since the
procedure is a pioneering one?” There are a thousand questions that
can be asked, but decision makers should never be annoyed about
them since they are made for the benefit of the patients. Negative
comments should also be entertained as they are concerns that must
be recognized even if they straddle between the pertinent or
impertinent. Some of these may be distressing or bothersome, but
entertaining them as important does not unnecessarily hurt or harm
the decision makers or even the patients.
 It must be borne in
mind that the patient’s life should first and foremost be protected and
defended as a matter of fundamental right. Probable risks in the
procedures have therefore to be communicated clearly to the patient
and/or his family and should never be kept away from them. It is
highly prudent that decisions must be backed up by proper, honest
and knowledgeable experts respected for their ethical stand and
integrity.
How should issues of ethical nature be prevented or if these
are already present, how should they be handled? How should issues
in the hospitals be well addressed and resolved? The answer is
simple --- the creation of a Bioethics Committee in hospitals. This
committee works as a team, the members of which know clearly their
functions. The appointment of the Chair and members is certainly
crucial. Their selection should be put aright in a manner that those
selected must accept the task with strong commitment and a deep
sense of dedication. The Chair and members should possess the
virtue of honesty and courage to truly defend decisions, not only
because it is ethically right, but certainly because it is what ought to
be done to obtain the best outcome. However, before they can even
start working, they should first be trained in the discipline of
Bioethics. It is strongly urged that the Ethics Committee be well
supported by the administration of the Hospital, lest it remains an
unnecessary appendage to the technical service of medicine.
The (General) Functions of the Bioethics Committee. The
Bioethics Committee is a forum where ethical dilemmas (or issues)
on decision making can be addressed. It should not be regarded as a
decision icon or “lawgiver” that can simply dictate what one should
do in the face of conflicts or concerns. This forum discusses the facts
and information that resulted in the dilemmas. The forum makes
resolutions that can be reached by the Chair and members based on
reasoned principles of judgment while respecting the values of the
patient and the family concerned. It must be able to bring about
enlightenment to all the stakeholders. This committee must finally be
able to reach a decisive point which in the present situation is the best
that can ethically be done. But whatever decisions are reached, this
committee can only make recommendations for final disposition by
the authorities concerned. However, the final determination of the
decisive action lies primarily in the hands of the patient (or the
family) acting on a free and informed consent.
In sum, the following are the fundamental functions of the
Bioethics Committee, to wit:
1. To act as a consultative or referral body
2. To educate and be a source of knowledge and
enlightenment
3. To help or guide in policy formulation
4. To function as a recommendatory team
5. This last function is something that is not fundamental to
the Bioethics Committee but certainly highly praiseworthy. Every
Bioethics Committee must endeavor to craft ethical guidelines or
policies that will govern the medical practice of health professionals.
The advantage of this is that every member of the Committee will be
guided already as to how a medical dilemma or issue will be
resolved. These will set a right path through which the members will
be able to navigate and make decision that is rational and ethical.
Although it must be presumed that the bioethical guidelines must be a
living document, i.e., must be open to amendments depending on the
ethical needs of the situation. This could be more meaningful also to
situations like pandemics. Lest anyone forgets, the crafted policies
must earn the nod of the administration and must formally be adopted
to make it official.
 Prof. Amnon Carmi of the University of Haifa, Israel and
Chair of the UN Bioethics Department captures very succinctly the
nature of Bioethics Committee. This is what he says below:
Health care institutions as well as
government and policy agencies recognize the
importance of developing formal mechanisms to
address and resolve ethically charged or value-laden
problems in the rapidly shifting dynamics of
everyday health care and health policy.
A bioethics committee is a committee that
systematically and continually addresses the ethical
dimensions of the health sciences, the life sciences
and innovative health policies. A bioethics committee
is typically composed of a range of experts, is usually
multi-disciplinary and its members employ a variety
of approaches to work toward the resolution of
bioethical issues and problems, especially moral or
bioethical dilemmas. Although bioethics committees
have been established to advise the medical
community and health professionals on how they
ought to act with respect to specific moral
controversies, some of these committees are also
expected to advise policy makers, politicians or
lawmakers.
There are many reasons for establishing and
activating bioethics committees. The principal
objectives of bioethics committees are to provide
expertise and represent different viewpoints
concerning ethical issues raised in biology, medicine
and the life sciences, to improve patient-centered
care, to protect persons who become involved in
research trials and to facilitate the acquisition and
use of new knowledge directed to improving health
and the delivery of health care.
The Members of the Bioethics Committee. The Bioethics
Committee Chair and the members must be selected on a purely merit
basis and must be multi-disciplinary. The Chair must of course be a
respected and reliable head. He must be known for his integrity or
probity and whose moral standards are beyond reproach. He must
have a sense of dedication and a sense of duty. The members, too,
must have the same qualities as the Chair. They must be able to
discuss with moral courage the issues in the case and recognize the
real dilemmas, issues or problems that bother the patient and his
family as well as the health care professionals.
There are no known criteria as to who should compose the
Bioethics Committee. The following composition of members is
suggested and therefore recommendatory but the number of members
depends on a need basis.
1. One representative from each specialty group. He can sit in
the meeting when the case is under his specialty;
2. A bioethicist;
3. A medico-legal representative (preferably with knowledge
in Bioethics, or a doctor-lawyer);
4. A Chaplain with training in Bioethics;
5. A member of the community or a nursing staff or medical
social service personnel (preferably with knowledge in Bioethics);
and
6. A member of the administration (this is very important
since the support of the administration can either make or break the
(continued) success of the Bioethics Committee).
The International Bioethics Committee (IBC). The name
International Bioethics Committee (IBC) is so-called because of its
global reach and relevance. Its function is basically recommendatory
and acts as a body that analyzes cases that are medical and ethical in
nature. It pronounces judgment on cases of international interest. Its
member-composition is necessarily international. The member
countries who are signatory to it who are signatory have the option to
follow its recommendations.
Presently, the International Bioethics Committee (IBC) is a
body of 36 independent experts that follows progress in the life
sciences and its applications in order to ensure respect for human
dignity and freedom. It was created in 1993.
The IBC provides the only global forum for in-depth
bioethical reflection by exposing the issues at stake. It does not pass
judgment on one position or another. Instead, it is up to each country,
particularly lawmakers, to reflect societal choices within the
framework of national legislation and to decide between the different
positions.
For added and supplementary information on how bioethics
committee works, the International Bioethics Committee has
something to impart to readers, especially the students and
practitioners of the health care professions. The following are,
according to this committee, the fundamental tasks entrusted to any
bioethics committee functioning with a global character, namely:
1. To promote reflection on the ethical and legal issues raised
by research in the life sciences and their applications; and to
encourage the exchange of ideas and information, particularly through
education;
2. To encourage action to heighten awareness among the general
public, specialized groups and public and private decision-makers
involved in bioethics;
3. To co-operate with the international governmental and
non-governmental organizations concerned with the issues raised in
the field of bioethics as well as with the national and regional
bioethics committees and similar bodies;
4. And (a) To contribute to the dissemination of the principles
set out in the Universal Declaration on the Human Genome and
Human Rights, and to the further examination of issues raised by their
applications and by the evolution of the technologies in question;
 (b) To organize appropriate consultations with stakeholders;

(c) To make recommendations addressed to the General

Conference, to give advice concerning the follow-up of the
Declaration, and to identify practices that could be contrary to human
dignity.
The IBC provides the only global forum for in-depth
bioethical reflection by exposing the issues at stake. It does not pass
judgment on one position or another. Instead, it is up to each country,
particularly lawmakers, to reflect societal choices within the
framework of national legislations, and to decide between the
different positions.

From the above, it can

be concluded that a Bioethics Committee is imperative especially in
large health care facilities, due to the benefits this committee can
offer. Besides, it may save the health facility from more serious legal
problems.
 Lastly, it is also imperative that there has to be a
National Bioethics Committee under the Department of Health or
other agencies.

Decision-Making in Bioethics Committee and Justification Tips.

Experts in health care and Bioethics normally state that making
decisions in health care, especially when medical cases are dilemma-
filled and problematically-charged, is very difficult. There can be
scenarios that even the Bioethics Committee can face a lot of
problems and complaints especially when some parties in the case are
not satisfied with the decisions. There are some important matters
that need to be known and understood to make decision-making easy,
although not usually simple. The following guidelines are important
and they can offer us immense advice following some accepted stages
that committee members should follow:
1. The level of Beneficence and Non-maleficence. One of
the things that every member of the Bioethics Committee should
know is the complete medical indications or data relevant to the case.
Everyone has to answer how this patient can be benefited by medical
and nursing care, and how harm can be avoided?
2. The Autonomy Level. A premium principle that every
Committee member should answer is “if the patient’s right to choose
is being respected to the extent possible both in ethics and law”.
3. The Quality of Life Level. The members must be
circumspect with regard to potential prognosis. They have to answer
the questions like: What are the prospects for a return to normal life
with and without treatment? Is this desirable or acceptable to the
patient or to the family?
4. The Contextual Features Level. These contextual
features are very important as they are factors necessary in the
resolution of cases that can consequently help those involved in
making free and informed decision, namely: family, provider issues
and financial, religious, legal, cultural factors, both institutional and
even personal. In the Philippines, compared to other developed
countries, it is always important to consider the person who foots the
hospital bills.
In decision-making, each member must be able to know why a
decision is to be reached or not. The following will help the
committee members assess the motivations in the decisions made.
It is therefore important to know the following motivations in
decision-making that should guide stakeholders through which they
can take a solid stand. The following questions must be asked if a
decision made is due to the following:
Stage 1 – Is it to punish?
Stage 2 – Is it to reward people who helped?
Stage 3 – Is it to please people who care for me? (or my
loved ones or others?)
Stage 4 – Is it my role in the society?
Stage 5 – Is it a contribution to social well-being, to
each member of the society that has an obligation to every other
member?
Stage 6 – Does it appeal to personal conscience and universal
ethical principles?
It must be noted that the first three motivations are only within
the level of the patient and are considered the lowest motivations. The
fourth is rather utilitarian as it considers the benefit of the majority in
the society. The last two motivations are under the level of the
Bioethics Committee, and the highest motivations so far that can be
considered. It must be noted that these are parts of the theories that
Köhlberg advanced in the explanations about his view on the moral
development of individuals. It sits well with and in the view of
Bioethics Committees’ motivation.
It should also be remembered that the members of the
Bioethics Committee need to be sure and be clear about what values
they hold important, both as individuals and as members of a group as
this will penetrate incisively in their judgment without them
sometimes being aware of it. They must also determine where the
conflict lies, like: Is the conflict between or among values, principles,
or rules and other factors that belong to different ethical systems?
Moreover, members should be aware of the level of their reasons or
motivations (cf. above) and the extent possible of the level of others’
reasons or motivations. These factors are indeed very crucial in
making decisions, difficult as they may seem. And it should be
presumed that ethical decision-making is equally difficult as medical
decisions.

Case Questions:
1. There are those who believe that an Ethics Committee
should only be consultative or advisory in its nature and function. Is
there a serious ethical issue if it is given a decisive role?
2. What do you think will the consequences be if it has a
decisive role?
3. Can members of the Bioethics Committee be charged in
court in case their decision is legally wrong?
4. What if their decision is ethically right but legally wrong?
5. What do you think is the administration’s role in a Bioethics
Committee?
6. Is it highly recommendable to have a legal counsel in the
Bioethics Committee?
7. Should a family member be a part of the Bioethics
Committee?
8. What is the ideal composition of any Bioethics Committee?
9. Is it always necessary to have a Bioethics Committee in
health care facilities?
10. Should the members in the Bioethics Committee be paid or
remunerated at least?
 Give and gifts will be given to you;
a good measure, packed together,
shaken down and over flowing,
will be poured in your lap.
Lk. 6:38

EPILOGUE
here had been so much development in medical science in the past
T decade. As it is with medical science so is Bioethics. Both have
to go together on a parallel line. Neither one or the other should
be ahead or behind. Otherwise, medical practice will cease to be an
ethical practice and that is tragic. When both these disciplines part
ways or act so independently from each other, then there will be so
much confusion, distraction and negativity. The scene will be like the
one that happens between Law and Ethics. And the enmity will be
endless. And we do not want to tread that path.
 It has been viewed by many of those in the academe,
paraphrasing an unknown author that “Specifically, in medical
schools (and generally in the health profession), every medical
student experiences having collectively embarked on a great journey
to the frontiers of medical and scientific knowledge. It is safe to
assume that every doctor or health professional passes by this long
crucible medical or nursing school’s sometimes ordeal-filled training.
They certainly have experienced theoretical and practical exploration
in the infinitely interesting yet inexhaustibly charted territory of
suffering and pain. Allegedly, till now there are only few fully known
diseases with real experimental cure out of the thousand diseases in
the world. Many newer illnesses are coming up and some turn to be
more virulent like COVID-19 that turned the whole world upside
down in 2020 (bold letter are author’s). As a matter of fact, after
several thousand years in medical art and science, we are still
dazzled and baffled to applaud whether or not this art or science can
win the war against disease. Many people die unnecessarily (most are
due to the absence of medical attention although the world’s life
expectancy has gone up.”)
Truth to tell, it is humbling as it is overwhelming for this
writer to reveal as for the reader to hear, that the so-called skills and
knowledge needed by doctors or health professionals to defeat
sickness do not a good and ideal professional make. To retain this
hard earned prestige in the world, an energized effort toward the
revitalization and systematization of professional ethics, that is,
Bioethics in medical and health professional practice is of the
essence. This is the key to the survival of the profession of medicine
or any health related profession. One may lose his patients to death in
the practice of the art and science of healing, but he can still regain
them through their family in the practice of his personal character
befitting a good professional. Such moral quality speaks well of the
physician’s or health professional’s inner moral character more than
anything else. This is one single attribute that any patient would like
to see and feel among physicians and health practitioners to whom are
entrusted their dear life. As has been said in the introduction, “a
doctor without ethics is just a technician, but with ethics he becomes
properly called a physician.”
One can reflect on this: “Fifty years from now, it will not
matter what our account was, the sort of house we lived in, or the
kind of car we drove . . . but the world and humanity may be different
because we have touched the lives of our patients, those entrusted to
us and their families. Sharing generously our time and efforts, in a
conduct befitting a man of character to the sick and the weak, is the
key to our immortality.”
Moreover, “Success is always temporary. When all is said
and done, the only thing left permanently is one’s moral character.”
And “for life to be enjoyed, be it sleep, riches, health or knowledge, it
has to be interrupted. Nothing can better interrupt it than by a sense
of rightness.” (cf. Jean Paul Richter, 2002).
Lest we forget, the road that we tread towards the direction of
our destiny is sometimes obscured by the mists of our vague thoughts
that lurk ahead. Bioethics is the lamp through which we see the path
ahead and recognize the signposts. Should we now train it before we
continuously straddle, struggle and stumble?
Last Word of Exhortation and Caution. Man is a created being
that is too complex to simplify through a plain explication.
Unarguably, the more we know of man, the more we realize our
inadequacy to fully know him. The more we try to know something
more of him, the more we discover new things in him. No wonder,
man is the most misunderstood being that has walked this earth in
spite of the million years of his history. The simple reason for this
difficulty is that man possesses many facets that are left undiscovered.
Knowing the countless details of his biological dimension alone is in
itself a challenge. Take for instance the trillions of his DNA which
scientists up until now are still trying to decode through the powerful
electronic processes and without much success. His mental and
psychological, social as well as his moral and spiritual dimensions are
certainly crucial aspects that leave a lot of room for study and
understanding. No wonder there is no stopping to the fascination by
scientists the world over in their study of man and his usually
misunderstood nature.
We can take comfort in knowing though that the more we
try to know him, the more we fall in love with him. This is a mystery
that our heart has reasons which reason itself oftentimes does not
know.
It has been loosely accepted that man has three general
motivations through which he pursues his chosen action. Firstly, one
acts because there is an economic need that he wants to fulfill. This
refers to the Marxist view of understanding man’s conduct.
Secondly, man pursues actions because they are related to fulfilling a
sexual need. Even through a simple mannerism, like touching one’s
nose or hair can have a sexual connotation. This is the Freudian type
of human motivation. Thirdly, man pursues actions that he knows
have eternal value. He acts because he believes there is a divine
reward for the good acts he does. “Seek first the kingdom of heaven
and his righteousness, and everything else will be given to you
besides,” says Christ. (Mt. 6:33). This is Christ’s teaching to His
disciples and would-be believers. It belongs to the moral and spiritual
domain and it is divine in essence and character.
It has been said that since man is vested with various
dimensions in life, these should naturally compel him to pursue them.
But to pursue just one dimension and dismiss the rest would leave a
vacuum in his being and unduly lead him to anxiety. This situation
will create incompleteness that will endlessly haunt him. Its
consequences will throw him into the pit of a deep chasm. In the end
he becomes an absurdity, to borrow the term of the existentialist
philosopher, Albert Camus.
It is therefore imperative that he must pursue every
dimension of his life to achieve fuller satisfaction. When a man is
able to reach that, it is easy for him to die in peace and live fully
beyond space, time and death. There is always something inside man
that impels him to be what he is, to be complete in all his dimensional
attributes. Therefore, in everything that man does, whether it be
personal or professional, he must pursue those which will make him
complete. To possess only a few is to miserably lose the whole.
This is the case of those who pursue only the earthly and not the
heavenly, the temporary and not eternity and the human and not the
divine.

At this
juncture, a word of caution is properly in place. The bioethical
concepts and principles elucidated in this book should never lead the
reader to an absolutist attitude. It was not the purpose of this book to
give a regimented canon of bioethical principles that everyone should
follow hook, line and sinker. This book intends only to give the
readers an informed guide that should help clarify their ethical
choices or decisions especially in their professional lives. The
following should give them this clarification. The bioethical
principles herein:

• Must not be ridiculously restrictive but

inspiringly responsive;
• Not primarily punitive but essentially corrective;
• Not unreasonably reprehensive but
positively constructive;
• Not extremely stringent but comfortably relevant; and
• Not precisely to condemn but to generously enlighten.
For those who wish to live a complete life, they must include
an ethical life. It certainly works and they will not regret it. Here is
the meaning of Jesus exhortation to his disciples when He said:
“Produce good fruits. Even now the ax lies at the root of the trees.
Therefore, every tree that does not produce good fruit will be cut
down and thrown into the fire.” (Lk. 3:8-9)
What could be a better life than for anyone whose reflective
spirit would always exhort him that after a day’s work and before
retiring to bed to face the mirror and tell himself who this man is in
front of him. This is a moment in which he or she can examine
himself or herself and learn according to Socrates that “an
unexamined life is not worth living.” Accordingly, here is a
challenge posed on anyone who faces the mirror at any time he or she
can.
You may fool the whole world down the
pathway of life and get pats on your back as you pass,
but your final reward will be the heartaches and tears
if you’ve cheated the man in the glass. (Dale Window,
The Heart of a Leader)
In other words, there is no life as the life of an ethical person,
personally, socially or professionally.
A Prayer
Lastly, as part of the epilogue, it is certainly worth sharing this
beautiful prayer by Ruth McKeon with the readers and with those
who, in one way or another, may want to have interest in this deeply
rich but often controversial world of Bioethics:

My Prayer
With this, the talent I possess,
Dear Lord, let me bring happiness.
In some small way to those who read
Let it be said no word of mine
Shall turn a heart away from Thine;
But, if frivolity can make
A little less the bitter ache
That fills one soul; or for a while
Induce a tired face to smile;
Dear Lord, perhaps You will not care
If this is what I call my prayer.
 SELECTED REFERENCES
Books:
Aguirre-Miguel, Angelita. Ethical and Social Issues Facing
Life, Love and Family: A Handbook. Q.C.: Human Life International
Asia (2005).
Akabayashi, Akira, Satoshi Kadama and B.T. Singsby.
Biomedical Ethics in Asia: A Casebook for Multicultural Learners.
Singapore: McGraw Hill. (2010).
Alcorn, Randy. Pro-life Answers to Pro-choice Arguments.
Oregon: Multnomah Publishers, Inc. (2000).
Alora, MD, Angeles Tan (ed.) Casebook in Bioethics.
Southeast Manila: Asian Center for Bioethics. (1993).
Ashley, OP, Benedict M. and O’Rourke, OP, Kevin D.
Ethics of Health Care. Washington, D.C., USA: Georgetown
University Press. (2002).
Ashley, OP, Benedict M. and O’Rourke, OP, Kevin D.
Healthcare Ethics: A Theological Analysis. St. Louis, MO: The
Catholic Health Association of USA. (1989).
Basterra, Francisco Javier E. Bioethics. U.K.: The
Liturgical Press. (1994).
Beauchamp, Tom L. and Childress, James F. Principles of
Biomedical Ethics. Oxford et al.: Oxford University Press. (1994).
Beauchamp, Tom L. and Walters, Leroy (eds.).
Contemporary Issues in Bioethics. Belmont: Wadsworth Publishing
Co. (1982).
Bioethics Forum 1. Bioethics: A Growing Concern.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (1994).
Bioethics Forum 2. Special Issue in Bioethics. Department
of Bioethics, UST Faculty of Medicine and Surgery. Manila: UST
Press. (1995).
Bioethics Forum 3. Relevant Ethical Issues in Healthcare.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (1996).
Bioethics Forum 4. Bioethics: The Journey Continues.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office, (1997).
Bioethics Forum 5. Conscience, Cooperation, Compassion.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (1998).
Bioethics Forum 6. Impact of High Technology on Health
Care. Department of Bioethics, UST Faculty of Medicine and
Surgery. Manila: UST Printing Office. (1999).
 Bioethics Forum 7. Love/Life-making, Confidentiality,
Xenotransplants, Aging. Department of Bioethics, UST Faculty of
Medicine and Surgery. Manila: UST Printing Office. (2000).
Bioethics Forum 8. Justice, Patient’s Rights, Psychoethics.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (2001).
Bioethics Forum 9. Current Practical Issues in Bioethics.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (2002).
Bioethics in Pulmonary Medicine. Unpublished Lectures.
Unilab Medical Education and Development, Antipolo City. (2003).
Brody, B. E. (ed.). Moral Theory and Moral Judgments in
Medical Ethics. Kluwer, Dordrecht. (1987).
Clowes, PhD, Brian. The Facts of Life. Front Royal,
Virginia: Human Life International. (1997).
Current Bioethical Issues in Pediatric Practice (2003).
Unpublished Lectures. Unilab Medical Education and Development.
Antipolo City.
Dickenson, Donna L. (ed.) Ethical Issues in Maternal-Fetal
Medicine: Cambridge, UK, USA et al. (2002).
Duncan, A. S., Dunstan, G. R. and Welbourn (eds.)
Dictionary of Medical Ethics. New York: Crossroad. (1977).
Dunn, MD, H. P. Ethics for Doctors, Nurses and Patients.
New York: Alba House. (1999).
Edge, Raymond S. and Groves, John Randall. Ethics of
Health Care: A Guide to Clinical Practice. Singapore et al.: Delmar
Publishers-Thomson Learning Asia. (1999).
Engelhardt, H. T. The Foundations of Bioethics. New York:
Oxford University Press. (1986).
Educational Research Staff. Health Ethics: Concepts and
Moral Issues. Manila: Giuani Print House. (2005).
Ethical Guidelines for Medical Practice. Department of
Bioethics, UST Faculty of Medicine and Surgery. Manila. UST
Printing Office. (2001).
Fuchs, SJ, Josef. Christian Morality: The Word Became
Flesh. Washington, D.C.: Georgetown University Press. (1987).
Gillon, R. Philosophical Medical Ethics. London and New
York: John Wiley & Sons. (1986).
Gomez, OP, Fr. Fausto B. A Pilgrim’s Notes: Ethics,
Social Ethics & Bioethics. Manila: UST Publishing House. (2005).
Gomez, OP, Fr. Fausto B. The Journey Continues: Notes on
Ethics and Bioethics. Manila: UST Publishing House. (2009).
Gorovitz, S. et al. (eds.). Moral Problems in Medicine.
Englewood Cliffs: Prentice Hall. (1983).
Hastings Center Survey. (1974).
Hellriegel, Don, Slocum, John W. and Woodman, Richard.
Organizational Behavior, 7th ed. New York et al: West Publishing
Co. (1995).
Horn, Peter. Clinical Ethics Case Book. Wadsworth
Publishing Co. USA. (1998).
Johnsen, A. R. Clinical Ethics: A Practical Approach to
Ethical Decisions in Clinical Medicine. New York: MacMillan.
(1986).
Jones, J. Bad Blood: The Tuskegee Syphilis Experiment: A
Tragedy of Race and Medicine. NY: The Free Press, (1981).
Kass, Leon. Toward a More Natural Science. Free Press. New
York. (1985).
Lammers, S. E. and Verhey, A. (eds.). On Moral Medicine.
Grand Rapids. Michigan: Eerdmans. (1987).
Levine, C. Taking Sides: Clashing Views on Controversial
Bioethical Issues. Guildford: Dushkin Publication Group. (1987).
Loringer, S. J. Human Values in Critical Medicine. New
York: Praeger Publication. (1986).
Luper, Steven. (ed.) Life and Death. Cambridge, UK:
Cambridge University Press. (2014).
Mappes, Th. A. and Zembaty, J. S. Biomedical Ethics.
New York: McGraw Hill. (1986).
Mahoney, John. Bioethics and Belief. London: Sheed and
Ward. (1984).
Maranon, Gregorio Vocacion y Etica. Madrid: Espasa
Calpe. (1985).
Mason, J. K. and McCall-Smith, R. A. Law and Medical
Ethics. Butterworth. London. (1991).
McCormick, R. A. Health and Medicine in the Catholic
Tradition. New York: Crossroad. (1984).
McCormick, R. A. How Brave a New World. Washington:
Georgetown University Press. (1985).
Monagle, J. F. and Thomasma, D. C. (eds.). Medical Ethics:
A Guide for Health Professionals. Rockville: Aspen Publication.
(1988).
O’Brien, Mary Elizabeth. Prayer in Nursing: The
Spirituality of Compassionate Caregiving. Boston et al.: Jones and
Bartlett Publishers. (2003).
O’Brien, Mary Elizabeth. Spirituality in Nursing: Standing
on Holy Ground. Boston et al: Jones and Bartlett Publishers. (2003).
O’Rourke, Kevin D. and Boyle, Philip. Medical Ethics:
Sources of Catholic Teachings. Washington, D.C: Georgetown
University Press. (1993).
Panizo, OP, Alfredo. Ethics or Moral Philosophy. Manila:
Novel Publishing Co., Inc.
Pastrana, Gabriel. Medical Ethics: Ethical Reasoning in
Medical Practice. Faculty of Medicine and Surgery. Manila. UST
Printing Office.
Pellegrino, E. D. and Thomasma, D. C. A Philosophical
Basis of Medical Practice: Toward a Philosophy and Ethic of Healing
Professions. New York: Oxford University Press. (1981).
Quinlan, J and Quinlan, J. D. Karen Ann: The Quinlans Tell
Their Story. New York: Bantam Books. (1977).
Rachels, J. (1986). The Elements of Moral Philosophy.
Temple University Press. Philadelphia.
Ramsey, Paul. Patient as Person: Exploration in Medical
Ethics. New Haven: Yale University Press. (1970).
Reich, W. T. Encyclopedia of Bioethics. New York:
MacMillan-Free Press. (1978).
Sassone, Robert L. Handbook on Population. Stafford, VA:
American Life League, Inc. (1994).
Senfield, F. and Sureau C. (eds.). Ethical Dilemmas in
Assisted Reproduction. New York and London: The Parthenon
Publishing Group. (1997).
Senge, Peter M. The Fifth Discipline. NY: Doubleday.
(1990).
 Shannon, Thomas S. An Introduction to Bioethics. New
York: Paulist Press. (1997).
Shelp, E. E. (ed.). Theology and Bioethics: Exploring the
Foundations and Frontiers. Hinham: Kluwer Acedemic. (1985).
Sigerist, H. E. A History of Medicine. (n.d.)
St. Tomas Aquinas, OP. Summa Theologiae.
The New American Bible (The New Catholic Translation).
Metro-Manila: St. Pauls. (1991).
Veatch, R. M. A Theory of Medical Ethics. New York: Basic
Books. (1981).
Wilkinson, John. Christian Ethics in Health Care. London:
The Handsel Press. (1988).
Wilks, MPS, John. A Consumer’s Guide to the Pill and Other
Drugs. Mandaluyong City: National Bookstore. (2000).
Wright, R. Human Values in Health Care: The Practice of
Ethics. New York: McGraw-Hill Book Company. (1987).
Booklets:
Manlangit, OP, Jerry Reb. (ed.). Documentary References
in Bioethics for Health Carers. Manila: UST Printing Office. (1999).
Senander, Mary. Imposed Death: What You Need to Know
about Mercy Killing and Assisted Suicide. New York: Life Cycle
Books. (1999).
Articles:
D’Agostino, Francesco. “Is Euthanasia the Proper
Answer?” L’Osservatore Romano, 6:10, Vatican City. Rome. (2007).
Figueroa-Rivera, MD, Esperanza. “Professional Ethics,”
CPGP Newsletter (36), 1, 5. (2002).
Francisco, MD, Angelica D. “Bioethical Awareness in
Medical Schools,” Forum in Bioethics 1, UST Department of
Bioethics. Manila: UST Printing Office. (1994).
Frye, Pharm.D., Carla B. BCPS. “Disclosing Conflicts of
Interest Involving Clinicians who Prepare Therapeutic Guidelines,”
American Journal of Health-System Pharmacy (62), 361-2. (2005).
“Hospitals Aim to Give Faster Care,” International Herald
Tribune. (n. v., n.p.), Manila Bulletin. (2006).
 Human Rights Watch, US (2008).
Manlangit, OP, Fr. Jerry R. “Abortion: A Modern-day
Ethnic Cleansing,” The CPGP Newsletter (36), 2, Manila. (2001).
Also in Philippine Daily Inquirer, Manila. (2001), Philippines Star,
Manila. (2001) and Asian Federation of Catholic Medical
Associations Newsletter, (2), 4. (2001).
Manlangit, OP, Fr. Jerry R. “The Theological Bases of
Human Dignity,” The CPGP Newsletter, (36), 3. (2001).
Manlangit, OP, Fr. Jerry R. “The Enemy of Medical
Practice and Relevant Provisions in the Medical Code of the
Philippines,” The CPGP Newsletter, (36), 1. (2002).
Manlangit, OP, Fr. Jerry R. “Suffering: A Blessing or
Curse?” The CPGP Newsletter, (36), 1, 6-7. Manila. (2002).
Manlangit, OP, Fr. Jerry R. “Religion and Science: 2 Paths
Towards One Truth,” Asian Federation of Catholic Medical
Associations Newsletter, (3). Manila. (2002).
Manlangit, OP, Fr. Jerry R. “Patient Rights: Ethical
Perspective,” Life, Holiness. Hope. Faculty of Sacred Theology.
Manila: UST Printing Office. (2003).
Manlangit, OP, Fr. Jerry R. Philosophy of Man. Manila.
(2019).
Maranon, Gregorio, MD. Notes on Vocacion y Etica. (n.p.).
(1985).
Martinez-Gonzalez, M.D., Oscar Javier. “The Teaching of
Bioethics in Medical Schools,” Instituto de Humanismo en Ciencias
de la Salud. Mexico: Universidad Anahuac. (n.d.).
“’Mary Doe' of Doe v. Bolton Files Motion To Overturn
Companion Case to Roe v. Wade,” Kaiser Daily Reproductive
Health Report (2003-08-27).
Montalvan III, Antonio. “Kris-Crossing Mindanao,”
Philippine Daily Inquirer. Manila. (2008).
Moral, MD, Patrick Gerald L. “Pain and Suffering:
Fraternal or Siamese Twins,” The CPGP Newsletter, (36), 1,5.
(2000).
Moral, MD, Patrick Gerald. “To Fee or How to Fee: That is
the Question,” The CPGP Newsletter, (36), 1,3. (2002).
Musick, D.W. “Teaching Medical Ethics: A Review of the
Literature from North American Medical Schools with Emphasis on
Education,” Journal of Medicine, Health Care and Law, 2:239-254,
(1999).
Ordinario, Artemio, MD. “The Principle 0f Double-Effect.”
Bioethics Forum 9. Current Practical Issues in Bioethics.
Department of Bioethics, UST Faculty of Medicine and Surgery.
Manila: UST Printing Office. (2002)
O’Rourke, Kevin D. “Role of Ethics in Medical Decision
Making,” Ethical Issues in Health Care, 9: 3, (n.p.). (1987).
Piga, Alfonso Abad. “The Balance between Theoretical and
Practical Work in Bioethics and Medical Ethics at the University of
Alcala,” The Book of Abstracts. Spain: EEMS, University of Alcala.
(2004)
Pineda, MD, Sisenando B. “An Increasing Commitment,”
Forum in Bioethics 1, 95-98, UST Department of Bioethics. Manila:
UST Printing Office. (1994).
Rivera-Figueroa, MD, Esperanza. “Professional Ethics,”
The CPGP Newsletter, 36 (1): 1, 5. (2002)
Santos, MD, Natividad E. “Bioethical Problems in
Teaching”, Forum in Bioethics 1, UST Department of Bioethics.
Manila: UST Printing Office. (1994).
Scheler, Max in A. Deeken. “Process and Permanence in
Ethics”. (n.p.). (1974).
Sierpina, MD, Victor S. and Boisaubin, MD, Eugene. “Can
You Teach Medical and Nursing Students About Spirituality?”
Complementary Health Review, (6), 147-155. (2001).
Aimee A. Silva, MD. “On Professional Fees,” CPGP
Newsletter, (2002).
Church Documents:
Catechism of the Catholic Church. The Vatican. (1997).
Catholic Bishops’ Conference of the Philippines (CBCP).
Catechism for Filipino Catholics. Manila. (1997).
Catholic Bishops’ Conference of the Philippines (CBCP).
Letters and Statements. Manila. (1984-1990).
Catholic Bishops’ Conference of the Philippines (CBCP).
Second Plenary Council Acts and Decrees. Manila. (1992).
 Charter for Health Care Workers. Pontifical Council for
Pastoral Assistance to Health Care Workers. Pasay City: Daughters
of St. Paul. (1996).
Communio et Progressio. Vatican II.
Deus Caritas Est. Pope Benedict XVI. (2005).
Donum Vitae. Pope John Paul II. (1987).
Ethical and Pastoral Dimensions of Population Trends (n.d.).
The Authentic Catholic Teaching on Population. Libreria Editrice
Vaticana, Citta del Vaticano.
Evangelium Vitae (The Gospel of Life) Encyclical Letter of
Pope John Paul II on the Value and Inviolability of Human Life.
Pasay City: Daughters of St. Paul. (1995).
Ethics in Advertising. Pontifical Council for Social
Communication. (1997).
Ex Corde. The Apostolic Constitution on Catholic
Universities by Pope John Paul II.
Gaudium et Spes. Vatican II.
Humanae Vitae. Pope Paul VI.
Pontifical Council for the Family. The Truth and Meaning of
Human Sexuality. Pasay City: Daughters of St. Paul. (1996).
Pope Pius XII. Address to the Eye Specialists. (May 24,
1957).
Pope John Paul II. Address to Anesthesiologists. (1988).
Pope John Paul II. Redemptoris Missio. (1990).
Veritatis Splendor. Encyclical Letter of Pope John Paul II
Regarding Certain Fundamental Questions of the Church’s Moral
Teachings. Pasay City: Daughters of St. Paul. (1995).
World Hunger, A Challenge for All: Development and
Solidarity. Pasay City: Daughters of St. Paul. (1997).
World Wide Web (links):
www.Findlaw.com, The Supreme Court of the United States-
Jane Roe Report. (2010).
www.google.com, "Medical Experiment,” Jewish Virtual
Library (retrieved 2010, and "The Doctors Trial: The Medical Case of
the Subsequent Nuremberg Proceedings,” The United States
Holocaust Memorial Museum. (2010).
 www.healthsystem.virginia.edu. (2010).
www.countryjoe.com. (2010).
www.yahoo.com
Minor References:
Aristotle’s Nichomachaean Ethics and Politica. (quoted, n.d.).
Debello, V. L. New York’s Willowbrook State School.
(2008).
“Nancy Cruzan,” Tampa Tribune. Tampa, Fl. (2008).
Puno, Ricardo. Philippine Daily Inquirer. Manila, Philippines.
(January 10, 2007).
 APPENDICES
APPENDIX I
OATH OF HIPPOCRATES
(Hippocrates of Cos [c. 5 BC] is probably the greatest
figure in the entire history of Medicine. He was in fact described as
the “Father of Medicine”. He wrote 72 works especially about
physicians, medicine and health. He had a deeply profound
understanding of human suffering and had always placed the doctor
at the service of the sick, saying that his place was at the bedside of
the sick. It was for this that he composed the time-honored Oath.
This Oath, as one would notice, set a very high standard of
professional conduct which had become the moving spirit and ideal
for those who practise the noble profession of healing.)
I swear by Apollo Physician and Asclepius and Hygieia and
Panacea all the Gods and goddesses, making them witnesses, that I
will fulfill according to my ability and judgment this oath and this
covenant.
To hold him who has taught me this art as equal to my
parents and t live my life in partnership with him and if he is in need
of money to give him a share of mine, and to regard his offspring s
equal to my brothers in male lineage and to teach them this art – if
they desire to learn it – without fee and covenant; to give a share of
precepts and oral instruction and all the other learning to my sons and
to the sons of him who has instructed me and to pupils who have
signed the covenant and have taken an oath according to the medical
law, but to no one else.
I will apply dietetic measures for the benefit of the sick
according to my ability and judgment; I will keep them from harm
and injustice.
I will neither give a deadly drug to anybody if asked for it,
nor will I make a suggestion to this effect. Similarly, I will not give
to a woman an abortive remedy. In purity and holiness, I will guard
my life and my art.
I will not use the knife, not even on sufferers from stone,
but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of
the sick, remaining free of all intentional injustice, of all mischief and
in particular of sexual relations with both female and male persons, be
they free or slaves.
If I fulfill his oath and do not violate it, may it be granted to
me to enjoy life and art, being honored with fame among all men for
al time to come; if I transgress it and swear falsely, may the opposite
of this be my lot. (Sigerist, H. E., A History of Medicine)
 APPENDIX II
INTERNATIONAL CODE OF MEDICAL ETHICS
(The International Code of Medical Ethics was adopted by the 3rd General
Assembly of the World Medical Association, London, England, October 1949 and amended
by the 22nd World Medical Assembly Sydney, Australia, August 1968 and the 35th World
Medical Assembly Venice, Italy, October 1983 and the WMA General Assembly, Pilanesberg,
South Africa, October 2006.)

DUTIES OF PHYSICIANS IN GENERAL

A always exercise his/her independent professional

PHYSICIAN judgment and maintain the highest standards of
SHALL professional conduct.
A respect a competent patient's right to accept or refuse
PHYSICIAN treatment.
SHALL
A not allow his/her judgment to be influenced by personal
PHYSICIAN profit or unfair discrimination.
SHALL
A be dedicated to providing competent medical service in
PHYSICIAN full professional and moral independence, with
SHALL compassion and respect for human dignity.
A deal honestly with patients and colleagues, and report to
PHYSICIAN the appropriate authorities those physicians who
SHALL practice unethically or incompetently or who engage in
fraud or deception.
A not receive any financial benefits or other incentives
PHYSICIAN solely for referring patients or prescribing specific
SHALL products.
A respect the rights and preferences of patients,
PHYSICIAN colleagues, and other health professionals.
SHALL
A recognize his/her important role in educating the public
PHYSICIAN but should use due caution in divulging discoveries or
SHALL new techniques or treatment through non-professional
channels.
A certify only that which he/she has personally verified.
PHYSICIAN
SHALL
A strive to use health care resources in the best way to
PHYSICIAN benefit patients and their community.
SHALL
A seek appropriate care and attention if he/she suffers
PHYSICIAN from mental or physical illness.
SHALL
A respect the local and national codes of ethics.
PHYSICIAN
SHALL
DUTIES OF PHYSICIANS TO PATIENTS
A always bear in mind the obligation to respect human
PHYSICIAN life.
SHALL
A act in the patient's best interest when providing medical
PHYSICIAN care.
SHALL
A owe his/her patients complete loyalty and all the
PHYSICIAN scientific resources available to him/her. Whenever an
SHALL examination or treatment is beyond the physician's
capacity, he/she should consult with or refer to another
physician who has the necessary ability.
A respect a patient's right to confidentiality. It is ethical to
PHYSICIAN disclose confidential information when the patient
SHALL consents to it or when there is a real and imminent
threat of harm to the patient or to others and this threat
can be only removed by a breach of confidentiality.
A give emergency care as a humanitarian duty unless
PHYSICIAN he/she is assured that others are willing and able to give
SHALL such care.
A in situations when he/she is acting for a third party,
PHYSICIAN ensure that the patient has full knowledge of that
SHALL situation.
A not enter into a sexual relationship with his/her current
PHYSICIAN patient or into any other abusive or exploitative
SHALL relationship.
DUTIES OF PHYSICIANS TO COLLEAGUES
A behave towards colleagues as he/she would have them
PHYSICIAN behave towards him/her.
SHALL
A NOT undermine the patient-physician relationship of
PHYSICIAN colleagues in order to attract patients.
SHALL
A when medically necessary, communicate with
PHYSICIAN colleagues who are involved in the care of the same
SHALL patient. This communication should respect patient
confidentiality and be confined to necessary
information. (World Medical Association General
Assembly, Pilansberg, South Africa, October, 2006)

APPENDIX III
THE DECLARATION OF GENEVA
(The World Medical Association is an association of national medical associations.
This oath seems to be a response to the atrocities committed by doctors in Nazi Germany.
Notably, this oath requires the physician to "not use [his] medical knowledge contrary to the
laws of humanity." This document was adopted by the World Medical Association only three
months before the United Nations General Assembly adopted the Universal Declaration of
Human Rights (1948) which provides for the security of the person.)
At the time of being admitted as a member of the medical
profession:
I solemnly pledge myself to consecrate my life to the
service of humanity;
I will give to my teachers the respect and gratitude which is
their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will maintain by all means in my power, the honor and the
noble traditions of the medical profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality,
race, party politics or social standing to intervene between my duty
and my patient;
I will maintain the utmost respect for human life, from the
time of conception;
Even under threat, I will not use my medical knowledge
contrary to the laws of humanity;
I make these promises solemnly, freely and upon my honor.
(Adopted by the General Assembly of the World Medical
Association, Geneva, Switzerland, September 1948 and amended by
the 22nd World Medical Assembly, Sydney, Australia, August 1968)
APPENDIX IV
THE DECLARATION OF HELSINKI
(The Declaration of Helsinki was developed by the World Medical Association and
is the WMA's best-known policy statement. It is a set of ethical principles for the medical
community regarding human experimentation. It is widely regarded as the cornerstone
document of human research ethics (WMA 2000, Bošnjak 2001, Tyebkhan 2003), although it
is not a legally binding instrument in international law. The first version was adopted in 1964
and has been amended six times since, most recently at the General Assembly in October
2008. The current (2008) version is the only official one; all previous versions have been
replaced and should not be used or cited except for historical purposes.)
INTRODUCTION
1. The World Medical Association (WMA) has developed the Declaration of
Helsinki as a statement of ethical principles for medical research involving human subjects,
including research on identifiable human material and data.
The Declaration is intended to be read as a whole and each of its constituent
paragraphs should not be applied without consideration of all other relevant paragraphs.
2. Although the Declaration is addressed primarily to physicians, the WMA
encourages other participants in medical research involving human subjects to adopt these
principles.
3. It is the duty of the physician to promote and safeguard the health of patients,
including those who are involved in medical research. The physician's knowledge and
conscience are dedicated to the fulfillment of this duty.
4. The Declaration of Geneva of the WMA binds the physician with the words,
"The health of my patient will be my first consideration," and the International Code of
Medical Ethics declares that, "A physician shall act in the patient's best interest when
providing medical care."
5. Medical progress is based on research that ultimately must include studies
involving human subjects. Populations that are underrepresented in medical research should
be provided appropriate access to participation in research.
 6. In medical research involving human subjects, the well-being of the individual
research subject must take precedence over all other interests.
7. The primary purpose of medical research involving human subjects is to
understand the causes, development and effects of diseases and improve preventive,
diagnostic and therapeutic interventions (methods, procedures and treatments). Even the best
current interventions must be evaluated continually through research for their safety,
effectiveness, efficiency, accessibility and quality.
8. In medical practice and in medical research, most interventions involve risks and
burdens.
9. Medical research is subject to ethical standards that promote respect for all
human subjects and protect their health and rights. Some research populations are particularly
vulnerable and need special protection. These include those who cannot give or refuse
consent for themselves and those who may be vulnerable to coercion or undue influence.
10. Physicians should consider the ethical, legal and regulatory norms and
standards for research involving human subjects in their own countries as well as applicable
international norms and standards. No national or international ethical, legal or regulatory
requirement should reduce or eliminate any of the protections for research subjects set forth
in this Declaration.
B. BASIC PRINCIPLES FOR ALL MEDICAL RESEARCH
11. It is the duty of physicians who participate in medical research to protect the
life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of
personal information of research subjects.
12. Medical research involving human subjects must conform to generally accepted
scientific principles, be based on a thorough knowledge of the scientific literature, other
relevant sources of information, and adequate laboratory and, as appropriate, animal
experimentation. The welfare of animals used for research must be respected.
13. Appropriate caution must be exercised in the conduct of medical research that
may harm the environment.
14. The design and performance of each research study involving human subjects
must be clearly described in a research protocol. The protocol should contain a statement of
the ethical considerations involved and should indicate how the principles in this Declaration
have been addressed. The protocol should include information regarding funding, sponsors,
institutional affiliations, other potential conflicts of interest, incentives for subjects and
provisions for treating and/or compensating subjects who are harmed as a consequence of
participation in the research study. The protocol should describe arrangements for post-study
access by study subjects to interventions identified as beneficial in the study or access to
other appropriate care or benefits.
15. The research protocol must be submitted for consideration, comment, guidance
and approval to a research ethics committee before the study begins. This committee must be
independent of the researcher, the sponsor and any other undue influence. It must take into
consideration the laws and regulations of the country or countries in which the research is to
be performed as well as applicable international norms and standards but these must not be
allowed to reduce or eliminate any of the protections for research subjects set forth in this
Declaration. The committee must have the right to monitor ongoing studies. The researcher
must provide monitoring information to the committee, especially information about any
serious adverse events. No change to the protocol may be made without consideration and
approval by the committee.
16. Medical research involving human subjects must be conducted only by
individuals with the appropriate scientific training and qualifications. Research on patients or
healthy volunteers requires the supervision of a competent and appropriately qualified
physician or other health care professional. The responsibility for the protection of research
subjects must always rest with the physician or other health care professional and never the
research subjects, even though they have given consent.
17. Medical research involving a disadvantaged or vulnerable population or
community is only justified if the research is responsive to the health needs and priorities of
this population or community and if there is a reasonable likelihood that this population or
community stands to benefit from the results of the research.
18. Every medical research study involving human subjects must be preceded by
careful assessment of predictable risks and burdens to the individuals and communities
involved in the research in comparison with foreseeable benefits to them and to other
individuals or communities affected by the condition under investigation.
19. Every clinical trial must be registered in a publicly accessible database before
recruitment of the first subject.
20. Physicians may not participate in a research study involving human subjects
unless they are confident that the risks involved have been adequately assessed and can be
satisfactorily managed. Physicians must immediately stop a study when the risks are found to
outweigh the potential benefits or when there is conclusive proof of positive and beneficial
results.
21. Medical research involving human subjects may only be conducted if the
importance of the objective outweighs the inherent risks and burdens to the research subjects.
22. Participation by competent individuals as subjects in medical research must be
voluntary. Although it may be appropriate to consult family members or community leaders,
no competent individual may be enrolled in a research study unless he or she freely agrees.
23. Every precaution must be taken to protect the privacy of research subjects and
the confidentiality of their personal information and to minimize the impact of the study on
their physical, mental and social integrity.
24. In medical research involving competent human subjects, each potential
subject must be adequately informed of the aims, methods, sources of funding, any possible
conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and
potential risks of the study and the discomfort it may entail, and any other relevant aspects of
the study. The potential subject must be informed of the right to refuse to participate in the
study or to withdraw consent to participate at any time without reprisal. Special attention
should be given to the specific information needs of individual potential subjects as well as to
the methods used to deliver the information. After ensuring that the potential subject has
understood the information, the physician or another appropriately qualified individual must
then seek the potential subject's freely-given informed consent, preferably in writing. If the
consent cannot be expressed in writing, the non-written consent must be formally
documented and witnessed.
25. For medical research using identifiable human material or data, physicians
must normally seek consent for the collection, analysis, storage and/or reuse. There may be
situations where consent would be impossible or impractical to obtain for such research or
would pose a threat to the validity of the research. In such situations the research may be
done only after consideration and approval of a research ethics committee.
26. When seeking informed consent for participation in a research study the
physician should be particularly cautious if the potential subject is in a dependent relationship
with the physician or may consent under duress. In such situations the informed consent
should be sought by an appropriately qualified individual who is completely independent of
this relationship.
27. For a potential research subject who is incompetent, the physician must seek
 informed consent from the legally authorized representative. These individuals must not be
included in a research study that has no likelihood of benefit for them unless it is intended to
promote the health of the population represented by the potential subject, the research cannot
instead be performed with competent persons, and the research entails only minimal risk and
minimal burden.
28. When a potential research subject who is deemed incompetent is able to give
assent to decisions about participation in research, the physician must seek that assent in
addition to the consent of the legally authorized representative. The potential subject's dissent
should be respected.
29. Research involving subjects who are physically or mentally incapable of giving
consent, for example, unconscious patients, may be done only if the physical or mental
condition that prevents giving informed consent is a necessary characteristic of the research
population. In such circumstances the physician should seek informed consent from the
legally authorized representative. If no such representative is available and if the research
cannot be delayed, the study may proceed without informed consent provided that the
specific reasons for involving subjects with a condition that renders them unable to give
informed consent have been stated in the research protocol and the study has been approved
by a research ethics committee. Consent to remain in the research should be obtained as soon
as possible from the subject or a legally authorized representative.
30. Authors, editors and publishers all have ethical obligations with regard to the
publication of the results of research. Authors have a duty to make publicly available the
results of their research on human subjects and are accountable for the completeness and
accuracy of their reports. They should adhere to accepted guidelines for ethical reporting.
Negative and inconclusive as well as positive results should be published or otherwise made
publicly available. Sources of funding, institutional affiliations and conflicts of interest
should be declared in the publication. Reports of research not in accordance with the
principles of this Declaration should not be accepted for publication.
C. ADDITIONAL PRINCIPLES FOR MEDICAL RESEARCH COMBINED WITH
MEDICAL CARE
31. The physician may combine medical research with medical care only to the
extent that the research is justified by its potential preventive, diagnostic or therapeutic value
and if the physician has good reason to believe that participation in the research study will
not adversely affect the health of the patients who serve as research subjects.
32. The benefits, risks, burdens and effectiveness of a new intervention must be
tested against those of the best current proven intervention, except in the following
circumstances:
- The use of placebo, or no treatment, is acceptable in studies
where no current proven intervention exists; or
- Where for compelling and scientifically sound methodological reasons the use of
placebo is necessary to determine the efficacy or safety of an intervention and the patients
who receive placebo or no treatment will not be subject to any risk of serious or irreversible
harm. Extreme care must be taken to avoid abuse of this option.
33. At the conclusion of the study, patients entered into the study are entitled to be
informed about the outcome of the study and to share any benefits that result from it, for
example, access to interventions identified as beneficial in the study or to other appropriate
care or benefits.
34. The physician must fully inform the patient which aspects of the care are related
to the research. The refusal of a patient to participate in a study or the patient's decision to
withdraw from the study must never interfere with the patient-physician relationship.
 35. In the treatment of a patient, where proven interventions do not exist or have
been ineffective, the physician, after seeking expert advice, with informed consent from the
patient or a legally authorized representative, may use an unproven intervention if in the
physician's judgment it offers hope of saving life, re-establishing health or alleviating
suffering. Where possible, this intervention should be made the object of research, designed
to evaluate its safety and efficacy. In all cases, new information should be recorded and,
where appropriate, made publicly available. (59th WMA General Assembly, Seoul, Korea,
Oct. 22, 2008)

APPENDIX V
THE NUREMBERG CODE
(The Nuremberg Code is a set of research ethics principles
for human experimentation crafted as a result of the subsequent
Nuremberg Trials at the end of World War II. Specifically, the code
was in response to the inhumane Nazi human experimentation carried
out during the war by individuals such as Dr. Josef Mengele. The
code includes such principles as informed consent and immunity of
the subject from coercion; properly formulated scientific research;
and beneficence towards experiment participants.)
The code states:
1. The voluntary consent of the human subject is absolutely
essential.
2. The experiment should be such as to yield fruitful results
for the good of the society, unprocurable by other means or means of
study, and not random and unnecessary in nature.
3. The experiment should be so designed and based on the
results of animal experimentation and knowledge of the human
history of the disease or other problem under study that the
anticipated results will justify the performance of the experiment.
4. The experiment should be so conducted as to avoid all
unnecessary physical and mental suffering and injury.
5. No experiment should be conducted where there is a
prior reason to believe that death or disabling injury will occur, except
perhaps in those experiments where the experimental physicians also
serve as subjects.
6. The degree of risk to be taken should never exceed that
which is determined by the humanitarian importance of the problem
to be solved by the experiment.
7. Proper preparations should be made and adequate
facilities provided to protect the experimental subject against even
remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by
scientifically qualified persons. The highest degree of skill and care
should be required through all stages of the experiment of those who
conduct or engage in the experiment.
9. During the course of the experiment that human subject
should be at liberty to bring the experiment to an end if he has
reached the physical or mental state where continuation of the
experiment seems to him to be impossible.
10. During the course of the experiment the scientist in
charge must be prepared to terminate the experiment at any stage, if
he has probable cause to believe, in the exercise of the good faith,
superior skill and careful judgment required of him that a continuation
of the experiment is likely to result in injury, disability, or death to the
experimental subject. (World Medical Association Bulletin, The
Nuremberg Code, 1947)
 APPENDIX VI
CODE OF ETHICS OF THE MEDICAL PROFESSION 0F THE
PHLIPPINES
Jointly adopted on September 2019
PREAMBLE
This Code of Ethics is promulgated to provide the
physicians with proper ethical and professional standards in the
practice of Medicine to ensure the safety and welfare of patients. This
Code sets forth the fundamental ethical principles and the
professional responsibilities of physicians towards patients, the
healthcare system, the community, their colleagues and the
profession, allied professionals and the health products industry. On
entering the profession, a physician assumes the obligation of
maintaining the honorable tradition that confers the well-deserved
title of a "friend of mankind". The physician should cherish a proper
pride in the calling and conduct himself/herself in accordance with
this Code and in the generally accepted principles of the International
Code of Medical Ethics.
ARTICLE I
FUNDAMENTAL PRINCIPLES
Sec. 1. The fundamental principles to guide the physicians
in the practice of their profession.
1.1. Principle of Respect for Life. The right to life is
inviolable. Life is a necessary condition for all other human goods. It
must be protected and fostered at all its stages beginning from
conception to its natural end.

1.2. Principle of Respect for Person. Every person has an

intrinsic worth and dignity. Trust shall be central to the physician-
patient relationship. Physicians shall respect patient autonomy.

1.3. Principle of Social Justice. All patients have a right to

basic healthcare and a just process in the allocation of resources.
 1.4. Principle of Beneficence. The interest of the patient shall
be placed above those of the physician. Societal pressures, financial
gains and administrative exigencies shall not compromise this
principle.

1.5. Primum Non Nocere. The foremost responsibility of

the physician is to do no harm to the patient.

ARTICLE Il
GENERAL PRINCIPLES
Sec. 2. General principles to guide the physicians in the
practice of their profession.
2.1. The primary objective of the practice of medicine
is service to mankind.
2.2. Physicians should be upright, diligent, sober,
modest, imbued with professionalism and well-versed in
the science, the art and the ethics of the profession.
2.3. Physicians shall promote the health of their patients
as their primary consideration
2.4. Physicians should be upright, diligent, sober,
modest, imbued with professionalism and well-versed in
the science, the art and the ethics of the profession.
2.5. Physicians should work together in harmony
and mutual respect.
2.6. Physicians should cooperate with other
healthcare professionals in the context of inter-professional
and collaborative practice in support of better
healthcare.
2.7. Physicians, although they have certain rights in
relation to their patients, shall always observe the dictum
service beyond call of duty.
 ARTICLE Ill
PROFESSIONAL RESPONSIBILITIES TO PATIENTS
Sec. 3. Physicians' responsibilities to patients:

3.1. Professional Competence. Physicians shall

be committed to lifelong learning and dedicated
to providing holistic, competent, compassionate
medical care while upholding the highest professional
and ethical standards and respect for human dignity.

3.2. Patients' Trust. Physicians shall maintain a fiduciary

relationship with their patients by displaying competence, reliability,
integrity and open communication.

3.3. Human Dignity. Physicians shall be compassionate and

approach patients in a courteous and professional manner. Physicians
shall conduct physical examinations in a modest, caring and gender-
sensitive manner. Physicians shall ensure that free and informed
consent by the patients and precautions to preserve patients' dignity
and anonymity prevail at all times.

3.4. Professional Fees. The physician shall ensure that

professional fees are reasonable and commensurate to the services
rendered, nature of the case, time consumed, risk involved,
professional standing of the physician, and the financial status of the
patient.

3.5. Disclosure. Physicians shall exercise good faith, honesty,

and tact in expressing opinions as to diagnosis, treatment options,
risks involved and prognosis to a patient under their care. Physician
shall neither conceal, understate nor exaggerate the patient's
condition. Timely notice of the worsening condition of the patient
shall be revealed to him/her and/or his/her family. When foreseen and
unforeseen complications arise during treatment, patients should be
properly informed. Analysis of the cause of the complication shall
provide the basis for appropriate prevention and treatment strategies.
The physician shall inform the patient about the need for referral to an
appropriate specialist in serious or difficult cases, or when the
circumstances of the patient or the family so demand or justify. The
physician shall make sure that all communications regarding
diagnosis and treatment are understood by the patient and
accompanying relatives. Physicians shall compose, understandable,
legible and useful, written communications, i.e. chart notes, discharge
summaries, treatment plans, referrals and patient instructions.

3.6. Autonomy. A physician shall obtain voluntary informed

consent prior to performing any procedure or treatment. The patient's
decision must be based on his/her free will and choice. The
physician shall provide all relevant information in a simple
and understandable manner leading patients to either accept or refuse
a proposed action. The physician shall inform the patient about the
consequences of his/her choices. When a patient is incompetent to
decide, the consent must be given by the next of kin, or his/her legally
authorized representative.

3.7. Privacy and Confidentiality. The physician shall hold

as private and highly confidential whatever may be discovered or
learned pertinent to the patient even after death, except when required
by law, ordinance or administrative order in the promotion of justice,
safety and public health. The commitment extends to discussion with
persons acting on a patient's behalf. Safeguards shall be applied
especially when using electronic information systems for compiling
patient data, and when dealing with genetic information.

3.8. Emergent Cases. In an emergency, provided there is no

risk to his or her safety, a physician shall administer at least first aid
treatment and then refer the patient to a more competent physician
and appropriate facility if necessary.

3.8.1 In emergencies, when a decision must be

made urgently, when the patient is not able to participate
in decision making, and the patient's
kin/authorized representative is not available,
physicians may initiate treatment without prior informed
consent in such situations provided that the physicians
should inform the patient/authorized representative at the
earliest opportunity and obtain consent for ongoing
treatment, and document the informed consent in the medical
record of the patient.

3.9. Decorum and Behavior of a Physician.

3.9.1. The physician shall be free to choose

whom they will serve, except in cases of emergency;

3.9.2. The physician shall demonstrate

professionalism at all times when dealing with patients;

3.9.3. The physician shall demonstrate

humility, empathy and compassion toward patients;

3.9.4. The physician shall attend to patients

within the limits of his capabilities;

3.9.5. The physician shall respect the patient's

right to seek a second opinion;

3.9.6. The physician shall not exploit patients for

any personal gain.

ARTICLE IV
PROFESSIONAL RESPONSIBILITIES
TO THE HEALTH CARE SYSTEM
Sec. 4. Physicians' responsibility to the health care system:

4.1. Improving quality of care. Physicians shall be dedicated

to continuous improvement in the quality of healthcare. This entails
maintaining clinical competence through lifelong study and
working collaboratively with other professionals to enhance
patient safety, optimize outcomes of care, and the proper use of
healthcare resources. Physicians shall actively participate in the
development and application of better measures of quality of care.

4.2. Improving access to care. Physicians must contribute to

improving access to equitable healthcare by providing appropriate
medical services within the different levels of the healthcare system,
in both the public and private sectors.

4.3. Cost-effective management of limited healthcare

resources. Physicians should place paramount consideration on the
cost of diagnostic tests and procedures, and of management and
treatment modalities recommended. Physicians shall avoid
superfluous tests and procedures, unnecessary medical services,
unproven remedies, which expose patients to possible harm,
additional expense and inappropriate utilization of limited resources.

4.4. Research. Physicians should obtain the approval of the

Institutional Review Board or Institutional Ethics Board before
conducting any form of research, while operating in accordance with
national and/or local regulations, as well as with International Council
on Harmonization (ICH) Good Clinical Practices (GCPs) guidelines.
The physician participating as principal investigator shall exercise full
disclosure and ensure that patients/participants are well informed
about the difference between physician-patient relationship in clinical
practice and patient participation in any form of research.

The physician as a researcher should ensure that the research

shall be scientifically sound and must meet the
following criteria:

4.4.1. The objectives of the research shall

be relevant;
4.4.2. There shall be sufficient proof of the
concept tested;
4.4.3. Results shall contribute to the solution of
the research problem;
4.4.4. The research design is appropriate
and feasible;
4.4.5. Research subjects shall be exposed
to minimal risks in relation to any benefits that
might result from the research;
4.4.6. Research results that improve patient
care shall be shared with colleagues in the
health profession.

ARTICLE V
PROFESSIONAL RESPONSIBILITIES
TO THE COMMUNITY

Sec. 5. The physicians' responsibility to the community:

5.1. Government. Physicians' shall assist the State by:

5.1.1. Participating in the formulation and

proper implementation of health policies;

5.1.2. Acting as expert witness or amicus curae

when requested in the administration of justice;

5.1.3. Providing up-to-date and accurate

information on health issues.

5.1.4. Assisting in the promotion of health

and safety.

5.2. Duly Constituted Health Authorities. Physicians

shall cooperate with the duly constituted health authorities
by:
 5.2.1. Educating the community,
enforcing measures for the prevention,
promotion, management, and
rehabilitation, in accordance with existing
laws, rules, and regulations;

5.2.2. Attending to victims in times of epidemic

and calamity, except when his/her personal safety is
at stake;

5.2.3. Increasing the level of awareness of

the public and the constituted health authorities on
the dangers of communicable and non-
communicable diseases;

5.3. Protection against unlicensed practitioners. It

is unprofessional for physicians to aid and abet the practice
of the medical profession by unqualified and
unregistered individuals. Physicians have the duty and
obligation to expose and report to the proper government
agencies unlicensed medical practitioners, charlatans and
quacks, for the protection of the public.

5.4. Promotion of Practice. Physicians shall be

involved in the promotion of the medical profession.

5.4.1. Physicians shall not employ agents in

the solicitation and recruitment of patients.

5.4.2. For the promotion of medical

practice, physicians may use professional cards,
internet, directories and signboards.

5.4.3. Signboards shall not exceed one by two

(Ix2) meters in size. However, these signboards may
be placed by physicians within the confines
of his clinic or residence.

5.4.4. Signboards and internet postings

should contain only the name of the physician, field of
specialty, office hours and/or office or hospital affiliations.

5.4.5. The act of physicians in publishing

their personal superiority,
special certificates or
diplomas, postgraduate training, specific
methods of treatment, operative techniques Is not
allowed. However, these matters may be placed by
physicians within the confines of his clinic or
residence.

5.5. Media Exposure. Physicians involved in media must

be well informed of the subject matter under
discussion. Only the name of the physician and
membership to a society or institution may be mentioned or
posted. Articles written by physicians must be evidence-
based. They should disclose any potential conflicts of interest
if relevant. Physicians shall not commercially
endorse any medical or health product.

ARTICLE VI
PHYSICIAN RESPONSIBILITIES TO THE PROFESSION
Sec. 6. Responsibilities to the profession:
6.1. Continuing Professional Development.
Physicians should engage in Continuing Professional
Development (CPD) activities that will
result in the maintenance of their competence and their
fitness to practice the profession on their own or with the
support of their own institutions or professional societies.

6.2. Professional Interactions. Physicians have an

obligation to maintain the good image of the profession, and
should recognize, avoid, disclose to the general public, any
conflicts of interest that may arise in the course of their
professional duties and activities. Proper disclosure of
relationships between physicians and businesses should be
stated when engaging in activities such as, but not limited to:
6.2.1. Conducting clinical trials,
6.2.2. Serving in relevant committees,
6.2.3. Writing research papers, editorials
or therapeutic guidelines,
6.2.4. Serving as an editor of scientific journals,
6.2.5. Engaging in discussions, or in
6.2.6. Delivering presentations.
ARTICLE VII
PROFESSIONAL RESPONSIBILITIES TO
COLLEAGUES IN THE MEDICAL PROFESSION
Sec. 7. Physicians' responsibilities to their colleagues in the
medical profession.

7.1. Protecting the good name of a colleague.

Physicians should strive to protect the good name of
colleagues. However, when complaints are brought to one's
attention, the physician is duty bound to refer such
complaints to the proper forum for resolution.

7.2. Professional Courtesy to Colleagues. A physician

shall provide courtesy to colleagues and waive his
professional fee when providing essential and evidence-
based medical care to colleagues, spouse, minor and disabled
children, and parents. This includes waiving the professional
fees in package deals.

7.3. Conflict Management among Physicians.

Whenever there is an unsettled difference of opinions or
conflicts among physicians, it should be referred to
the proper forum for due process. The conflict may be settled
within the Ethics Committee/Commission of the following:

7.3.1. Department/s;
7.3.2. Institution;
7.3.3. Philippine Medical Association;
7.3.4. Professional Regulation Commission.

7.4. Substitution for Suspended Patient Care. In cases

where a physician has to suspend service in his clinic or
hospital, he must make sure that the reliever or substitute
physician shall have similar qualifications and shall treat the
patients with the same dedication and quality of care extended
to his own patients. Moreover, the patient should be duly
informed of the patient consents to the substitution including
professional fees, the care of the patient should be returned to
the primary physician as soon as possible. Alternatively, the
patient may request transfer of care or handover to his
physician of choice.

7.5. Professional compensation. The professional

compensation should be reasonable and shall be guided by the
patient's capacity to pay, the standard fees in the community
and such other factors as physician's expertise, the difficulty
of the case, and the patient's co-morbid conditions. Physicians
shall not give nor receive any referral fees, rebates, engage in
fee-splitting, charge exorbitant fees, and must not
engage in ghost practice of the profession.

7.6. Emergencies. ln an emergency, a physician

shall examine and treat a patient and shall continue
to provide that assistance until it is no longer
required.

7.6.1. In case the patient has a private physician,

the latter shall be notified of the diagnosis and
for further management.

7.6.2. In case the patient's private physician is

not available, referral to another physician should
be made.

7.7. Sharing Expertise with colleagues. The physician

shall share his expertise with his colleagues either in actual
care of patients or in scientific lectures, group
discussions, bedside rounds and other educational activities.

ARTICLE VIII
PROFESSIONAL RESPONSIBILITIES
TO ALLIED HEALTH PROFESSIONALS
Sec. 8. Responsibilities of the physician to the allied health
professionals:
8.1 Teamwork. Physicians shall work with other
members of the allied health professions as a team in a
climate of mutual acceptance, responsibility,
support, respect, openness, and cooperation.
Quality care involves active participation of the
health team in promoting the well- being.
8.2. Safeguarding Interest/Dignity. A physician
should cooperate with and safeguard the interest,
reputation, and dignity of every allied healthcare professional
with whom he shares the common objective of
promotion and maintenance of human health.
8.3. Maintaining Propriety. A physician shall
observe appropriate relationship when dealing with other
allied healthcare professionals. He shall avoid bullying,
sexual harassment, abuse or exploitation, unethical
practices, and abetment of any wrong-doing.
 8.4. Legitimate Practice; Illegal Practice of
Medicine. Physician shall report to the proper authorities any
illegal practice of medicine. A physician is engaged in
legitimate practice of medicine when he or she complies with
all the requirements imposed by the Board of
Medicine to be a licensed physician.
ARTICLE IX
PROFESSIONAL RELATIONSHIP WITH
THE HEALTH PRODUCT INDUSTRY
Sec. 9. Physicians' professional relationship with the health
product health industry:
9.1. Common Good. Physicians and the Health Product
Industry are partners in providing quality healthcare.
Physicians have the responsibility to provide quality medical
care by obtaining accurate, valuable scientific information on
the health products to be used in the diagnosis and
treatment of patients.

9.2. Ethical and Professional Conduct. Physicians must

ensure that they should not take advantage of the health
product industry, neither should they allow themselves to be
exploited in this relationship. The physician should not solicit
favors from the biopharmaceutical and medical device
companies for personal interest or gain. Physicians shall be
guided by the following:

9.2.1. Physicians should exercise sound

judgment, self- restraint, and discipline when
participating in activities organized by biopharmaceutical
and medical device companies, which may
be misconstrued as influencing their
prescribing practice.

9.2.2. Physicians shall not rely solely on

financial support from biopharmaceutical and
medical device companies in complying with their
requirements for Continuing Professional Development
(CPD).

9.2.3. Physicians may be engaged as

resource persons in the biopharmaceutical and medical
device companies to provide information or advice on
topics such as therapeutics, specific needs of patients,
product positioning, and pharmacovigilance. This
relationship should not bind physicians to promote, prescribe
or recommend a particular equipment/product.
9.2.4. Physicians shall not participate in
any marketing strategies including but not
limited to special prescription pads, rebates, commissions,
or raffles.
ARTICLE X
PENAL PROVISIONS
Violation of any section of the Code of Ethics shall constitute
unethical and unprofessional conduct, and therefore be a sufficient
ground for the reprimand, suspension, or revocation of the certificate
of registration of the offending physician in accordance with the
provisions of the Medical Act of 1959 as amended and Republic Act
8981 (PRC Modernization Act of 2000).

ARTICLE XI
AMENDMENTS

This Code of Ethics may be amended as follows:

a. Upon recommendation by PMA Commission on Ethics,

b. Upon approval by the PMA Board of Governors duly ratified by

the General Assembly, and,
c. Upon approval by the Professional Regulation Commission through
the Board of Medicine
Article XII
EFFECTIVITY
This Codes takes effect upon adoption by the Philippine
Medical Association and the Professional Regulation Commission
(through the Board of Medicine) and fifteen (15) days after posting in
the PMA Website and/or publication in the Newsletter "The
Physician" of the Philippine Medical Association, and publication in a
reputable publishing establishment.

APPENDIX VII
FLORENCE NIGHTINGALE PLEDGE
(The Florence Nightingale Pledge was composed by Lystra Greter, a nursing
instructress at the Old Harper Hospital in Detroit, Michigan. It was first used by its
graduating class in the spring of 1893. This pledge is a token of esteem and affection to the
founder of modern nursing, Florence Nightingale. Nightingale was known to have pushed
for reform of the British military health care system including hospitals. With that the
profession of nursing started to gain respect it deserved. This pledge is an adaptation of the
Hippocratic Oath taken by physicians.)

I solemnly pledge myself before God and in the presence of

this assembly, to pass my life in purity and to practice my profession
faithfully. I will abstain from whatever is deleterious and
mischievous, and will not take or knowingly administer any harmful
drug. I will do all in my power to maintain and elevate the standard
of my profession, and will hold in confidence all personal matters
committed to my keeping and all family affairs coming to my
knowledge in the practice of my calling. With loyalty will I endeavor
to aid the physician, in his work, and devote myself to the welfare of
those committed to my care. (Lavinia Dock and Isabel Stewart, A
Short History of Nursing.
www.countryjoe.com/nightingale/pledge.htm, 2010).

APPENDIX VIII
PRAYER OF A PHYSICIAN
Dear Lord, you are the Great Physician and I kneel before
your majesty. Every good and perfect gift comes from your great
love and generosity. I humbly recognize my inadequacies and
failures and deeply regret my impiety. You alone can heal the
afflictions of humanity and I am but an instrument of your healing
power. I pray that you give distinct skill to my hands, clear vision to
my mind, kindness of purpose and ability to alleviate the burden of
pain and suffering from my fellowmen just as you graciously did to
the sick. I pray that I will always realize that being a physician is a
privilege and honor that you share with me. May nothing desecrate
the nobility of my profession.
Lord, take from me all guile and worldliness so that with
the simple faith of a child, I will always rely on you. Show me the
WAY to a blameless conduct that I may act in the purity of heart.
Enlighten me with your TRUTH that I may be transformed into your
wonderful light. And after I have served my fellowmen in this
marvelous art of healing, let me take delight in your LIFE for all
eternity. Amen.
 What the experts say . . .
This book addresses more thoroughly than any book that I’ve
read in Bioethics, and the dilemmas that confront us in our
healthcare practice. It is evidence-based, practical and incisive in
providing a theoretical framework for ethical decision-making
process. The case scenarios and reflective questions capture the
essence of values clarification as one attempts to resolve clinical
practice dilemmas. It is a landmark book and should be a required
reading for everyone, students and practitioners alike, in healthcare.
Sallie M. Poepsel, BSN, MS, CRNA,
APN, PhD
Nurse Anesthetist, MSMP Anesthesia
Services, LLC,
Reviewer for Mosby Books and Company, Columbia,
Missouri Public Policy &
Administration
Walden
University, Minneapolis, Minnesota
A very timely and much needed textbook in Bioethics. This
book will be very helpful to a great many types of people,
professionals and lay. Students in life sciences, teachers, preachers,
theologians, and philosophers will surely find this book very helpful
and illuminating.
Further, this book gives the impression that the writer has
excellent command of the subject matter – a virtue manifest in the
straightforward flow of words and ideas which move from principles
to application to ethical reflection and judgment in the exercise at the
end of each unit of exposition and discussion.
Florentino H. Hornedo, PhD
Professor, Anthropology and Philosophy
University of Sto. Tomas & Ateneo de Manila University, Manila
The very extensive work aims not only at explaining important
concepts of Bioethics but also at helping the readers understand how
these concepts came to be and how they have affected and should
affect the resolution of specific dilemmas. It expands to the historical
and legal dimensions of ethical issues and call attention to local real
life situations. The book will be a very interesting reading for anyone
receiving, providing or learning about health care.
Angeles Tan-Alora, MD
Dean, UST Faculty of Medicine and Surgery Executive
Director, Southeast Asian Center for Bioethics, Manila
This book exudes a profound respect and love for each human
person made in God’s image and likeness. As the author betrays his
Thomistic background in the orderliness and clarity of his ethical
concepts, he breathes into it a new life by providing it with flesh and
blood through the current issues and contemporary insights on
human birth, health and death. Being thorough and expansive, it can
very well serve as the gospel of Bioethics.
Virgilio Aderiano Abad Ojoy, OP, PhD, STD
Theologian and Professor
Ecclesiastical Faculties, University of Sto. Tomas, Manila
. . . a masterful treatment of the principles of Bioethics set in
the context of Faith and the teaching of St. Thomas Aquinas. This
book is replete with realistic cases against the backdrop of
contemporary local setting that will lead students to a synthesis of
faith and reason in the lucid reflection and discourses of ethical
dilemmas presented herein. The book is highly recommended reading
for health professionals seeking solid Catholic Christian formation
where deeply meaningful Christian values become wisdom and
guidepost in the practice of their profession.
Prof. Lilian J. Sison, PhD
Dean, Graduate School, University of Sto. Tomas, Manila
. . . highly informative, enlightening, incisive and insightful.
This book is a wellspring of bioethical wisdom and knowledge that
anyone can drink from. The discussions of the concepts and principles
are compellingly rational and plausible. No doubt, it can easily pass
for global acceptance. I will not hesitate to recommend this to all my
colleagues in the health profession and place it on the table of anyone
who wishes to discover truth of moral significance.
 Noli R. Zosa, MD
President, Rio Hondo Medical Group, Inc., Los Angeles, CA
The timely publication of this eloquently written book is a big
boost to the development of bioethics, an emerging discipline in the
health sciences. I recommend it warmly to all health professionals.
Fr. Manlangit writes with divine inspiration on a great range of
delicate and sensitive bioethical principles and moral issues
including abortion, death and dying, human sexuality, organ
transplantation and patient rights.
In a simple, clear, readable style, Fr. Manlangit expounds on
the path leading to a more humane and compassionate practice of
medicine. He has the ability to make the complex readily understood.
This enlightening book contains a careful, critical, remarkable
and lucid exposition of Bioethics, the ethics of life. It gives practical
insights on the study and practice of bioethics as an important
dimension of medicine.
Ramon L. Arcadio, MD,
MHPEd
Professor and Chancellor, University of the Philippines, Manila

Fr. Jerry R. Manlangit, OP has written Fundamental

Concepts, Principles and Issues in Bioethics, a comprehensive book
of basic bioethics. This is the ripe fruit of the author’s many years of
teaching Bioethics in the University of Sto. Tomas and elsewhere.
From an ethical and theological perspective, Fr. Manlangit gives us a
substantial and relevant text. This text is substantial, because the
writer grounds and develops well the fundamental topics of
Bioethics. It is likewise relevant, because he studies the issues in
context by giving important to our situation – global as well as local
– and laws, and by providing practical cases at the end of every
chapter. Fr. Manlangit’s textbook is a helpful study on basic
Bioethics, particularly for physicians, nurses and other health care
professionals, and also for teachers and students of the ever growing
significance of Bioethics in our world.
Fr. Fausto B. Gomez, OP, STD
Professor, Faculty of Theology, University of Sto. Tomas, Manila
Regent of Studies, Dominican Province of the Holy Rosary,
Macao, China
I would like to recommend Fr. Manlangit’s effort in writing a
book like this. While many of us are content with what we have
learned from our own institutional studies, Fr. Manlangit continues to
broaden more his knowledge on the subject closest to his heart –
Bioethics. This book has certainly been a product of all his
researches, lectures and first-hand experience in hospital situations.
This can be a lasting contribution to the intellectual tradition of the
Province and the Order as well.
Fr. Rodel E. Aligan, OP, STD
Dean, Faculty of Theology, University of Sto. Tomas, Manila
 About the Author

REV. FR. JERRY REBLORA MANLANGIT, OP,

MHA, PhD is a professor of Ethics and Bioethics at the Ecclesiastical Faculties of Theology and
Philosophy, Faculty of Medicine and Surgery, Sisters’ Formation Institute and Graduate School of the
University of Sto. Tomas, Manila and the Recoletos School of Theology, QC. He is also an off-site
professor at the Makati Medical Center. He also teaches the subjects of Hospital Administration and
Human Resource Management at the same University.
Born in a rustic town of Oas, Albay on March 28, 1955, Fr. Manlangit entered the Dominican Order in
1972. He was ordained a Dominican priest by His Eminence +Jaime Cardinal Sin on April 3, 1982.
He obtained his bachelor’s degrees in Philosophy, Dominican Studium Generale, QC, cum laude and
Sacred Theology, University of Sto. Tomas, Manila, cum laude. He earned his degree in Master of
Hospital Administration at the University of the Philippines, Manila, magna cum laude, and finished
his two diplomates in Health Care Management at Harvard University, Boston, MA and Bioethics at St.
Louis University, St. Louis, MO. He later earned his PhD in Human Resource Management, magna
cum laude at the UST Graduate School.
Currently, Fr. Manlangit is an active lecturer and speaker on various topics in Ethics and
Bioethics to doctors, nurses, allied health care professionals, hospitals, medical societies and other
interest groups. He has written various articles in Ethics and Bioethics. He has published books
entitled, The Way of the Word, YR 2010; The Truth of the Word, 2011 and The Life of the Word, 2012 –
all Sunday and Weekday Homilies. He also wrote a pioneering book, Fundamental Concepts,
Principles and Issues in Bioethics (now newly revised), 2020; a Marian booklet for meditation, The
Journey of Mary, 2014 and Philosophy of Man: Comprehensive and Introspective Perspectives.

Address communications to:

jerryjay_heaven@yahoo.com; jerry7jay7heaven@gmail.com
www.amazon.com