BIOETHICS — NUR81012
o Voluntary consent
Ethics & Research
RESEARCH
• The creation of new knowledge
• Use of existing knowledge in a new creative way
• Before conducting, to ensure that all the principles of
ethics are considered and none of it is violated, there
are standards / protocols / guidelines that are set in
place
• The history of research shows us that there are
researchers / experiments that blatantly violated the
human rights of its participants
The Nuremberg Trial
• Held in December 1946
• There were senior officers of the Nazi party, physicians
and judges that were put on trial by the international
military tribunal
• Charges: violations against peace (war crimes) and
against humanity
• Churchill, Roosevelt and Stalin who signed the
London agreement so that the international military
tribunal will be able to prosecute the leaders because of
the crimes committed during the WW2 & post-WW2
• There were 23 doctors charged for conducting
experiments to the prisoners of war
o 7 were acquitted
o 7 were executed by hanging
o The rest were sentenced to death
• There were 11 subsequent trials
o e.g. Some were placed in low-pressure
chambers as simulation so that information
can be gathered that will help German pilots to
safely and effectively eject from high altitudes.
Those who survived were subjected to brain
dissections
o e.g. they studied hypothermia and its effects to
the human body, inmates were exposed sub 0
temperatures naked
o e.g. they inoculated healthy inmates with
extracts from malaria-infected mosquitoes then
some nerve, muscle, and bone tissues were
harvested which resulted to physical and
emotional torture to the inmates (some
disfigured)
o e.g. forcing inmates to drink salt water, to
know if salt water is potable
• When prisoners of war were deemed to be not useful,
they were euthanized
THE NUREMBERG CODE
• National Institutes of Health
• May 1947
10 standards
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Aim to protect the rights of the human subjects
• absolutely essential without coercion or undue
duress nature, extent and duration must be
explained in terms they will understand
2. Fruitful result for society
• Clinical relevance, necessary in nature, safe
3. Based on previous knowledge
4. Avoid suffering
• physical and mental
5. Will not cause death or disability
If there is a risk then it must not be conducted
6. Risks do no not outweigh benefits
7. Adequate preparation; facilities provided
For the safety and security of the participant
8. Scientifically qualified researchers
If Not an expert in the field – he should not be the
main researcher in the study
9. Freedom to withdraw
Make it knowledgeable
10. Probable cause to terminate the study
Researcher must terminate if probable cause is
identified
Declaration of Helsinki
• CORNERSTONE
• World Medical Association, 1964, Finland
• international and independent confederation of free
professional medical associations, therefore
representing physicians worldwide
• formally established on September 18, 1947 and has
grown in 2018 to 113 national medical associations and
more than 10 million physicians
It is the cornerstone document in human
experimentation. This is parallel to the Nuremberg
Code but this is MORE SPECIFIC & MORE
ENCOMPASSING
• “While the primary purpose of medical research is to
generate new knowledge, this goal can never take
precedence over the rights and interests of the
individual research subjects.”
• “The responsibility for the protection of research
subjects must always rest with the physician and other
health care professionals and never with the research
subjects, even though they have given their consent”
The responsibility to protect lies to the physician or
other HCP involved
10 STANDARDS
1. Risks, Burdens, Benefits
Benefits > Risks / burdens
2. Protection of vulnerable groups and individuals
e.g. the poor, women, children
3. Scientific Requirements/Protocols
It must be followed, based on thorough knowledge
on scientific knowledge
4. Research Ethics Committee
E. Fineza | 2NUR4
 The study must be approved by research ethics
committee who reviews the protocol
5. Privacy and Confidentiality
6. Informed Consent
7. Use placebo
Only allowable if there is no known treatment /
intervention
8. Posttrial provisions
Continuous access for participants even If the
study ended already especially if the participant still
needs intervention that are identified to be
beneficial
9. Registration, publication, dissemination
Of the results – to the community and to the society
10. Unproven intervention
May be allowed if this offers reasonable hope for
saving a life / you establish health that can help
alleviate suffering
Tuskegee Experiments
• Treatment for syphilis withheld to observe course of
disease
In medical history, it is the longest nontherapeutic
experiments on human beings (1932-1972, 40 years)
- they were not given / informed about their disease
and also of their treatment
- in 1930’s, mercury as treatment but found
noneffective and dangerous
- in 1940’s, penicillin was already discovered
- in 1950’s penicillin was widely available
• Main purpose: to determine the natural course of
untreated syphilis in African American males in
Alabama
They recruited the Tuskegee by giving false
information (flyer)
• ‘do you have bad blood?’ with ranging
symptoms of headaches and other
possible symptoms
• Free blood tests and treatment
• ‘come and bring your family’
• “special treatment”
A spinal tap – aspiration of CSF to check for
infections, so that the neurological effects of
syphilis will be monitored
• Stopped in 1970’s but only in 1997 that the President
Bill Clinton apologized to the people who were made as
participant in the experiment
o 200,000 dollars was donated for a center
Bioethics in research at Tuskegee University
o 10M dollars in an out of court settlement
o Lifetime free benefit to 8 survivors, widows and
children (to healthcare)
INCENTIVES
• Free physical examination
• Free rides to and from the clinic
Tuskegee are farmers = poor
• Hot meals on examination days
• Free treatment of minor ailments
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e.g. fevers
• Payment of burial stipends
ETHICAL ISSUES
o No Informed Consent
Participants cannot really give informed consent
because they were misinformed
o Participants denied of Treatment
Violation of human dignity and vulnerable rights
o Researchers utilized misleading advertisement
o Vulnerable participants rights were violated
o Risk to society
Since they didn’t know that it was syphilis, sexual
relations continued
- many in the community was infected and may
cause blindness to newborn child
Other Violations
WILLOW BROOK STATE SCHOOL
• Hepatitis vaccines tested on institutionalized children
Children were mentally retarded and was
intentionally given hepatitis so that they could tract
the progression of the disease
• Lasted for 14 years (started in 1956)
• Violent of the children’s rights and by which they are
part of the vulnerable group
• No one can protect them because they were
institutionalized and they cannot protect themselves
(due to mental retardation)
BROOKLYN CHRONIC DISEASE HOSPITAL
• Elderly Jews were injected with Cancer (Ca) cells
Under the skin of their thighs
They considered the elderly as volunteers
They had chronic illness but it is not cancer
Belmont Report
• Ethical Principles and Guidelines for the Protection of
Human Subjects in Research
Adheres to the Nuremberg Code and Helsinki
Declaration but it specifies the 3 core bioethical
principles in terms of human experimentation
• April 18, 1979 – US National Commission for the
protection of human subjects.
• 3 CORE PRINCIPLES OF ETHICS:
1. Respect
Along with the privileges attached to it
2. Beneficence
3. Justice
INTERNATIONAL CODES, DECLARATIONS & GUIDELINES
in the ethical conduct of research
• Nuremberg code
• Helsinki Declaration
• UN Declaration of Human Rights
• Belmont Report
E. Fineza | 2NUR4
 • CIOMS (Council for International Organizations of Ethical Framework
Medical Sciences)
• ICH-GCP (International Conference on Harmonization- 1. MOTIVE
Good Clinical Practice) Guidelines • potential significance for the good of society
• WHO Guidelines for Ethical Review Committees any result is significant
• any research contrary to the true good of the human
person is immoral
National Ethical Guidelines e.g. Tuskegee which is innately contradictory to the
• The PH has own set of guidelines for health-related true good of the human person; no autonomy & no
researches, last updated in 2017 treatment given even it was able
• Authored by Philippines Health Research Ethics Board
in partnership with different associations ~ ethical or not?
• Search for a drug to stay young
• Cloning beautiful people
Joint Memorandum Order 21012-001
• Search for poison gas for terrorism
• by DOST, DOH, CHED, UP Manila • Self-aggrandizement, public acclaim, financial gain,
promotion
Requirement for Ethical Review of Health Research
Involving Human Participants 2. TOPIC
1. Ethics Review and Clearance • Research is justified if there is reasonable likelihood
Before actual study is conducted that population will benefit from results
2. Ensure safety, dignity and well-being • Must be appropriate for health priorities, health needs of
3. Registered / Accredited Ethics Review Committee participants (for population of country)
Be approved MUST BE BENEFICIAL
4. Manual of SOPs o e.g. the Jews injected with Cancer – any result
5. Review Fee will not be beneficial for them
6. Institutional support (in terms of funding, staff, o e.g. Research on AIDS in the Philippines: not
honoraria) a prevalent disease in the community drugs
are expensive & beyond capacity
RA 10532
3. RESPECT FOR DIGNITY
• Philippine National Health Research System Act
• Inherent dignity of human persons
• institutionalizes the establishment of a health research
• Equal rights and freedom
system in the country to improve the health status,
Fully inform = freedom to decide
productivity and quality of life of Filipinos through health
• PARTICIPANTS are treated as
research and development
o ENDS not means
Rights are protected from harm
o PERSONS not objects
For the benefit of the participant
Who are responsible? o CONTRIBUTORY PARTNERS not subjects of
work
• Physicians who refer patients
o e.g. study for certain types of cancer and • Entails:
certain medications, even if his attending ✓ Autonomy
physician is not part of the study, he should ✓ Free and Informed Consent
still be responsible for their patients ✓ No hidden coercion or duress of “preferred
subjects”
• Investigators / researchers
o Responsible for outcome or any anomalies
VULNERABLE GROUPS
• IRBs
• Mental Health
o a.k.a. Institutional Review Boards
o for anything that happens before, during or • Indigenous People
after the study • Minors and Children
• Institution • Older persons
o Where it is conducted • People with disabilities
• Governments • Populations in disaster situations and Disease
o e.g. researches that is allowed by the outbreaks
government they may be enticed with certain benefits from the
• Sponsors research where they have no choice but to take
o e.g. private persons, pharmaceuticals because of much need
• Pregnant and Breastfeeding Women

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4. RISK / BENEFIT RATIO
• Risks must be assessed, safeguard
• Minimum unavoidable harm
The risks when they participate in the study is no
different from the risks they have to undergo when
they go with the usual treatment
o forbids endangering lives, equilibrium, health,
aggravation of illness
e.g. hypertensive participants - refrain from
activities that will further increase BP
o destruction, mutilation, grave danger
o social stigma, discrimination
e.g. Leprosy participants, there should be
guidelines and SOPs that are followed
e.g. Tuskegee, discrimination against
African-American people
• Privacy & Confidentiality
• If risks outweigh benefits, must be stopped
• Long term monitoring
• Any injury must be justly compensated
Anything that the participants need, the researchers
or investigators must provide
~ benefits:
• To the participant and community
• free standard care for specific health needs
e.g. two groups: 1 standard care & 1 standard +
intervention that you want to study (control and
experimental) – regardless, equal treatment
otherwise one group will be put at risk
• e.g. poor countries – substandard drugs
5. ETHICAL RESEARCHER
• Scientifically qualified person
• Aware of limitations
• Avoiding conflicts of interests
e.g. researchers that have something to benefit
from the research itself
e.g. researcher is hastening the research because
of ill family member
• Protected from harm
• Just compensation
e.g. researchers were employed in several
provinces to collect the data, the government
should shoulder transportation and allowance
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DEATH & DYING
- a very heavy topic to discuss but as HCP, it is very
inevitable so you must be knowledgeable of the ethical
principles applicable to it.
TERMINAL CONDITION
• an incurable condition caused by injury, disease/illness,
which regardless of the application of life sustaining
procedures would, within reasonable medical
judgement, produce death, and where the application of
life-sustaining procedures serve only to postpone the
moment of death of the patient.
Be clear in terms of conditions
LIFE SUSTAINING PROCEDURE
• any medical procedure or intervention which utilizes
mechanical or other artificial means to sustain, restore
or supplant a vital function, which when applied to a
qualified patient, would serve only to artificially prolong
the moment of death and where, in the judgement of
the attending MD, death is imminent or not such
procedures are utilized
We can only postpone date but we cannot stop it
Artificial = Chemical / medications (like epinephrine)
Mechanical = ventilators / intubating a patient
QUALIFIED PATIENT
• a patient diagnosed and certified in writing to be
afflicted with a terminal condition by 2 physicians, one
of whom shall be the attending MD, who have
personally examined the patient
if brain dead, neurologist
IMMINENT DANGER OF DEATH
• means that death probably will occur, in the ordinary
course of events within 2 weeks
anticipation
IRREVERSIBLE CONDITION
• can refer to both patients who are in terminal condition
(as defined above) or to patients who are terminally ill
(persons who are acutely psychotic, mentally retarded
or senile) but who are in a permanent comatose state or
in persistent vegetative state (PVS) and
a. there is no reasonable, medical possibility that the
patient will avoid death and return to normal
cognitive and sapient state
by the specialist, check laboratory results, and
data (like previous studies)
b. life can be sustained only through the use of
medically extraordinary life sustaining procedures
MEDICAL FUTILITY
• treatment is useless, merely preserve permanent
unconsciousness or cannot end dependence on
intensive medical care
ineffective management / useless
E. Fineza | 2NUR4
SELF-DETERMINATION
• a person’s capacity to form, revise and pursue his/her
plans for life in keeping with personal values and goals
and in fidelity to personal convictions of dignity and self-
worth
Important especially to patients who are terminally
ill while they are capable to
- provide / present the options
DEATH
• a person is dead when he has irreversibly lost all
capacity to integrate and coordinate the physical and
mental functions of the body (Vatican Pontifical
academy of Science, 1985)
use of Harvard criteria when determining death
• A person may be declared really dead when he reaches
an irreversible cessation of total brain functions
according to the usual and customary or reasonable,
standards of medical practice (AMA)
The patient is only alive because of the machine
• A concept of Stoppage
• A concept of Bondage – punishment for sins
• But for a Christian it is a:
o Time to reconcile with God
o Join in Christ’s suffering
o Time to reconcile with family
And be with them
• It is extinguishing the lamp because the dawn has come
Christian faith’s look on suffering / death
• Suffering is evil because o is a violation of the human
person, ultimately resulting from sin
From original sin
• Suffering can be liberating and grace-filled experience if
the proper motivation is present
May liberate from what is hindering him
It will give the patient time to reconcile with God
and others, and time to resolve issues that remain
unresolved in his life
Pain at the time of death
• Pain is not an absolute human evil alleviating pain by
medicine / surgery does not constitute euthanasia, even
if the person’s life might be shortened by these
procedures
By providing pain medications / interventions
• Sever / excruciating pain is not an excuse for
euthanasia or suicide
There are processes or management in alleviating
pain
• If the patient is unable to decide, the family in
consultation with the MD should have the right and
obligation to determine whether aggressive pain control
should be used
Aggressive pain control usually renders a patient
unconscious, so they will be in a coma
Some pain management / medication may have side
effects that will hasten / shorten the life span
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Principle of Growth through Human Suffering
• As bodily pleasure should be sought as the fruit of the
satisfaction of some basic need of the total human
person, so suffering and even bodily death when
endured with courage can and should be used to
promote personal growth in both private and
communal living
We have an ultimate destiny to fulfill and that is to
reconcile and be with our Creator
As HCP, we understand that death is something
that we will go through and something we will help
the patients to go through and there is no other
treatment that can prevent death to occur
DEATH WITH DIGNITY
• is dying in a way which is not only burdened by the
prolonged use of life- sustaining technology in an
alienating and depersonalizing environment; it is the
dignity of the dying person that must determine what
measures are to be taken to sustain life, perhaps even
beyond the natural limits.
• To some people dying with dignity means that one
should be able to make the decision to die when dying
will be better than to go on living with an incurable
distressing illness
When the person believes this, the patient has no
hope
• To some people dying with dignity means facing pain
and suffering
• People who face the realities of life with courage and
die with dignity
As nurses, we do everything in both our
professional capability and moral obligation to help
this patient build his courage to die with courage
ISSUES
1. Determining death
• How will we know? Who pronounces?
• Harvard Criteria
• Irreversibility of death
2. Truth telling the Dying
• How and who will tell them?
• Principle of Professional Communication
• The Ethical & Religious Directives for Catholic
Health Facilities (#55)
o We help patients prepare for death: provide
necessary information for decision-making
o Persons in danger of death should be provided
with whatever information is necessary to help
them understand their condition and have the
opportunity to discuss their condition with their
family and HCP. They should also be offered
appropriate medical information that would make
it possible to address the morally legitimate
choices available to them
E. Fineza | 2NUR4
 Morally legitimate choices = ordinary means Why should life be preserved?
that may be applied / the patient has willingly This is one of the things we swore to as HCP
go to so they should prepare themselves and • Human life is sacred, it is a gift from God
their family - Human soul is an image close to God, we are
• The questions should not be “should we tell?” but “How gifted with intelligence and free will – in God’s
do we share this with the patient” image and likeness
- We are given a SHARE dominion, not an absolute
CRUCIAL FEARS OF THE PHASES OF DYING dominion
TERMINALLY ILL (E. Kubler Ross)
1. Feat of unbearable pain
- God alone is the author, HCP can anticipate but
1. Denial
Inform patient of interventions God knows when
2. Fear of excessively
burdensome and futile
2. Anger • By the principle of stewardship, we are given a shared,
treatment 3. Bargaining not absolute dominion over life
3. Fear of loss of autonomy
and personal dignity
4. Depression • God alone is the author of life and he alone can
4. Fear of dying alone in
5. Acceptance and Hope
determine when our life ends
loneliness

3. Euthanasia and Suicide IRREVERSIBILITY

• Euthanasia
o Good death
o Pleasant death “mercy killing”
o A medical act that renders a patient to end his
suffering
• Suicide
o Killing oneself either by acts of commission or
omission
o Commission: active performance
Drinking a medicine that will cause death
o Omission: passive / negative performance
Not drinking / taking treatment or therapy
• Moral Evaluation: IMMORAL
And illicit
o Intentional killing and opposes the natural
inclination to preserve life
opposite what we are as HCP
o Maybe performed for self-interest or other
consequences
o HCP may be tempted not to do their best to
save the patient; a simple way out and to
disregard any other alternative
4. Allowing to Die
• e.g. Dysthanasia & Orthothanasia
• When is it acceptable to allow the patient to die?
• This time might be used to compose oneself and come
into terms with death, deal spiritually with God and
others
There is no reasonable hope even If the
management is given to the patient
• A time comes when prolonging life may not contribute
to the spiritual purpose of life (serving God and others)
Prolonging life = burdensome; won’t be
contributing to purpose of life for the patient
• Not rejecting life but accepting what God has given him
/ her
5. Pain and Dying
is recognized when evaluation discloses that:
1. The cause of coma is established and is sufficient to
account for the loss of brain functions.
2. The possibility of recovery of any brain functions is
excluded.
3. The cessation of all brain functions persists for at least
24hours of observation and therapy
Criteria for CESSATION OF BRAIN FUNCTION include:
1. irreversible coma
2. no spontaneous respiration and no response to apnea
test for 6 minutes
no spontaneous breathing
3. absence of the following brain stem reflexes: pupillary,
corneal, gag and caloric test
Exclusions to the above criteria are the following:
1. drug and metabolic intoxication
2. hypothermia
May mimic symptoms in Harvard criteria
3. children (18 years and below)
4. shock
Not necessarily dead, manage the shock then
assess again
HARVARD CRITERIA OF DEATH
1. unreceptive, unresponsive
2. absence of spontaneous movements and breathing
3. absent reflexes, fixed dilate pupils
4. persistently isoelectric EEG
electroencephalogram = brain-related
no heartbeat is present
5. persistence of these finding over a 24-hour period in the
absence of intoxication or hypothermia.
As long as the patient is not intoxicated /
hypothermic because they may mimic the following
symptoms

6. Care for the Corpse and Cadaver

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 5. To prevent any conflict of interest, the dying patient’s
EUTHANASIA
doctor would be distinct from the transplant team
EUTHANASIA DYSTHANASIA ORTHOTHANASIA
d e s c r i p t i o n
“eu” “thanatos” “dys” “thanatos” “orthos” ‘thanatos”
MAN’S LIFE: DUTY OF PRESERVING IT
– good death, easy – bad death, difficult, – right or good death
death, happy death ugly death
Guiding Principles/Moral Considerations:
mercy killing, trying to stop or Patient dies because 1. Human life belongs to the Creator alone as its Supreme Lord
compassionate prevent death by any of underlying
and Master. Neither any individual nor the State has any right
killing, death with possible manner or pathology
dignity at all cost through the death at one’s to destroy it.
Vatican declaration use of extraordinary, appointed time and 2. From the moment of conception, the life of every human
on Euthanasia – an disproportionate, designated hour
action or omission burdensome means being is to be respected in an absolute way because man is
which of itself or by which in reality only the only creature on earth that Gad has :wishedhas wished
intention causes prolongs the dying
death in order that process or terminally for Himself” and the spiritual soul of each man is immediately
all suffering in this comatose life by created by God; his whole being bears the image of the
way be eliminated. interrupting the
Euthanasia’s terms biological process of allowing the patient to Creator.
of reference, death for hours, die in peace. • Human life is sacred because from its beginning; it
therefore, are to be days, weeks and
found in the intention often without any real involves the “creative action of God” and it remains
of the will and in the therapeutic forever in a special relationship with the Creator, who is
methods used. proportionate benefit
to the patient its sole END. God alone is the Lord of life from its
f u n c t i o n a l c h a r a c t e r i s t i c s beginning until its end; no one can; in any
Confronts life Confronts death Neither advances nor
delays death circumstance, claim for himself the right to destroy
Advances death, Delays death, makes Neither favors death directly an innocent human being.
helps to die, favors dying difficult nor makes it difficult
death • No one can make an attempt on the life of an innocent
Shortens or reduces Prolongs, extends, Neither confronts person without opposing God’s love for the person,
life lengthens life (opposes) life nor
fights for it
without violating a fundamental right and therefore
Kills Does not allow to die, It does not kill; it without committing a crime of the utmost gravity.
it stops death simply permits, allow 3. Man, as a creature, is then viewed as a caretaker, is a
to die
steward too whom the responsibility is being given to
CLASSIFICATION OF EUTHANASIA administer all the goods that he has received. The care and
ACTIVE PASSIVE
preservation of his life, as a foundation for any further human
Direct active Cessation of positive development, becomes a moral obligation for which man has
inducement of death measures to prolong life to account.
commission omission
- positive act - negative act • This obligation is based on the very nature of man; man
VOLUNTARY Conscious patient Conscious patient in the is created to develop to the fullest possible degree all
conscious GRANT requests and is given a midst of death refuses
wishes lethal dose life prolonging treatment the talents and potentialities that he received at the
and request is granted moment of his creation. This natural imperative /
NON-VOLUNTARY Comatose patient is in Cessation of life
comatose the midst of death is prolonging treatment for
obligation of the natural law of man, imposes on a
administered a lethal comatose patient in the certain negative precept as well as positive demands,
injection midst of death
INVOLUNTARY A lethal injection is A conscious patient in
i.e. certain things that man ought to avoid and others
conscious given to a conscious the midst of death is that must do to protect his life
AGAINST wishes patient in the midst of treatment even though 4. Everyone has the duty to lead his life is accordance with
death against his he requests that life
wishes prolonging treatment be God’s plan. That life is entrusted to the individual as a good
e.g. People in death continued. that must bear fruit already here on earth but that find its
row
fullest perfection only in eternal life.
Guidelines for the determination of death for Organ 5. Man is MORALLY OBLIGED to adopt all ORDINARY means
Transplants: of preserving health and life. The failure to supply the
~ Philippine criteria for brain death ordinary means of preserving life is equivalent to euthanasia.
1. No members of the transplant team should determine It is NEVER licit to suspend the ordinary means in patients
death even if the prognosis is fatal
2. The dying patient’s doctor should determine that the • Man is not normally obliged to adopt
patient is dead. This should be confirmed by a EXTRAORDINARY means of preserving health and life.
neurologists/neurosurgeon. • EXCEPTIONS: 1) Spiritually unprepared 20 Person vital
3. Throughout the process, the attending MD should work to the common good
in concert with the family, pastoral staff and the legal • Man may adopt extraordinary means to conserve health
officers. and life if it appears to be useful, desirable and prudent
4. An individual who has sustained either irreversible thing to do
cessation of circulation and respiratory functions or 6. Whatever is the motive and means, direct euthanasia is
irreversible cessation of all functions of the entire brain morally wrong and unjustified – immoral as it is contrary to
including the brain stem is DEAD. natural and positive law.
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 7. The patient is master of his own life, within certain limits and Standard, recognized, established
medicine, procedures during that
condition, should also be master of his death; should be able period at the level of medical
to exercise choice over the way in which he intends to live his practice
Includes not only normal food,
final moments. Heroic, ineffective or burdensome measures, drinks, and rest but also in terms of
when not requested or accepted by the patient, violate his hospital practice, all medicines,
treatments, procedures which offers
right by imposing upon him a constraint which in fact fails to reasonable hope of benefit. For the
take into consideration his wished and his rights to refuse - patient which can be obtained and
used for excessive expense, pain or
personally or through proxy – such extraordinary optional other inconvenience
means.
8. The decision to allow oneself or another to die in such
e.g. if patient has to travel to get
treatment; and patient has no
means and it is risky for him to
travel
A medicine or procedure that may be
fanciful, bizarre, experimental,
incomplete and not recognized
All medicines, treatments and
operations which cannot be obtained
or used due to excessive expense,
pain or other inconvenience for the
patient or for others, on which if used
would not offer a reasonable hope
for the patient

circumstances, is not equivalent to suicide nor euthanasia. It

should be considered as an acceptance of the human “Medical treatment is extraordinary when it is futile and imposes
condition or a wish to avoid the application of a medical grave burden on the patient and family involved and therefore,
procedure not to impose excessive expense on the family or nom-obligatory.” – Pope Pius XII
the community (Vatican declaration)
• Orthothanasia can be justified on the basis of personal Integral Approach to patient Management
autonomy or right to self-determination and the principle
The following aspects should be considered:
of stewardship and double effect
1. Biological aspects
• “here one does not will to cause death: one’s inability to
2. Human aspect
impede is merely accepted. The decision should be o the patient must be considered to be more
made by the patient if he is competent and able, or if than a biological organism but respected as
not, by those legally entitled to act for the patient, shown in the courteous and effective caring
whose reasonable will and legitimate interest must manner the nurse treats them
always be respected” 3. Spiritual aspect
9. Even if death is imminent, the ordinary care owed to the sick
a. Respecting the patient as a person, as one who
person can’t be legitimately interrupted. The use of painkillers comprehends what is happening to him. He should
to alleviate the sufferings of the dying, even at the risk of be given all necessary explanations about
shortening their lives, can be morally in conformity with treatment, protocol and diagnostic tests. Help
human dignity if death is not willed as either an end or as a patient to attain self-fulfillment as well as coping
means, but only foreseen and tolerated as inevitable
with his fears, worries and anxieties. LISTENING
(Catechism of the Catholic Church) to patient is very IMPORTANT!
10. Withholding treatment (that was never started) and b. Help patients make decisions – foster decision
withdrawing treatment (already started) – moral grounds for making in both little things of daily life and making
withdrawing are identical to those for withholding treatment. plans, choosing rest, etc. – things related to family,
11. Even in the face of intense and incurable pain, human social life
science admit defeat, the health care professional will not
c. Spiritual care
consider their work done. They should bring to such suffering o person’s right to spiritual attention; a necessity:
should a deeper insight into life and a realization that they it is during illness when spiritual dimension of
may use pain as means of spiritual union with God. Such a the human person easily manifests itself.
role is truly great and noble. o “Illness makes man feel more forcefully his
12. Those whose lives are diminished or weakened deserve being taken out of focus and side-lined;
special respect. Sick or handicapped persons should be
consequently, he desires fulfilment and
helped to lead lives as normal as possible. intimate union with the Being who is LOVE”
o It is not the exclusive task of the priest.
d. Assisting the patient find meaning in his illness –
ORDINARY MEANS EXTRAORDINARY MEANS know himself better.
a.k.a. proportionate a.k.a. disproportionate
Surgical & medical procedures & treatments which:
a. offer REASONABLE hope of a. do not offer reasonable hope of
The Health Care Professional should have:
benefit or success for the success or positive benefit to 1. capacity for self-giving
patient the patient. risk > benefits
2. generosity, not just fulfilling duties, vigilance, affection,
b. easily attainable b. cannot be obtained or used
without imposing serious compassion
hardships on the patient and 3. order
family
c. can be used WITHOUT c. involves excessive pain/burden 4. sense of responsibility
excessive expense, pain or on the patient. 5. loyalty
other grave hardship
These measures are MORALLY Principle: One is not obliged 6. simplicity and sincerity
SERIOUSLY BINDING in all men normally bound to use extraordinary 7. optimism
and failure to use them will constitute means based on the “duty of always
a serious negligence on the part of avoiding evil and that of doing good 8. patience and understanding
the patient, the family, the physician as much as it is possible in the 9. role model of hope
or society in general. situation”

Page 8 of 9 E. Fineza | 2NUR4

 WITHOLDING / WITHDRAWING LIFE SUPPORT
• This may be compatible with beneficence, non-
maleficence and autonomy
doing good, preventing harm, respecting the
patient’s right to decide for himself
• Use of proportionate (morally obligatory) and
disproportionate means (morally non-obligatory)
reasonable or not
life sustaining machines, the family does not have
the duty in turning it off because it will bring guilt
– usually, the person who intubates the patient will
extubate as well; in the presence of the family
DO NOT RESUCITATE (DNR)
• It must be made for the best interest of the patient – not
the family, HCP, insurance company or society at large
• All involved parties should agree what a DNR means;
e.g. no CPR if heartbeat / breathing stops
Usually with the consent of patient & family in
consideration of patient’s condition
• It must be treatment, which is heroic or
disproportionate, futile, or excessively burdensome
• It must be periodically evaluated
Check status and progress
ADVANCE DIRECTIVES
other document to respect the patient’s decision
• Document in which a person either states choices for
medical treatment or designates an individual who
should make treatment choices if the patient lose his
decision-making capability
• It can also apply to oral statements from patients to
the caregivers / HCP given at a time when the patient
was capable in making decisions
Our responsibility to document in properly
FORMS of Advance Directives
• It does not preempt the physician’s moral responsibility
to offer a diagnosis and prognosis directed toward
patient benefit
AlsoAlso, management / intervention
• The proxy realizes that her responsibility is to act in the
best interest of the patient, not merely to convey a
request made in the past when the circumstances were
not known
The patient may have said something in the past,
always decide with the question “What would have
the patient decided if he could deicide for himself
right now”
1. LIVING WILL
• Patient must be terminally ill
• Must lack decision making capacity
2. DURABLE POWER OF ATTORNEY
• Document that designates a surrogate decision maker
should the patient becomes incompetent
Page 9 of 9
• It does not require the patient to be terminally ill
MORAL DIFFERENCES BETWEEN
EUTHANASIA ALLOWING TO DIE
Intention brings about death by Patient dies because of fatal
performance or withholding an act pathology
Death directly intended by the agent
Death is an unwanted side effect of
a good ethical action
Unwanted side effect of a good
To kill
ethical action / Respecting DNR
Care for the Dying
• HCP must address their own beliefs, anxieties and fear
about their personal mortality before they can care
appropriately for patients who face their own dying
You should be clear
• We must accept that the dying process can be aided by
good medicine but can be perverted by medicine
In cases of euthanasia
Truth we should Accept in Caring for Dying Persons
• Sickness and death are natural parts of life
We are only mortals and we have all experience
sickness, and eventually dying (hopefully later on)
• Dying is a human process not a medical event
• Dying persons are living persons
• Goal of care should be to help them live well while
dying
Responsibility: care on both the patient and family
(morally)
GOALS of Care & Treatment in the Terminally Ill
• Well-being of the patient achieved through attention to
the physical, mental, social, and spiritual needs of the
dying person
• Appropriate pain management is to relive physical pain
It is not effective for emotional pain
• Skillful interventions to facilitate expression of emotions
that accompany mental pain
• We have to accept that dying persons are living
persons so we have to help them live will while dying
• Supportive services are to allay guilt and sadness over
unfulfilled social commitments
Most of them feels guilt and sadness
May refer to supportive services like counselors
To cure sometimes, to help often, to comfort and console. . .
Always”
E. Fineza | 2NUR4