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HEALTH CARE
Health Care Ethics ETHICS
Orientation By:
MARY ELEANOR N. USIS, MSN, RN
Introduction to Bioethics

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What can we expect to gain from an

Introduction
• Ethics originated from the Greeks with a word “ethos”.
• Ethos means moral duty in modern language.
• It simply focuses on how people regard of what is right or
wrong.
• Nurses have to encounter ethical issues almost every day
in their line of work.
• Ethics has something to do with making choices that are
best for the person, or community at right times and
taking responsibility of the results of such choices.
ethics class?
More clarity and better understanding about what is right
and wrong, therefore, more confidence about our choices
and about the reasoning process we use to defend our
behavior
Understanding about other possible and legitimate ways
to arrive at ethical answers
Understanding about some of the pitfalls involved in
trying to differentiate right from wrong
 Preparation for situations different from ones we usually
encounter

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Significance in NURSING
Values, Morals and Ethics
profession

 Ethics reflects the standards that govern a proper conduct in a Values
particular profession.  These are operational beliefs an
 For instance, the nurse on duty knows that she is obligated to act individual chooses as the basis for
for the good of the client and to prevent any incident to harm the behavior which can change over
time.
patient.
 This principle of doing no harm to the client is the intervention of  These beliefs serve as the building
blocks of moral and ethical
knowing the ethics in nursing. development.
 To formulate an ethical decision, the nurse should gain knowledge  Values influence not only the
on the situation taking a look at all angles to promote maximal behavior but also the decision
benefit to the client.
making of a person. It could be
 Aside from scrutinizing every possible aspect of the problem the based on the following:
nurse should be able to understand the relationship between values, Experience, Religion, Education
morals and ethics. Culture, Professional peer group
Morals
 are personal opinion or principle
that a particular action or behavior
is absolutely right or wrong in all
situations.
 Usually a person is reluctant or
unwilling to change his personal
opinions on specific issues of a
moral nature.
 For instance, some people view
abortion a totally wrong and there is
no justifiable excuse for it.
 However, some hold the belief that
aborting a fetus is better rather than
improperly rearing a child.

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Ethics
Ethics

Defined as the science of standards or principles of moral
judgment or actions.
 Or, A science of the morality of human conduct
A science - It provides a methodical system in
differentiating right from wrong basing on a certain belief.
Moral – because it is related to personal opinion or
principle that a particular action or behavior is absolutely
right or wrong in all
 Human conduct – deals with deliberate and free human
activity and how one should act.
Ethics is about choices - presupposition of ethics (no
choices, no ethics)
Ethics is about evaluation - evaluation is between good
and bad (choose the good and avoid the bad)
Ethics includes reasoning - faced with challenges of
life, we have to figure out what is truly good for ourselves
and what is truly bad.
 Our traditions are not enough--they sometimes misguide us
(slavery), and they sometimes become obsolete (organ
transplants, sustaining life with machines) "All people seek the
good, not the way of their ancestors.“

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Healthcare Ethics and Professional

Bioethics and Health Ethics
Ethics
• Bioethics - A division of Ethics that relates • Healthcare Ethics – Study of moral issues
to human life or the Ethics of the life that concerns health care professionals..
sciences and healthcare, both delivery and Nightingale’s oath remember? “to do no
research harm”
• Health Ethics – a division of Ethics that • Professional Ethics – Division of Ethics
relates to human health. It is also considered that relates to professional behavior.
as ethics for the health professionals.

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Answer Key:
The Florence Nightingale Pledge A – Ethics D - Professional Ethics
I solemnly pledge myself before God and presence of this assembly; B – Bioethics E - Healthcare Ethics
To pass my life in purity and to practice my profession faithfully. C – Health Ethics
I will abstain from whatever is deleterious and mischievous and will not take or
knowingly administer any harmful drug.
1. Edna is failing in class. Greta is a high achiever.
I will do all in my power to maintain and elevate the standard of my profession Greta sits besides Edna during an examination and
and will hold in confidence all personal matters committed to my allows Edna to copy her answers in order for Edna to
keeping and family affairs coming to my knowledge in the practice of my pass.
calling.
2. Edmond freely choose to tell a lie to someone to
With loyalty will I endeavor to aid the physician in his work, and devote save himself from shame.
myself to the welfare of those committed to my care.
3. Ethics that relates to human life.

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Answer Key: Answer Key:

A – Ethics D - Professional Ethics A – Ethics D - Professional Ethics
B – Bioethics E - Healthcare Ethics B – Bioethics E - Healthcare Ethics
C – Health Ethics C – Health Ethics

4. Moral issues that relate to health care professionals
5.A student nurse participates in the conduction of
research of a new medicine that proves to be fatal.
6.The nurse fails to discuss procedures before
administering treatments.
7. Nursing students become noisy during duty hours.
8. Philippe comes to work on time.
9. Anna was asked to administer blood transfusion to
her client but, refuses to follow and told her supervisor
that it was against her religion.
10. Nurse Amy failed to administer the 4PM medication
of her client

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Forms of Ethical Theories

Theories and Principles
of Health Ethics
Deontology
• Derived from the Greek word “deon” which means
“duty”
• Deontology is a category of normative ethical theories
that encompasses any theory which is primarily concerned
with adherence to certain rules or duties
• Consequences DO NOT matter!
• Intention is relevant. “I am acting a certain way only if I
act for the right reason.”

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Forms of Ethical Theories Forms of Ethical Theories

Teleology
• “Telos” = Greek for goal.
• Begins with intuitions about “the good life” and what
it means to be an ideal human being
• Emphasizes the virtues, the capacity for always
knowing how to act well in a given situation.
Utilitarianism
• An ethical theory that holds that an action is right if
it tends to produce the greatest amount of good for
the greatest number of people affected by the action.
Otherwise, the action is wrong.
• Adopts a teleological approach to ethics and claims
that actions are to be judged by their consequences.

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Virtue Ethics

• A virtue ethics for nursing is therefore

concerned with the character of individual
nurses and seeks ways to enable nurses to
develop character traits appropriate for actions
that enhance wellbeing.

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Basic Ethical Concepts

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Dignity of MAN
Nurses should recognize and respect the intrinsic worth of
each person. Common good
 This is the basis for human rights
The source of human dignity is rooted in the concept of
Imago Dei, in Christ’s redemption and in our ultimate
destiny of union with God.
• Consists of all the conditions of society
One direct normative implication of human dignity is that and the goods secured by those
every human being should be acknowledged as an inherently conditions, which allow individuals to
valuable member of the human community and as a unique
expression of life, with an integrated bodily and spiritual achieve human and spiritual flourishing.
nature.
 This principle is foundational for the understanding
of distributive justice, the common good, the right to
life and the right to health care

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PERSONHOOD Compare the following:

• Every human person has an inner worth and inherent
dignity. 1. Stone, tree, dog, man

• This he possesses not because of what he has or what he 2. Newborn, healthy adult, senile elderly
does but because of what he is: a human person 3. Comatose patient, crazy individual
• As a human person he must be respected regardless of the 4. Illiterate man, university president, uneducated
nature of his health problem, social status, competence, housemaid, convicted killer
past actions, etc. Guiding questions:
• To be a person is to have moral value and intrinsic worth. 1. Are they all persons?
• Being a person is to be a subject, and deserve to be treated 2. Do they have equal human dignity?
as a subject, and not merely as an object.

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Principle of Distributive Justice Patient as a PERSON

Refers to what society owes individual members in proportion to:
1) the individual’s needs, contribution and responsibility
2) the resources available to the society
3) the society’s or organization’s responsibility to the common good.
o In the context of health care, distributive justice requires that everyone
receive equitable access to the basic health care necessary for living a fully
human life insofar as there is a basic human right to health care.
• Also implies that society has a duty to the individual in serious need and that
all individuals have duties to others
• In decisions regarding the allocation of resources, such
as rationing decisions, the duty of society is not diminished because of the
person’s status or nature of illness.
• Everyone is entitled to equal access to basic care necessary for living in a
human way.
• Nurse-patient relationships depends on a nurse’s ability to
know and care for both the physical aspects of a patient’s
disease and the person who presents with the disease.
• A patient is vulnerable because he is sick (unable to make
decisions, unable to heal himself, choose quality of health
care)….. Therefore, he must be protected from harm
(exploitation)
• Patients are expected to accept responsibility and cooperate
with health provider (must give respect, gratitude and
compensation to providers)
• In all these, patients remains.. Always as a person with dignity
and must be given with respect. His privacy must be protected

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Healthcare Provider as a PERSON Healthcare Provider as a PERSON

• Patients seek healthcare and providers accepts that As a result, the health care provider must be:
person as a patient… therefore they enter into a o Committed
relationship that requires: o A patient advocate (patient’s best interest is the priority)
• Mutual respect o Competent in scientific and interpersonal skills
• Trust o Accepts patient’s values regarding what is acceptable to him
• Honesty and how he feels.

• Appropriate confidentiality o Guard against arrogant and showing undesirable bedside

manner but always be understanding, humane and
o Committed compassionate.
o A patient advocate (patient’s best interest is the priority) o Recognize limitations and ask help when needed.

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Healthcare Provider as a PERSON Case Scenario

• Mr L, an 85-year-old man, had been in ICU for 14 days
If the healthcare provider or you as a student nurse is in an
after abdominal surgery. He had a difficult postoperative
authority.. What will you observe to become worthy of
course: he could not be weaned from the ventilator and he
being a role model to other providers or younger
was having frequent arrhythmias. Mr L’s only family
colleagues and to upgrade the standards of our profession?
member was a son who lived in the province. Although the
son telephoned the nurses station daily to check on his
father, he was unable to visit.
• In report, Marta, the staff nurse, was told that Mr L was
"extremely withdrawn and got very jumpy whenever he
was touched." The nurse giving the report said Mr L
followed commands intermittently and seemed to have
"tuned out the world." The nurse also said that the staff
called him "Jakey."

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• "That’s kind of an odd name for an older man. How
do we know that’s what he likes to be called?" Marta
said.
• "I’m not sure; that’s what I was told to call him," the
other nurse replied.
• As Marta walked into Mr L’s room, she noted a sign
over the bed that read "Legally Blind." Mr L was lying
on his left side with his back to the door, his wrists
restrained, eyes open. Marta walked up to the bed with
Mr L’s back to her and said good morning.
Immediately Mr L became agitated, pulling at his
restraints and motioning with his head for Marta to
move to the left side of the bed.
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• Before doing any procedures with him, Marta
spoke to him from the left side, explained what
she was going to do, and asked him to help as
much as he was able. Although withdrawn, often
staring away when Marta tried to engage him in
conversation, Jacob was calm and indicated his
responses to direct questions appropriately. Jacob
was able to remain unrestrained for most of the
shift.
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• As she walked around the bed to the left side, Mr L
became calmer. Marta checked his pupils and noticed
that his right eye was completely clouded but that his
left eye was not. When Marta moved into Mr L’s field
of vision, he focused on her face, indicating that he
had partial vision in his left eye.
• Not feeling comfortable with calling an elderly man
Jakey, Marta asked Mr L how he would like to be
addressed. Because he could not speak, Marta listed 3
options: Mr L, Jakey, and Jacob. He indicated his
preference for Jacob by nodding.
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Nursing Implications
1. Marta, the nurse in this scenario, was very concerned
about addressing Mr L as he desired. Determining how
Mr L chose to be addressed was a way of recognizing his
uniqueness as a human being.
2. One can also say that the meaning of dignity explained in
this type of dignity is as "All people have dignity because
they are unique individuals and a special creation.“
3. In Mr L’s case, his dignity was compromised not only by
his severely debilitated state but also by the staff ’s failure
to recognize him as a unique individual.
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How do we conduct in a Guiding Questions

• The characteristics of a good health care provider. How
professional way? does the lack of these affect the delivery of health care?
• Must a health care provider always provide health care?
• Manifest a social conscience Under what circumstances is he justified to withhold
• Stand for justice for the poor healthcare?
• Make healthcare available at reasonable cost • If a member of your profession behave unethically, what
should you do?
• Avoid the temptation to exploit or take advantage of
the patient
• Always care about human values

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Comment on the roles of healthcare provider and receiver.

Discuss your answers and present to class next meeting.
Group 1: Elsa goes to the doctor because she has a vaginal
discharge. She however refuse to talk about her personal Conscience
life.
Group 2: Felix goes to the clinic for a chest X-Ray. As a • (Oxford dictionary) A moral sense of right and
radiology technician, you know that the x-ray machine has wrong especially as felt by a person and affecting
not been working properly, yet the owner continues to use behavior.
it.
Group 3: Linda, a speech therapist, is asked by her neighbor
• A personal practical judgment of reason upon a
Mrs. Ang to pass their house on her way home from work particular individual act as good and to be
to treat Gerly, her 7-year-old daughter, twice a week. Mrs. performed, or as evil and to be avoided.
Ang does not pay Linda, but gives her delicious meriendas
and a nice Christmas gift.

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Conscience
• A person must strive to develop and provide
himself a sound, true and certain conscience.
• Must seek the truth through his own perception,
sound education, understanding of natural law,
traditional wisdom, teaching of family and church,
experience, etc
• It can be an error as when one misunderstands
principles, misjudges facts or led by affections
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The Human Act
• A Human Act is an act which proceeds from the
deliberate free will of man.
• Man knows what he is doing and freely chooses
to do what he does
• Not all acts of man are human act or for man to
be fully responsible for an act (to be a moral
agent)
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The Morality of Human Acts
When it comes to making decisions in our lives, what do we
usually consider?
What other people might think of me?
Whether it will hurt anyone?
Am I really doing this for a good reason?
But…. The “Good things” to consider when choosing
to do or not to do in a particular thing are not
enough by themselves.. Because it depends on
several things
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Elements to consider the Acts of
Man as Human Acts
• Knowledge – of what it is about and what it
means
• Freedom – to do or leave it undone without
coercion or constraint. Freedom implies
voluntariness which is to rationally choose by
deliberate will of the object.
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In each case decide if it a human act or

an act of man
Nurses as Moral Agents
1. Edna is failing in class. Greta is a high achiever. Greta sits • Act for the welfare of their patients
beside Edna during an examination and allows Edna to • Most time spent with patients
copy her answers in order for Edna to pass. • Develop Caring Relationships “Knowing the
patient”
• Code of Ethics – Caring & Patient Advocacy
2.Bobby, a 3-year-old boy, wet his pants on his first day of
school • Nurses’ Integrity
• Lack the Power to Act = Moral Distress
3. Alvin vomits every time he eats mangoes • Risk Taking

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True or False:
1. The source of Human Dignity is rooted in the
concept of Imago Dei, in union with God.
2. A man who is doing an act based on a situation
that he does not truly knows or is innocent about
it, is called a human act.
3. An act of man is an act that shows this: Shirley
Basic Ethical Principles
drinks water every time she gets thirsty.
4. A nurse is a moral agent if she follows the Code of
Ethics
5. Good habits of a person reflect the principle of
Stewardship.

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What Are Ethical Principles, and How

Do They Help With Decision
Ethical Dilemma:
Making?
Conflict is inevitable.
Ethical principles provide
Situations necessitating a
the framework/ tools choice between two equal
which may facilitate (usually undesirable)
individuals to resolve alternatives.
conflict in a fair, just and
moral manner.

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Principles of Stewardship and Principles of Stewardship and

Accountability Accountability
 Stewardship requires us to appreciate the two great gifts that God
has given:
As responsible Stewards, we must:
 Human Life 1. Do no harm and improve or take care of
 Natural Environment them.
This principle: 2. Treat with utmost respect
3. Use creativity and originality to cultivate
 Requires that the gifts of human life and its natural environment be
used with profound respect for their intrinsic ends.
 Teaches us to take care of our own body or environment because them
4. Know and respect their limits
we are responsible for them
 Treat it with utmost respect and do no harm, but to improve it

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Accountability
This means being answerable or responsible
for what and how one carries out his
responsibility or obligation.
Two Major Attributes:
1. Answerability
2. Responsibility
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Principles of Totality
• Refers to the duty to preserve intact the
physical component of the integrated
bodily and spiritual nature of human life
• Whereby every part of the human body
"exists for the sake of the whole as the
imperfect for the sake of the perfect" (St.
Thomas Aquinas)
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Principles of Totality
• These principles dictate that the well-being of
the whole person must be taken into account in
deciding about any therapeutic intervention or
use of technology
• Therapeutic procedures that are likely to cause
harm or undesirable side effects can be justified
only by a proportionate benefit to the patient.
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Principles of Totality
This Suggests that:
 A part of the human body may be sacrificed if that
sacrifice means continued survival for the person.
 Sacrifices are normally justifiable under the principles of
integrity and totality, and may sometimes be forgone
under the Principle of Disproportionate Means
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Principles of Totality
Principle of Disproportionate Means Principles of Double EFFECT
• Any treatment that, in the given circumstances and in
the judgment of the patient or the caregiver,
either offers no reasonable hope of benefit (taking into • An action that is good in itself that has two
account the well-being of the whole person) or is too effects:
burdensome for the patient or others 1. An intended and not reasonably good
• i.e., the burdens or risks are disproportionate to or effect
outweigh the expected benefits of the treatment. Note: 2. Unintended and yet foreseeable evil effect
these determinations should be patient specific and take
into consideration the patient’s personal, financial, familial,
and social circumstances. Or….. An intended good : permitted evil

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Principles of DOUBLE EFFECT CASE STUDY: Foregoing Ventilator Treatment

Five Basic Moral Criteria:
1. Action must not be intrinsically evil.
2. Direct intention must to achieve beneficial effects and to
avoid foreseen harmful effects (indirect harm)
3. Foreseen benefits must not be achieved by means of
foreseen harmful effects
4. Foreseen benefits must be equal or greater than harmful
effects
5. Benefits must follow at least as immediately as the
harmful effects.
Forgoing ventilator treatment for a ventilator-
dependent patient, whose desires are not known
(Karen Quilan’s case) ARGUMENT:
• He must enhance the good whenever reasonable and eliminate
the harm whenever possible….
• He has two choices:
(a) Continue the ventilation sustaining Karen’s
permanently unconscious body, or
(b) Discontinue the ventilation, which would cause
Karen’s death.

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CASE STUDY: Foregoing Ventilator Treatment
 He must use the reasonable treatment standard for his decision-making.
 The treatment (ventilation) is not going to cure Karen; it has
no medical (curative) advantage at all.
 So, the reasonable treatment only is if you can justify its major purpose,
which is keeping Karen alive.
 So, the "burden of proof" lies on those who say continue treatment, not on
those who say it should be discontinued—default is no medical treatment
unless we have reason to use it.
• He cannot justify his belief by
• trying to re-describe his action as good.
• trying to camouflage his action as an omission (I am not doing
something that will lead to Karen’s death, but only "omitting the
technology necessary to support her life.")
• appealing to his feelings
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Presumption :
• To give treatment only when it has a purpose,
and the proof that both options are harmful
(so doing harm is unavoidable),
• Caregiver can argue that the harm caused by
option (a) is greater than the harm caused by
option (b); as we should choose the "less worse
option," (b) is the morally correct option.
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• If the caregiver is correct, then the caregiver could use the
following argument.
• Option (a) does no good for Karen (she cannot
experience good or bad), no good for the family (it makes
no sense—he would know this best) no good for society
or the common good—in other words, there is nothing
gained by the treatment—it is unreasonable treatment. In
fact, it undermines the common good by its unreasonable
use of financial resources contributed by others. Option
(a) therefore causes harm.
• Option (b) would also cause harm, i.e., it would kill
Karen. However, what is the magnitude of the harm? Do
all deaths cause equal harm?
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MORAL CONCLUSIONS FROM THE QUINLAN CASE
• Got to use Reasonable Treatment Standard
• The good of continued life of a patient is not a sufficiently strong
enough reason to justify continuing expensive ventilator
treatment.
• The good of continued life of a patient is not a sufficiently strong
enough reason to justify continuing expensive ventilator treatment
when the patient’s desires are not known.
• The good of continued life of a patient is not enough reason to
justify overriding a proxy’s request to discontinue ventilator
treatment.
• The request of proxy to forgo life-sustaining ventilator treatment
of an irreversibly unconscious patient is enough to justify
forgoing that treatment.
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Principle of COOPERATION Principle of SOLIDARITY

• Participation of one agent with another agent to produce • To be one with others to give a positive outcome.
a particular effect.
• Nurses must be one in provision of healthcare, especially
Types of Cooperation: with the poor, disadvantaged and the marginalized.
1. Formal – secondary agent willingly participates as when
one agrees, consoles, promotes or condones
2. Material – secondary agent does not willingly
participates
3. Immediate – secondary agent is inherently bound to
perform the evil action.
4. Mediate – secondary agent is not inherently bound to
perform evil action

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Beneficence
Implies that all individuals have some moral obligation to
Specific Ethical benefit others

Principles • The practice of doing acts of goodness, kindness and

charity to patients under all circumstances
• In short, “Doing Good and Avoiding Evil”

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Baby Fae
• The case of Baby Fae raises important issues in the area
of human experimentation.
• On October 26, 1984, Dr. Leonard Baily and the transplant
team of Loma Linda University Medical Center in California
removed the defective heart (hypoplastic left heart syndrome,
in which the left side is much smaller than the right) of a five
pound baby girl (known as Baby Fae).
• It was replaced with the heart of a baboon, a procedure
known as xenotransplantation (cross-species transplantation).
• Twenty days later, on November 15th, the baby died of
complications caused when her body began to reject the
transplanted heart.
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Nonmaleficence
Implies that we have a moral obligation not to harm others
• Primum non nocere, commonly translated as "first, do no
harm”
• In this respect, it shares the same characteristics of beneficence
and is considered as a middle principle.
• Is sometimes interpreted to imply that if one cannot do good
without also causing harm, then one should not act at all (in
that particular circumstance).
• The difficulty with this rigorist interpretation, however, is that
it makes action almost impossible in a world where even the
best actions may have some harmful results
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Baby Fae
• Among the ethical issues raised by the Baby Fae case are:
• The risk/benefits ratios for the human subject
• Experimentation
• Quality of informed consent
• Surrogate decision-making
• Exploration of other options
• Introduction of expensive and untested technology
Regarding other options, the doctors at Loma Linda never
sought a human heart and the chances for a successful
xenograft were very slim.
• Principles & Concepts: beneficence, benefit and
burdens, disproportionate means, best interests.
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Autonomy
• The right to participate in and decide on a
course of action without undue influence
(free from coercion in deciding to act)
• Self-Determination: which is the freedom to
act independently. Individual actions are
directed toward goals that are exclusively
one’s own.
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Autonomy
•This also implies that one should is Autonomy
obligated to protect confidentiality, respect
privacy, and tell the truth. Three Basic Elements in Autonomy:
•In the practice of health care, a person’s 1. The ability to decide
autonomy is exercised through the process 2. The power to act upon your decision
of obtaining informed consent. 3. Respect for the individual autonomy of
others
•The principle of respect for autonomy,
however, does not imply that one must
cooperate with another’s actions in order to
respect that individual’s autonomy.

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Autonomy Justice
encompasses fairness and equality
Respect for autonomy involves not only refraining
others from interfering with other person’s choices,
but sometimes it entails providing them with
necessary conditions:
 Protect confidentiality (protection of information Fairness Equality
revealed by the patient)
 Obtain Informed Consent- the right and
responsibility of every competent individual to
advance his own welfare.
Prerequisite: 1) adequate disclosure of information;
2) patient freedom of choice; 3)
patient comprehension of information; and 4)
patient capacity for decision making

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Justice
The principle that deals with fairness,
equity and equality and provides for an
individual to claim that to which they
are entitled.
2 Types:
• Comparative Justice - Making a
decision based on criteria and outcomes.
ie: How to determine who qualifies for one
available kidney. 55 year old male with
three children versus a 13 old girl.
• Noncomparative Justice: ie: a method
of distributing needed kidneys using a
lottery system.
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In general, justice refers to what is owed
or due to the individual members of
society.
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Justice
• This relates to the provisions of equal access to health care
to all and equitable allocation or in equal proportion to:
1. The individual’s needs, contribution and
responsibility
2. The resources available to the society or
organization (market considerations would be
included under this, as well as other financial
considerations)
3. The society’s or organization’s responsibility to the
common good.
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inviolability of Life
• The principle proposed as the Sanctity, the Dignity or Respect
for Human Life
• A form of sacredness – fear of losing life
• Therefore, not to be violated, opposed or destroyed, but to
affirm, cherished, respected, defended and preserved.
• A commitment to choosing life and fighting to protect it.
• Being against to violence, pollution of environment, drug
addiction and treachery
• Measures for survival of human and freedom to have children.
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Questions?

Thank You!!!!

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