PROTECTING PATIENT’S PRIVACY AND CONFIDENTIALITY

Bill of rights

- These rights can be exercised on the patient’s behalf by a designated surrogate or proxy
decision maker if the patient lacks decision- making capacity, is legally incompetent or is a
minor.

PATIENTS RIGHTS

Patient rights are a subset of human rights.

Whereas the concept of human rights refers to minimum standards for the ways persons can expect to
be treated by others, the concept of ethics refers to customary standards for the ways persons should
treat others.

As such, rights and ethics are usually flip sides of the same coin, and behind every ‘patient right’ is one
or more ethical principle from which that right is derived

Bill of Rights, Philippine Constitution 1987

In the Philippines’ 1987 Constitution, the Filipino patient’s right to privacy and confidentiality is
guaranteed under Article 3, Section 3:

“ The privacy of communication an correspondence shall be inviolable except upon lawful order of the
court, or when public safety or order requires otherwise, as prescribed by law.”

1. Right to Appropriate Medical Care and Humane Treatment.

- Every person has a right to health and medical care corresponding to his state of health, without any
discrimination and within the limits of the resources, manpower and competence available for health
and medical care at the relevant time.

The patient has the right to appropriate health and medical care of good quality. In the course of such,
his human dignity, convictions, integrity, individual needs and culture shall be respected.

If any person cannot immediately be given treatment that is medically necessary he shall, depending
on his state of health, either be directed to wait for care, or be referred or sent for treatment
elsewhere, where the appropriate care can be provided. If the patient has to wait for care, he shall be
informed of the reason for the delay.

Patients in emergency shall be extended immediate medical care and treatment without any deposit,
pledge, mortgage or any form of advance payment for treatment.

2. Right to Informed Consent.

The patient has a right to a clear, truthful and substantial explanation, in a manner and language
understandable to the patient, of all proposed procedures, whether diagnostic, preventive, curative,
rehabilitative or therapeutic, wherein the person who will perform the said procedure shall provide
his name and credentials to the patient, possibilities of any risk of mortality or serious side effects,
problems related to recuperation, and probability of success and reasonable risks involved:

Provided, That the patient will not be subjected to any procedure without his written informed
consent, except in the following cases:

a) in emergency cases, when the patient is at imminent risk of physical injury, decline Of death if
treatment is withheld or postponed. In such cases, the physician can perform any diagnostic or
treatment procedure as good practice of medicine dictates without such consent;
b) when the health of the population is dependent on the adoption of a mass health program to
control epidemic;

c) when the law makes it compulsory for everyone to submit a procedure;

d) When the patient is either a minor, or legally incompetent, in which case. a third party consent Is
required;

e) when disclosure of material information to patient will jeopard ize the success of treatment, in
which case, third party disclosure and consent shall be in order;

f) When the patient waives his right in writing. Informed consent shall be obtained from a patient
concerned if he is of legal age and of sound mind. In case the patient is incapable of giving consent and
a third party consent is required. the following persons, in the order of priority stated hereunder, may
give consent:

i. spouse;

ii. son or daughter of legal age;

iii. either parent;

iv. brother or sister of legal age, or

v. guardian

If a patient is a minor, consent shall be attained from his parents or legal guardian. If next of kin,
parents or legal guardians refuse to give consent to a medical or surgical procedures necessary to save
the life or limb of a minor or a patient incapable of giving consent, courts, upon the petition of the
physician or any person interested in the welfare of the patient, in a summary proceeding, may issue
an order giving consent

3. Right to Privacy and Confidentiality.

- The privacy of the patients must be assured at all stages of his treatment. The patient has the right to
be free from unwarranted public exposure, except in the following cases:

a) when his mental or physical condition is in controversy and the appropriate court, in its discretion,
order him to submit to a physical or mental examination by a physician;

b) when the public health and safety so demand; and

c) when the patient waives this right in writing.

The patient has the right to demand that all information, communication and records pertaining to his
care be treated as confidential. Any health care provider or practitioner involved in the treatment of a
patient and all those who have legitimate access to the patient's record is not authorized to divulge
any information to a third party who has no concern with the care and welfare of the patient without
his consent, except:

a) when such disclosure will benefit public health and safety;

b) when it is in the interest of justice and upon the order of a competent court; and

c) when the patients waives in writing the confidential nature of such information;

d) when it is needed for continued medical treatment or advancement of medical science subject to
de-identification of patient and shared medical confidentiality for those who have access to the
information.
Informing the spouse or the family to the first degree of the patient's medical condition may be allowed;
Provided That the patient of legal age shall have the right to choose on whom to inform. In case the patient
is not of legal age or is mentally incapacitated, such information shall be given to the parents, legal
guardian or his next of kin.

4. Right to Information.

- In the course of his/her treatment and hospital care, the patient or his/her legal guardian has a right
to be informed of the result of the evaluation of the nature and extent of his/her disease, any other
additional or further contemplated medical treatment on surgical procedure or procedures, including
any other additional medicines to be administered and their generic counterpart including the
possible complications and other pertinent facts, statistics or studies, regarding his/her illness, any
change in the plan of care before the change is made, the person's participation in the plan of care and
necessary changes before its implementation, the extent to which payment maybe expected from
Philhealth or any payor and any charges for which the patient maybe liable, the disciplines of health
care practitioners who will fumish the care and the frequency of services that are proposed to be
furnished.

- The patient or his legal guardian has the right to examine and be given an itemized bill of the hospital
and medical services rendered in the facility or by his/her physician and other health care providers,
regardless of the manner and source of payment. He is entitled to a thorough explanation of such bill.

- The patient or his/her legal guardian has the right to be informed by the physician or his/her
delegate of his/her continuing health care requirements following discharge, including instructions
about home medications, diet, physical activity and all other pertinent information to promote health
and wellbeing.

- At the end of his/her confinement, the patient is entitled to a brief, written summary of the course of
his/her illness which shall include at least the history, physical examination, diagnosis, medications,
surgical procedure, ancillary and laboratory procedures, and the plan of further treatment, and which
shall be provided by the attending physician.

- He/she is likewise entitled to the explanation of, and to view, the contents of medical record of
his/her confinement but with the presence of his/her attending physician or in the absence of the
attending physician, the hospital's representative.

- Notwithstanding that he/she may not be able to settle his accounts by reason of financial incapacity,
he/she is entitled to reproduction, at his/her expense, the pertinent part or parts of the medical
record the purpose or purposes of which he shall indicate in his/her written request for reproduction.
The patient shall likewise be entitled to medical certificate, free of charge, with respect to his/her
previous confinement.

5. The Right to Choose Health Care Provider and Facility.

- The patient is free to choose the health care provider to serve him as well as the facility except when
he is under the care of a service facility or when public health and safety so demands or when the
patient expressly waives this right in writing.
- The patient has the right to discuss his condition with a consultant specialist, at the patient's request
and expense. He also has the right to seek for a second opinion and subsequent opinions, if
appropriate, from another health care provider/practitioner.

6. Right to Self-Determination.

–The patient has the right to avail himself/herself of any recommended diagnostic and treatment
procedures.

Any person of legal age and of sound mind may make an advance written directive for physicians to
administer terminal care when he/she suffers from the terminal phase of a terminal illness: Provided
That

a) he is informed of the medical consequences of his choice;

b) he releases those involved in his care from any obligation relative to the consequences of his
decision;

c) his decision will not prejudice public health and safety.

7. Right to Religious Belief

-The patient has the right to refuse medical treatment or

procedures which may be contrary to his religious beliefs, subject to

the limitations described in the preceding subsection:

Provided, That such a right shall not be imposed by parents upon

their children who have not reached the legal age in a life threatening

situation as determined by the attending physician or the medical

director of the facility

8. Right to Medical Records.

-The patient is entitled to a summary of his medical history and condition.

He has the right to view the contents of his medical records, except psychiatric notes and other
incriminatory information obtained about third parties, with the attending physician explaining
contents thereof.

At his expense and upon discharge of the patient, he may obtain from the health care institution a
reproduction of the same record whether or not he has fully settled his financial obligation with the
physician or institution concerned.

The health care institution shall safeguard the confidentiality of the medical records and to likewise
ensure the integrity and authenticity of the medical records and shall keep the same within a
reasonable time as may be determined by the Department of Health.

The health care institution shall issue a medical certificate to the patient upon requests. Any other
document that the patient may require for insurance claims shall also be made available to him within
forty-five (45) days from request
9. Right to Leave.

-The patient has the right to leave hospital or any other health care institution regardless of his
physical condition: Provided. That

a) he/she is informed of the medical consequences of his/her decision

b) he/she releases those involved in his/her care from any obligation relative to the consequences of
his decision;

c) his/her decision will not prejudice public health and safety.

No patient shall be detained against his/her will in any health care institution on the sole basis of his
failure to fully settle his financial obligations. However, he/she shall only be allowed to leave the
hospital provided appropriate arrangements have been made to settle the unpaid bills: Provided.

Further, that unpaid bills of patients shall be considered as loss income by the hospital and health care
provider/practitioner and shall be deducted from gross income as income loss only on that particular
year.

10. Right to Refuse Participation In Medical Research.

- The patient has the right to be advised if the health care provider plans to involve him in medical
research, including but not limited to human experimentation which may be performed only with the
written informed consent of the patient:

Provided, That, an institutional review board or ethical review board in accordance with the
guidelines set in the Declaration of Helsinki be established for research involving human
experimentation:

Provided, further, That the Department of Health shall safeguard the continuing training and
education of future health care provider/practitioner to ensure the development of the health care
delivery in the country: Provided, furthermore, That the patient involved in the human
experimentation shall be made aware of the provisions of the Declaration of Helsinki and its
respective guidelines.

11. Right to Correspondence and to Receive Visitors.

- The patient has the right to communicate with relatives and other persons and to receive visitors
subject to reasonable limits prescribed by the rules and regulations of the health care institution.

12. Right to Express Grievances.

- The patient has the right to express complaints and grievances about the care and services received
without fear of discrimination or reprisal and to know about the disposition of such complaints.

Such a system shall afford all parties concerned with the opportunity to settle amicably all grievances
13. Right to be Informed of His Rights and Obligations as a Patient.

- Every person has the right to be informed of his rights and obligations as a patient. The Department
of Health, in coordination with heath care providers, professional and civic groups, the media, health
insurance corporations, people's organizations, local government organizations, shall launch and
sustain a nationwide information and education campaign to make known to people their rights as
patients, as declared in this Act

Such rights and obligations of patients shall be posted in a bulletin board conspicuously placed in a
health care institution.

It shall be the duty of health care institutions to inform of their rights as well as of the institution's
rules and regulations that apply to the conduct of the patient while in the care of such institution.

FILIPINO PATIENT’S BILL OF RIGHTS

1. The patient has the right to considerate and respectful care irrespective of socio-economic status.

2. The patient has the right to obtain from his physician complete current information concerning his
diagnosis, treatment and prognosis in terms the patient can reasonably be expected to understand.
When it is not medically advisable to give such information to the patient, the information should be
made available to an appropriate person in his behalf. The patient has the right to know by name or in
person, the medical team responsible in coordinating his care.

3. The patient has the right to receive from his physician information Necessary to give informed
consent prior to the start of any procedure and/or treatment. Except in emergencies, such
information for informed consent should include but not necessarily limited to the specific procedure
and or treatment, the medically significant risks involved, and the probable duration of incapacitation.
When medically significant alternatives for care or treatment exist, or when the patient requests
information concerning medical alternatives, the patient has the right to such information. The patient
has also the right to know the name of the person responsible for the procedure and/or treatment.

4. The patient has the right to refuse treatment/life – giving measures, to the extent permitted by law,
and to be informed of the medical consequences of his action.

5. The patient has the right to every consideration of his privacy concerning his own medical care
program. Case discussion, consultation, examination and treatment are confidential and should be
conducted discreetly. Those not directly involved in his care must have the permission of the patient
to be present.

6. The patient has the right to expect that all communications and records pertaining to his care
should be treated as confidential.

7. The patient has the right that within its capacity, a hospital must make reasonable response to the
request of patient for services. The hospital must provide evaluation, service and/or referral as
indicated by the urgency of care. When medically permissible a patient may be transferred to another
facility only after he has received complete information concerning the needs and alternatives to such
transfer. The institution to which the patient is to be transferred must first have accepted the patient
for transfer.

8. The patient has the right to obtain information as to any relationship of the hospital to other health
care and educational institutions in so far as his care is concerned. The patient has the right to obtain
as to the existence of any professional relationship among individuals, by name who are treating him.

9. The patient has the right to be advised if the hospital proposes to engage in or perform human
experimentation affecting his care or treatment. The patient has the right to refuse or participate in
such research project.

10. The patient has the right to expect reasonable continuity of care; he has the right to know in
advance what appointment times the physicians are available and where. The patient has the right to
expect that the hospital will provide a mechanism whereby he is informed by his physician or a
delegate of the physician of the patient’s continuing health care requirements following discharge.
11. The patient has the right to examine and receive an explanation of his bill regardless of source of
payment.

12. The patient has the right to know what hospital rules and regulation apply to his conduct as a
patient.

THE RIGHT TO CONSENT: IS IT ABSOLUTE?

Informed consent is required for all medical investigations and procedures and is considered a corner
stone of modern medicine.

A process in which patients are given important information, including possible risks and benefits,
about a medical procedure or treatment, genetic testing, or a clinical trial. This is to help them decide
if they want to be treated, tested, or take part in the trial. Patients are also given any new information
that might affect their decision to continue. Also called consent process.

It is the obligation of the provider to make it clear that the patient is participating in the decision-
making process and avoid making the patient feel forced to agree to with the provider. The provider
must make a recommendation and provide their reasoning for said recommendation.

Adequacy of Informed Consent

The required standard for informed consent is determined by the state. The three acceptable legal
approaches to adequate informed consent are

(1) Subjective standard: What would this patient need to know and understand to make an informed
decision?

(2) Reasonable patient standard: What would the average patient need to know to be an informed
participant in the decision?

(3) Reasonable physician standard: What would a typical physician say about this procedure?

Many states use the "reasonable patient standard" because it focuses on what a typical patient would
need to know to understand the decision at hand. However, it is the sole obligation of the provider to
determine which approach is appropriate for a given situation

Exceptions to Informed Consent

Several exceptions to the requirement for informed consent include

(1) the patient is incapacitated,

(2) life-threatening emergencies with inadequate time to obtain consent, and

(3) voluntary waived consent. If the patient's ability to make decisions is questioned or unclear, an
evaluation by a psychiatrist to determine competency may be requested.
A situation may arise in which a patient cannot make decisions independently but has not designated
a decision-maker. In this instance, the hierarchy of decisionmakers, which is determined by each
state's laws, must be sought to determine the next legal surrogate decision-maker. If this is
unsuccessful, a legal guardian may need to be appointed by the court.

Children and Informed Consent

Children (typically under 17) cannot provide informed consent. As such, parents must permit
treatments or interventions. In this case, it not termed "informed consent" but "informed permission."
An exception to this rule is a legally emancipated child who may provide informed consent for himself.
Some, but not all, examples of an emancipated minor include minors who are

(1) under 18 and married,

(2) serving in the military,

(3) able to prove financial independence or

(4) mothers of children (married or not). Legislation regarding minors and informed consent is state-
based as well. It is important to understand the state laws

Informed Consent for Blood Transfusion

• The essential to patient autonomy. Informed consent requires a thorough understanding of

transfusions and the ability to convey this information to a patient in a way that they can understand
it.

• However, obtaining consent often has deficiencies in the explanation where benefits may not be
entirely true and risks related are omitted.

• It has been shown that involving experts from transfusion units in obtaining informed consent for
transfusion results in patients having a better understanding of the risks and benefits. However,
always involving an expert may not be the most efficient way to obtain consent, although new
graduate physicians have a knowledge deficit when it comes to transfusion medicine. However,
physicians that had previous transfusion medicine education displayed more understanding than
those who did not.

• As most physicians will need to obtain informed consent for a transfusion at one point in their
career, it could be argued that physicians should have enough education in regards to transfusion
medicine.

PROXY CONSENT

Proxy consent is the process by which people with the legal right to consent to medical treatment for
themselves or for a minor or a ward delegate that right to another person. There are three
fundamental constraints on this delegation:

1. The person making the delegation must have the right to consent.

2. The person must be legally and medically competent to delegate the right to consent.

3.The right to consent must be delegated to a legally and medically competent adult.
There are two types of proxy consent for adults. The first, the power of attorney to consent to medical
care, is usually used by patients who want medical care but are concerned about who will consent if
they are rendered temporarily incompetent by the medical care. A power of attorney to consent to
medical care delegates the right to consent to a specific person. The second type is the living will.

CONFIDENTIALITY

Republic Act 10173: Data Privacy Act of 2012

Under the Data Privacy Act, protection of patient privacy and confidentiality is protected under the
following:

“Section 13. Sensitive Personal Information and Privileged Information. The processing of sensitive
personal information and privileged information shall be prohibited, except in the following instances:
data subject consent; existing laws and regulations; to protect the life and health of data subject;
lawful and noncommercial objectives of public organizations and associations; medical treatment;
protection of lawful rights and interest of natural or legal person in court proceedings; or the
establishment, exercise, or defense of legal claims; or, when provided to governments or public
authority.”

Sec 19. Non Applicability. The preceding sections are not applicable if the processed personal
information are used only for the needs of scientific and statistical research the personal information
shall be held under strict confidentiality and used only for the declared purpose.

Philippine Health Information Exchange (PHIE), private hospitals have committed to comply with the
Data Privacy Act (DPA) of 2012 and are implementing data protection measures in their data
processing systems to protect sensitive personal information of their patients. This was revealed at
the first general assembly of Data Protection Officers (DPO) of Private Hospitals.

The PHIE is an electronic health (eHealth) initiative of the Department of Health (DOH), the
Department of Science and Technology (DOST) and the Philippine Health Insurance Corporation
(PhilHealth) that would ensure accurate and timely health information exchange that can be
instrumental in improving the services of these three agencies as well as the other organizations that
could use the said data.

Penalties for violations of data privacy that involve sensitive personal information (SPI) are higher
than those that involve personal information, as such, SPI need to be accorded a higher level of
protection. An example of this is unauthorized disclosure; under the DPA, the maximum fine of the
unauthorized disclosure of personal information is one million pesos, while if it involves SPI it’s two
million pesos.

What is data privacy?

The right of an individual to control the collection of, access to, and use of personal information about
him or her that are under the control or custody of the government or the private sector.
Why is data privacy important in the Health and Hospitals Sector?

Healthcare services are largely dependent on the free flow of information among all participants – be
it the client, the healthcare worker or the health institution. When clients feel confident that their
information are safe and secured at the hands of their healthcare provider, it encourages them to
provide complete and accurate data. A health institution that prioritizes data privacy is an institution
that cares for its clients.

How important is data privacy to our clients?

As a healthcare provider, most of the data you process are considered sensitive personal information.
Data privacy measures ensure your client that these information are safe and secured. It guarantees
them that their data are protected at all times and are not exposed to risks and vulnerabilities like
unauthorized access, processing, sharing and disclosure.

What is the Data Privacy Act of 2012?

Republic Act No. 10173 is also known as the Data Privacy Act of 2012 (DPA). It (1) protects the
privacy of individuals while ensuring free flow of information to promote innovation and growth; (2)
regulates the collection, recording, organization, storage, updating or modification, retrieval,
consultation, use, consolidation, blocking, erasure or destruction of personal data; and (3) ensures
that the Philippines complies with international standards set for data protection through National
Privacy Commission.

Who is the National Privacy Commission?

The National Privacy Commission (NPC) is the country’s privacy watchdog; an independent body
mandated to administer and implement the DPA, and to monitor and ensure compliance of the
country with international standards set for data protection.

Am I covered by the DPA?

The DPA applies to the processing of all types of personal information and to any natural and juridical
person involved in personal information processing including those personal information controllers
and processors who, although not found or established in the Philippines, use equipment that are
located in the Philippines, or those who maintain an office, branch or agency in the Philippines subject
to the immediately succeeding paragraph: Provided, That the requirements of Section 5 are complied
with.
Relevant Ethical Principles

Principle of double effect

• An action that is good in itself that has two effects- an intended and otherwise not reasonably
attainable good effect, and an unintended yet foreseen evil effect— is licit, provided there is a due
proportion between the intended good and the permitted evil.

To make appropriate ethical decisions:

The manager must use a professional approach that eliminates trial and error and focuses on proven
decision-making models or problem-solving processes.

The principle of double-effect

• A good act may have several good effect and is worthy of being performed thereby increasing its
goodness or even adding new goodness. An evil act may also have several evil effects and is unworthy
of being chosen

The four conditions:

1. The act must be good in itself, or at least, morally indifferent.

➢ being the primary moral determinant, the act by it very nature must be good. Its goodness
proceeds from within itself. If it not possible to be good, the act must not be evil in itself.

2. The good effect must directly proceed from the act itself and not from the evil effect. At the very
least, both effects must occur simultaneously.

➢ it indicates the fact that the good effect is the one that is being directly willed and not the evil effect
in the performance of an act. The good effect is the very purpose for which the act is done, and as such,
it is produced not by the evil effect but by the act itself. In fact, it comes ahead of the evil act.

3. There must be sufficient reason for the performance of an act in its attainment of the good effect.

➢ As determined by the nature of the act and its circumstances, sufficiency of reason exists when
there is no other means by which the desired good effect is as equally important as to permit the
occurrence of the evil effect.

4. The motive of the agent must be holy and honest.

➢ how can the agent be honest in his intention?

➢ By directly willing to obtain the good effect and not the evil effect of the act. This can be proven
when the evil effect just follows after the good effect is achieved.

When can the principle of double effect not be invoked?

1 . When the act by its nature is evil.

2. When the good effect directly proceeds from the evil effect and not from the act itself.

3. When there is no sufficient reason for the performance of an act with two effects, one-good, the
other-evil.

4. When the motive of the agent is not honest.

The MORAL Decision Making Model (Crisham, 1985)

• M Massage the dilemma.

• O Outline options.

• R Review criteria and resolve.

• A Affirm position and act.

• L Look back Evaluate the decision-making.

Murphy and Murphy (1976) Approach to Ethical Problem Solving

1. Identify the problem.

2. Identify why the problem is an ethical problem.

3. Identify the people involved in the ultimate decision.

4. Identify the role of the decision maker.

5. Consider the short- and long-term consequences of each alternative.

6. Make the decision.

7. Compare the decision with the decision maker's philosophy of ethics.

8. Follow up on the results of the decision to establish a baseline for future decision making.

Another error made by managers in ethical problem solving is using the outcome of the decision as
the sole basis for determining the quality of the decision making.

Ethics in Action

• In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by
nurse—managers involves some ethical component.

• "If a structured approach to problem solving is used, data gathering is adequate, and multiple
alternatives are analyzed, even with a poor outcome, the manager should accept that the best possible
decision was made at that time with the information and resources available."

The following forces ensure that ethics will become an even greater dimension in management
decision making in the future:

• increasing technology, regulatory pressures, and competitiveness among healthcare providers;

• national nursing shortages;

• reduced fiscal resources;

• spiraling costs of supplies and salaries;

• and the public's increasing distrust of the healthcare delivery system and its institutions.
Health care profession

• Is defined as a profession in which a person exercises skill and judgment or provides a service
related to:

— A. the preservation or improvement of the health of an individual

— B. the treatment or care of individuals who are sick, injured, harmed, disabled or infirmed.

Health care professionalism

• Profession and professional come from the Latin word "profession" which means a public
declaration with the force of a promise.

• Professionalism in health care requires that one strives for excellence in the following areas which
becomes part of the attitudes, behaviors and skills integral to patient care:

A. ALTRUISM

• A health care professional is obligated to attend to the best interest of patients rather than self
interest.

B. ACCOUNTABILITY

• A health care professional is accountable to their patients, to society on issues of public health and to
their profession.

C. EXCELLENCE

• Health care professionals are obligated to make a commitment to life-long learning.

D. DUTY

• A health care professional should be available and responsive, accepting a commitment to service
within the profession and the community.

E. HONOR AND INTEGRITY

• Health care professionals should be committed to being fair, truthful and straightforward in their
interactions with patients and the profession.

F. RESPECT FOR OTHERS

• A health care professionals should demonstrate respect for patients and their families and to the
other members of the team.

PRINCIPLE OF STEWARDSHIP

Stewardship requires us to appreciate the two great gifts that a wise and loving God has given: the
earth, with all its natural resources and our own human nature, with its biological, psychological,
social, and spiritual capacities. This principle is grounded in the presupposition that God has absolute
Dominion over creation, and that, in so far as human beings are made in God's image and likeness
(Imago Dei), we have been given a limited Dominion over creation and are responsible for its care.

• The principle of stewardship includes but is not reducible to concern for scarce resources, rather, it
also implies a responsibility to see that the mission of Catholic health care is carried out as ministry
with its particular commitment to human dignity and the common good.
Principles of integrity and totality

• These principles dictates 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.

• INTEGRITY refers to each individuals duty to "preserve a view of the whole human person in which
the values of the intellect, will, conscience and fraternity are pre-eminent"

• 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".

Moral and spiritual responsibilities of nurses

Principles or rules

1. THE GOLDEN RULE

• God said "do unto others what you would like others do unto you. "

2. The two-fold effects

• When a nurse is faced with a situation which may have both good and bad effects, how should she
choose which one to follow? The basis of action may be the following:

— That the action must be morally good

— That the good effect must be willed and the bad effect merely allowed

— That the good effect must not come from evil action but from the initial action itself directly; and

— That the good effect must be greater than the bad effect.

• It is not morally good if a boy steals in order to alleviate his hunger because the action itself is
already bad. On the other hand, if a patient who has cancer of the uterus submits to hysterectomy she
will not be able to bear a child. If she does not have the operation, she will die. It is the gynecologist's
intention to help the mother and no to harm the her. The surgeon's action is morally good since saving
the mother's life is of primary importance. Also the doctor himself did not will that the patient lose her
child-bearing function.

3. The principle of totality

• The whole is greater than any of its parts.

• Suppose a man's foot is gangrenous, should he consent to an amputation? Since the amputation will
save the patient's life and he can still walk through the aid of crutches or artificial limbs, he can
consent to an operation.

4. EPIKIA

• "exception to the general rule"

• It is a reasonable presumption that the authority making the law will not wish to bind a person in
some particular case, even though the case is covered by the letter of the law.
• if a mental patient went berserk and the doctor could not be contacted, the patient may be
restrained by the virtue of epikia. Another example is allowing a relative to see a seriously ill patient
who expresses the desire to see the former although it is not yet visiting hours.

5. One who acts through an agent is himself responsible

• For example, a patient wants to have an abortion and asks a nurse if she can do it. The nurse refuses,
but then recommends a doctor who is capable of performing an abortion. The nurse becomes liable to
such crime, since he/she is an accomplice of the said doctor.

6. No one is obliged to betray himself/herself

• In testifying before a court, no one can force any person to answer a question if such will incriminate
him/her.

7. The end does not justify the means

• Giving a sleeping tablet to a chronically ill person so he/she can die in peace is morally wrong. A
physician in the US assisted a woman, diagnosed as having Alzheimer's disease, in committing suicide.
This is both legally and morally wrong.

8. Defects of nature may be corrected

• Patients with a cleft palate may have their defects corrected by plastic surgery. What shall be the
role of the nurse in a case in which parents of a severely deformed newborn child (Down's Syndrome
with intestinal atresia) refuse to feed and allow their child to starve to death?

• Withholding nutrition can constitute nursing neglect and expose the nurse to criminal charges of
negligence or conspiracy to commit suicide.

If one is willing to cooperate in the act, no injustice is done to him/her

• Suppose a patient subjects himself/herself willingly to an experimental drug and he/she has been
told of the possible effects of the same, is of right age, and is sane, there is no violation of human
rights.

10. A little more or less does not change the substance of an act

• If a nurse gets a medicine from a hospital stock without permission or without prescription, he/she
will be guilty of theft even if he/she got only one tablet of the same.

11. No one is held to the impossible

• To promise that a patient with heart transplant will live may be an impossibility. Yet, such
procedures are done in the hope of saving or prolonging a patient's life. The doctor or the nurse
cannot be held to the impossible if they have done their best to take care of the patient and the latter
dies.

12. The morality of cooperation

• Formal cooperation in an evil act is never allowed. Immoral operations such as abortion shall not be
participated upon by a nurse even if the doctor commands
13. Principle relating to the origin and destruction of life

• "thou shall not kill"

• If God has given man a life, will it mean that God has already ceded his right to man?

• Assuming that God gave life to man, who will know that God does abhor a man who takes his own
life?

Basic moral criteria

• 1. The object of the act must not be intrinsically contradictory to one's fundamental commitment to
God and neighbour, that is, it must be a good action judged by its moral object (in other words, the
action must not be intrinsically evil).

• 2. the direct intention of the agent must be to achieve the beneficial effects and to avoid the foreseen
harmful effects as far as possible, that is, one must only indirectly intend the harm.

• 3. the foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects,
and no other means of achieving those effects are available.

• 4. the foreseen beneficial effects must be equal to or greater than the foreseen harmful effects (the
proportionate judgment)

• 5. The beneficial effects must follow from the action at least as immediately as do the harmful effects.

Principle of subsidiarity

• Often considered a corollary of the principle of the common good, subsidiarity requires those in
positions of authority to recognize that individuals have a right to participate in decisions that directly
affect them, in accord with their dignity and with their responsibility to the common good.

• Decisions should be made at the most appropriate level in a society or organization, that is, one
should not withdraw those decisions or choices that rightly belong to the individuals or smaller
groups and assign them to a higher authority.

The principle of indirect voluntary act

• Aside from an act with two-effects-one, good as directly intended and the other, evil as unintended-
there is also an act that is directly intended with an evil effect that is not directly intended though
foreseen or foreseeable.

• Sometimes, in the performance of human act which is of course a willed act as freely determined by
the will, an evil effect sprouts which is not directly willed. That is why, oftentimes, remarks like:
"sorry, I did not truly mean it," or "sorry, it was not really intended" are at once addressed by the one
who performs the act, with an evil effect which does not directly intend, to the other who suffers from
the said effect. This is what INDIRECT VOLUNTARINESS of an act is all about.

The three conditions:

1 . The evil effect must be foreseen or foreseeable in the performance of the act at least in a general
way.

➢ Common sense gives anyone the capacity to foresee that an evil effect, though indirectly willed,
may happen as it proceeds from a human act that is to be performed.
2. There must be freedom to choose not to do the act which is the cause of the evil act.

➢ A free act is elicited by the will having the power to choose to do or not to do it. However, freedom
cannot be exercised if there is no light of knowledge in the intellect.

3. Refraining from doing the act which is the cause of the evil effect holds the agent morally bound.

➢ Reason dictates that when the evil effect is foreseen or foreseeable and that the agent is free, he is
morally obliged not to pursue the performance of an act which serves as the cause of the evil effect.

The principle of stewardship

• STEWARDSHIP refers to the expression of one's responsibility to take care of, nurture and cultivate
what has been entrusted to him.

• In health care practice, STEWARDSHIP refers to the execution of responsibility of the health care
practitioners to look after, provide necessary health care services, and promote the health and life of
those entrusted to their care.

The principle of justice

• JUSTICE- simply means the rendering of what is one's due. A person who is justly doing an act to
another person gives the latter what is his due.

• Principle of justice- refers to a moral principle by which certain actions are determined and deemed
as just or unjust, as due or undue.

• RIGHT — is a moral power of performing, of possessing, or of requiring something which is due.

• DUTY — is defined as a moral obligation incumbent upon a person of doing or omitting (avoiding)
something.

Main duties and obligations of health care practitioners:

1. Preservation of life and health

2. Protection of bodily integrity from harm.

3. Respect for human dignity.

Distributive justice

• Pertains to a fair scheme of distributing society's benefits and burdens to its members.

• In health care milieu, benefits refers to various health care services, while burdens include the
necessary payment for the delivery of health care and participation in medical experimental research.

Two alternatives:

1. THE UTILITARIAN ALTERNATIVES

➢ These represents maximizing strategies to achieve the greatest amount of good or minimizing
strategies to reduce the amount of potential harm.
a. The medical success principle

• Gives priority to those for whom treatment has the highest probability of medical success. If the
condition of the patient shows favorable prognosis and that he has the utmost possibility of being
cured, his right to medical treatment prevails over the other.

b. The principle of immediate usefulness

• Gives priority to the candidate who is of greatest immediate service to the larger group under the
circumstances. In case of typhoon-related health problems in the community, the social worker or the
community leader has the greater right to medical assistance than the community folks.

c. The principle of conservation

• Gives priority to those candidates who require proportionally smaller amount of resources and
therefore more lives would be saved. If a group of patients needs smaller quantity of health benefits
proportionate to each of them, all members in that group are entitled to medical interventions.
Minimizing health care resources is equivalent to maximizing the number of health care recipients.
Hence, more patients are treated.

d. The parental role principle

• Gives priority to those who have the largest responsibility to dependents. The father with dependent
children would be given priority over a bachelor with no dependents.

e. The principle of general social value

• Gives priority to those believed to have the greatest general social worth thus leading to the good of
society. The municipal or city mayor has a right to medical treatment deemed greater than an
ordinary citizen.

2. The egalitarian alternatives:

• These represent maintaining or restoring the equality of the person in need.

a. The principle of saving no one

• Gives priority to no one because not all can be saved. If there are no enough resources for all who
need them, then no one should receive any.

b. The principle of medical neediness

• Gives priority to the candidates with the most pressing medical needs. Patients who are the most
seriously ill are the one who benefit from the limited health care resources.

c. The principle of general neediness

• Gives priority to the most helpless or generally neediest in an attempt to bring them as nearly as
possible to the level of well-being equal to that enjoyed by others. The poorest candidate would
receive the available resources.

d. The principle of first come, first serve basis

• Gives priority to those who arrive first. This principle is practical. It may apparently convey a
message of giving one what is his due as determined by the time he arrives. It also helps establish
order in the distribution of health care goods.

e. The principle of random selection

• Gives priority to those selected by chance or random. The candidate chosen in a lottery receives the
resources.
Health care burdens

• Burden may involve the necessary payment for the health benefits patients receive, their being
subjected, from time to time, to medical and experimental research, their donation of organs, and risks
involved in a recommended treatment. It is in accordance with the principle of justice to let patients
know both the due and undue burdens hat they are to undergo as they accept and submit for health
care intervention.

• DUE BURDEN- refers to a certain sense of pain or discomfort necessarily associated with one's
submission for health care intervention.

• Ex: buying medicines at the pharmacy as prescribed, the pain brought about by intravenous
insertion and injections, and others.

• UNDUE BURDEN- refers to a certain sense of pain or discomfort brought about by a certain medical,
experimental or surgical proceeding which is of no direct benefit to the subject. It may be deemed
unnecessary as far as the subject is concerned.

• Ex: donation of one's organ, paying for somebody else's hospital bill, and others. The principle of
cooperation

• Cooperation comes from the Latin word” cum” which means "with" and operari which means "to
work".

• COOPERATION is working with another in the performance of an action.

Various degrees of cooperation

• The degrees of cooperation may vary according to the gravity or essentiality of the shared act in the
performance of an evil action.

1. Formal and material

• FORMAL COOPERATION- consists of an explicit intention and willingness for the evil act. The one
formally cooperating categorically wills and intends the evil action.

• Ex: a medical director who wills and intends the evil act of contraception by means of hysterectomy
at the request of an interested party, by arranging with the members of the O.R. team as to the
operation and its schedule.

• MATERIAL COOPERATION- consists of an act other than the evil act itself but facilitates and
contributes to its achievement. The one materially cooperating may provide means apart from the evil
act itself which is used to carry out the performance of an evil act.

2. Direct and indirect

• DIRECT COOPERATION- consists of direct participation in the performance of an evil act. The one
directly cooperating gets involved by openly and straightforwardly taking part in the practice of an
evil action.

• INDIRECT COOPERATION- consists of an act that is not intimately connected with the performance
of an evil act as in formal and direct cooperation but whose effect may have an indirect bearing upon
it.

3. Proximate and remote

• PROXIMATE COOPERATION- consists of an act that is intimately linked with the performance of an
evil action due to its close bearing.

• REMOTE COOPERATION- consists of an act with a distant bearing upon or connection with the
execution of an evil act.
Moral rules governing cooperation

a. No one should formally and directly cooperate in the performance of an evil action.

b. If a reason sufficiently grave exists, material cooperation in the performance of an evil action may
be morally excused.

c. If the material cooperation is proximate, a reason sufficiently graver should exist so as to be morally
excused without which evil is incurred.

The principle of totality

• The whole implies the existence of its parts. The existence of its parts indicates the existence of the
whole.

• Parts as such should continuously be connected with the whole of which they are parts without
which they cease to be.

• However, if its state of condition and continuous existence as part pose a threat to do more harm
than good leading to the destruction of the whole and that there is no other means by which the
problem can be addressed, the principle of totality provides that it be removed and sacrificed for the
sake of the whole.

• Ex: a patient is admitted with a gangrenous leg. The attending doctor reasons out, based on scientific
medical basis, that there is no other way which the patient can be saved but to amputate the
gangrenous part of the patient's body.

• It is morally permissible for the doctor to do the amputation?

Principle of subsidiarity

• The principle of subsidiarity is a kind of sociological discipline adhered to and advocated by the
church. Its moral implication is embedded in its meaning.

• PRINCIPLE OF SUB SIDIARITY- means that what an individual, lower or smaller group can achieve
within his/her or its capacity should not be taken away and transmitted to the custody and
performance of a higher or bigger group.
Roles of the Nurse

 Coordinator
 Communicator
 Teacher
 Counselor
 Manager
 Leader
 Team player
 Motivator
 Delegator
 Critical thinker
 Innovator
 Researcher
 Advocate

Coordinator

 Coordinates and plans care

 Piece together fragmented care
 Prepares pt. for discharge
 Liaison in health

Communicator

 Establish rapport
 Establish therapeutic (helping) relationship
 Be aware of verbal & nonverbal communication
 Assertive communicator

Teacher

 Educate pt. to develop self-care abilities

 Provide knowledge to allow pt. to make informed decisions
 Demonstrate needed skills
 Promote health, prevent illness, restore health & facilitate coping

Teaching-Learner Process

Teaching-planned method to help someone learn

Learning- process by which an individual increases their knowledge or changes their behavior as a
result of an

Learning Domains

Cognitive learning- acquiring new knowledge

Psychomotor learning- acquiring a new physical skill

Affective learning- acquiring /changing values, feelings or attitudes experience

Developmental Considerations

 Children learn through play & experience

 Take into account their motor development along with their intellectual development
 Adolescents learn through their peers
 Take into account their intellectual, developmental, maturity and psychosocial development

Developmental considerations (androgogy)

• Adults- most must believe they need to learn before they are willing to learn

• Adults- bring life experiences as resources for learning

• Adults- believe learning should be useful immediately (rather than in the future). They Want
relevance!

• Adults - internally motivated and capable of self-regulation

Developmental Considerations (older adults)

• Assess for perceptual impairments

— Visual

— Auditory

— Memory

— Longer reaction times

AND ALSO

— Generational learning differences

Learning Styles

 Visual
 Auditory
 Tactile
 Combination
 Concrete Versus Abstract
 Active Versus Reflective
 Right Versus Left Brain
 Multiple Intelligences
o Verbal. Logical. Visual. Body. Musical. Inter or latrapersonal

Principles of teaching-learning

 Communication is important
 Thorough assessment of pt. learning needs and factors affecting their learning
 Include pt. in planning
 Use varied teaching strategies
 Utilize patient's previous life experiences
 Utilize nursing process
Barriers to Learning

 Language
 Cognitive level
 Lack of interest
 Cultural differences
 Literacy
 Health
 Stress

Utilizing Nursing Process

Assessment:

• Readiness to learn

• Ability to learn

• Learning strengths

• What do they know already??? • Do they WANT to LEARN?

Analysis:

• Knowledge deficit

Planning:

• Who, what. when. where & how. Determine whether cognitive, psychomotor, or affective goal. Write
with an "action verb"

• GET CLIENT COMMITMENT

Implementation:

• Include written, visual and tactile materials.

• Select strategy and methods: Content — Sequence — Timing Demonstration?Discussion?Role Play?

Evaluation: has pt. Learned/goal met? Return Demo

Counselor

• Assist and guide pt. in solving problems or making decisions

• Utilize the interpersonal (helping) relationship

• Nurse doesn't tell pt how to solve the problem Guides pt to decisions (self-determination)

• Utilize the nursing process

• "Could you just listen"

Manager

 Plans
 Organizes
 Directs
 Controls
 Delegates

Management Process

• Planning-Identify needs, dev. goals

• Organizing - Identify resources to meet goals

• Directing- leading others in reaching goals

• Control- monitoring ongoing evaluations

• Delegates

Delegation

• The five rights of delegation

— Right task

— Right person

— Right circumstances

— Right communication

— Right feedback

• Nurse who delegates maintains accountability

• Only the task is delegated NOT the accountability

• Who can you delegate tasks to?

ETHICAL RESEARCH IN NURSING

Ethics in nursing research can be defined as the act of moral principles which the researcher has to
follow while conducting nursing research to ensure the rights & welfare of individuals, groups or
community under study.

IMPORTANCE OF ETHICS IN NURSING RESEARCH

 Protect the vulnerable group & other study participants from harmful effects of the
experimental interventions.
 Participants are safeguarded from exploitation researchers.
 Establish risk — benefit ratio for the study subjects
 Ensure the fullest respect, dignity, privacy, disclose of information & fair treatment for study
subjects.
ETHICAL PRINCIPLE IN NURSING RESEARCH

 Principle of beneficence
 Principle of respect of human dignity
 Principle of justice

1. Principle of beneficence

 Establishing the positive risk benefit ratio, where the risk of the research should never exceed
expected benefits for people from knowledge generated by the research activity.
 A potential risk of the research study must be carefully assessed & participants are protected
from any harmful effect of research activity.
 In addition to physical harm, study subjects are also protected from expected adverse
psychological consequences caused by research study. For example, psychological or
emotional distress caused from self-discloser, introspection, fear of the unknown, or
interacting with a stranger.
 Research must be conducted by a scientifically qualified expert to avoid undue discomfort or
distress to study participants.
 Participants must be provided with maximum physical, psychological, social & religious
comfort & undue disturbance & time utilization of the subjects should be avoided.

2. Principle of respect of human dignity

 This principle of the ethics emphasizes on the freedom of choice, where participants have
right to accept or reject to be a part of the research study.
 Participants have full right to question the researcher for any additional information or
clarification of doubts.
 A fully informed consent must be taken from the participants. In case of the fetus, child,
psychological, neurological or physical inability to give informed consent; this can be obtained
from parents or legal guardians.
 The contents of an informed consent must include the following:
o Purpose of the research study.
o Procedural process & any intervention involved in the study.

3. Principle of justice

 This ethical principle directs the researchers to abide by the participant's right of fair
treatment & maintenance of privacy.
 The fair & non-discriminatory selection of the participants such as any risk & benefits will be
equally shared by study participants. Participant's selection should be based on research
requirement & not convenience, gullibility or compromised position

Nurse vs. Doctor: What's the Difference?

While both doctors and nurses hold patient-facing roles in the healthcare field, their level of
responsibility differs. For example:

• Doctors observe symptoms and form diagnoses, whereas nurses inform doctors by gathering and
reporting critical information.

• Doctors give orders and develop treatment plans, while nurses collaborate with a team of providers
to put those plans into practice.

• Doctors interpret reports such as lab results and X-rays; nurses help patients with activities of daily
living (ADLs).

• Doctors perform medical procedures; nurses serve as patient-advocates.

• It's worth noting that nurses have a much greater role in patient care than they did in days past, as
care providers have come to realize the extent of nurses' influence on health outcomes.

Relationships with Colleagues

CARING IS NOT JUST FOR PATIENTS

Caring may be a primary concept in nursing practice but it often does not get translated into colleague
relationships. Yet, our Code of Ethics clearly states that respect for persons extends to our
relationships with other staff as well as to our relationship with our patients. Disrespect, incivility,
and other methods of lateral violence can present overtly and covertly in the work environment.

PREVENTION AND PROACTIVITY

According to the American Nurses Association, nearly 50% of nurses have experienced some form of
bullying yet most of us stay silent about it. The Code of Ethics calls us to speak out when we
experience bullying and, in particular, when we see other colleagues being bullied. By silently
standing by, we become participants in the harassment.

Colleagues who are bullying others need to know that this practice is unethical and can be grounds for
intervention. Some State Boards of Nursing include adherence to the Code of Ethics for Nurses as a
part of their Nurse Practice Act. Hopefully, as awareness of the negative effects of lateral violence
grows, more correctional health care workplaces will initiate a Zero-Tolerance policy toward incivility
in staff relationships.

RELATIONSHIP RESPONSIBILITY

Our ethical responsibility toward healthy interpersonal relationships goes beyond the nurse-patient
relationship to include our interactions with other nurses, physicians, team members, and officers.
Poor work relationships lead to clinical errors, increased costs, and loss of quality staff.

It would be difficult for Lola to change her work environment as a new staff member, but it may only
take one staff member coming forward to address the issue of incivility to begin to make a difference.
Besides seeking management support to change the work environment, each of us can seek to stop the
horizontal violence.

•Don't listen to or tolerate blame, rumors, and gossip

•Encourage and perform acts of kindness

•Look for common ground in a conflict

•Encourage forgiveness

•Be a safe person to ask questions of or discuss a problem with

Self-care for Nurses

Nurses are caring individuals, which is why many are naturally drawn to the profession. Although the
work is rewarding, nurses often face stressful workdays, long hours and unpredictable schedules.

With the coronavirus pandemic, nurses worldwide have been responding to stressful and difficult
situations for months with no respite. While this work is heroic, meaningful and necessary, self-care
for nurses is more important to avoid burnout.

In this article, we'll discuss common causes of nurse burnout and offer guidance on prioritizing self-
care for nurses.
What Is Self-Care?

 According to the World Health Organization, "self-care is what people do for themselves to
establish and maintain health and prevent and deal with illness."
 Self-care is the act of caring for one's self in a holistic, intentional and important way. It means
making sure your needs are being met intellectually, emotionally, physically, relationally and
spiritually.
 Sometimes the focus on "self" causes self-care to be misinterpreted as a selfish or egotistical
endeavor. Shouldn't I care more about the other people in my life? And as a nurse, shouldn't I be
focused first and foremost on my patients?
 While these concerns stem from a good place, self-care for nurses is not selfish. Rather, it is self-
preservation and allows you to have more energy for others both at work and in your personal life.

What kind of stressor is common for nurses?

Prioritizing self-care is difficult when you work in an ever-evolving, fast paced environment. It's especially
challenging when you're expected to consistently work at your peak performance for long periods of time.
Everyday job-related stressors in nursing include:

•Short-staffed environments

•Ambiguity in role expectations

•Minimal role support

•Challenging management situations

Nurses also endure emotionally and psychologically tolling situations that may include witnessing suffering
and death of patients and being around loved ones who are mourning.

What are some examples of self-care for nurses?

Practice Mindfulness Meditation

Mindfulness meditation has become a popular tool for managing stress and fostering health. It entails
being "mindful" of your surroundings, feelings and thoughts.

Breathe Deeply

Deep breathing is an effective way to sneak in self-care during shifts.

Participate in Physical Activity

Exercise is another effective practice of self-care for nurses. It keeps you physically healthy, extends your
lifespan and boosts your energy. It also helps maintain mental health.

Practice Good Sleep Hygiene

Getting uninterrupted sleep—and enough of it— is essential for promoting physical health, mental clarity
and positive mood. Setting aside eight hours each night is one way to practice self-care for nurses.

Schedule Leisure and Recreation

Scheduling leisure and recreation during your week is an effective and enjoyable way to practice self-care.
Take More Breaks

As a nurse, it's difficult to take care of other responsibilities after a 12-hour shift. You may prefer catching
up on errands and housework on your days off.

Seek Professional Help When Needed