HEALTH CARE ETHICS

MODULE 5

DOCUMENTATION & HEALTHCARE RECORDS / ETHICAL CONSIDERATIONS

IN LEADERSHIP & MANAGEMENT

5.1 GUIDELINES & PROTOCOLS IN DOCUMENTATION & HEALTH CARE

RECORD
DOCUMENTATION
 Documentation is any written or electronically generated information about a
client that describes the status, care or services provided to that client.
 Through documentation, you communicate observations, decisions, actions and
outcomes of these actions for clients, demonstrating the nursing process.

WHY DO WE DOCUMENT?
 It is necessary for:
1. Communication between health care providers
2. Meeting legislative requirements (reimbursements)
3. Quality improvement (auditing health agencies)
4. Research
5. Legal proof of healthcare provided (legal proof)
6. Education
7. Planning client care
8. Health care analysis

QUALITY DOCUMENTATION
 The elements of the nursing process are evident in our documentation.
 Indicators:
1. Reflects the application of the nursing process.
2. Plan of care – client’s needs, circumstances, preferences, values, abilities &
culture, & supports the client self-management of care.
3. Implementation of intervention.
4. Evaluation & modification of care plan.
5. Critical inquiry – critical thinking & clinical judgement skills
6. Consultations & referrals

COMMON DOCUMENTATION SYSTEMS

1. Narrative charting, source-oriented charting, problem-oriented charting
(soap/soapie)
2. Problem-intervention-evaluation charting (pie)
3. Focus charting (darp-data, action, response, plan)
4. Critical pathways
5. Charting by exception – only abnormal or significant findings or exceptions to
norms are recoded
6. Computerized documents

FUNDAMENTAL ASPECTS OF DOCUMENTATION

F = factual
A = accurate
C = concise, complete, confidentialty
T = timely
Others: Organization, Currentness
WHAT IS HEALTH CARE RECORD?
RECORD - A record is a permanent written communication that documents
information relevant to a client’s health care management. A record is a clinical,
scientific, administrative and legal document relating to the nursing care given to the
individual family or community.

MAINTAINING SAFE & SECURE RECORDS

1. Storing records
2. Security
3. Protecting client information - especially use of devices (phone, text or email)
4. Transporting confidential information
5. Client’s access to records

PURPOSE OF KEEPING RECORDS

1. Communication
2. Aids to diagnosis
3. Education
4. Documentation of continuity
5. Research
6. Legal documentation
7. Individual case study

5.2 ETHICAL CONSIDERATIONS IN NURSRING LEADERSHIP AND

MANAGEMENT
 NURSING MANAGEMENT. The role of a nurse manager to control, coordinate,
supervise, and lead the nurses under him/her to provide quality nursing care.
 NURSING ADMINISTRATION. A specialty in nursing that integrates nursing
science, business, principles, organizational behavior and resource management
to prepare nurses to participate as full partners in managing and leading health
care organization.
 NURSING ADMINISTRATOR. Has a degree in nursing administration. He/she
will be trained in organization development, management principles, employee
relations and finance, which will help him/her to supervise and manage his/her
team effectively as well as help in policy planning for the health institution.

5.3 ETHICAL AND LEGAL ISSUES IN MANAGEMENT

A. HANDLING CONFLICTS AMONG THE STAFF, BETWEEN STAFF AND
MANAGEMENT, AND VICE VERSA
‒ The nurse administrator should solve the issues according to the nursing
ethical decision-making model;
‒ Should not be favoring anybody and the solution given should be reasonable
to both the parties at conflict;
‒ Should be skillful in tackling the issues exhibiting the qualities of justice,
veracity, and beneficence to the affected people in the conflicts.
‒ THIRONA AND HALLO RAW MORAL MODEL FOR ETHICAL DECISION
MAKING
1. M: Identify the members involved in ethical dilemma.
2. O: Outline or Delimit the Possible Options Clearly.
3. R: Resolve the Existing Dilemma.
4. A: Act or Implement the Chosen Action.
5. L: Look back or Evaluate/Take up a Feedback.
B. ‘WHISTLE-BLOWING’ ISSUES
‒ Whistle-blowers are those who alert or disclose internal or external danger,
malpractice, corruption, bribery, theft, fraud, negligence, resource wastage,
 misinterpretation, and safety volition done by an employee or the authorities
of management to the public and the concerned authorities.
‒ Anyone can make mistakes, but we have to follow certain ethical principles
to regulate the behavior of the workers.
C. UNETHICAL BEHAVIOR
‒ Examples: Libel, slander, negligence, malpractice, ill-treating patients, theft,
fraud work, bribery, wasting the hospital resource by staff, validating safety
measures, and misinterpretation of patient results

ETHICAL ISSUES IN PRACTICE

A. LIBEL. The false and harmful written reports given by the nurse with an intention
of hurting the colleague’s reputation in nursing practice.
B. SLANDER. The false and harmful oral report about one nurse given by another
nurse with an intention to hurt his/her reputation in nursing practice.
C. MALPRACTICE. The failure in performing professional duties or the lack of skill
or practice that causes injury or harm to the client or patient.
D. NEGLIGENCE. The failure of the nurse to administer or provide nursing care in
the right time to the right patient at the right place; it is also called
CARELESSNESS.
E. BRIBERY AND CORRUPTION. The act of violating the legal and medical laws
towards the patient care, such as performing illegal abortion by an untrained
nurse and getting some gift or money as bribe from the affected patient.
F. FORGERY AND FRAUD. Getting the signature from the patient in the informed
consent form is an important procedure. If the nurse signs instead of the patient
or if he/she signs in the register for another nurse, it is called forgery or fraud.
G. WASTING HOSPITAL RESOURCES
H. THEFT or STEALING
I. MISINTERPRETATION. Healthcare providers such as nurses or co-workers
should not confirm the diagnosis before the physician confirms and informs the
patient.
J. VIOLATING THE SAFETY NEEDS such as slippery floors; faulty and non-
repaired apparatus (e.g. defibrillator); faulty water heater; absence of side rails in
the bed or side rails not fixed properly; presence of inflammable substance
beside the O2 cylinder; presence of stray animals like dogs, cats, etc.;
inadequate lighting in the wards and bathrooms; and, no washing facilities or hot
water supplies when needed.
K. CRIMINAL ACTS or TORTS. A nurse should never indulge in a forbidden act
that is punishable by law. For example, a nurse may try to induce labor in a
pregnant woman admitted for normal delivery even before the warning signs of
labor start to deliver the child according to astrology and inject the drug oxytocin
IV without diluting it.
L. SAFETY OF WHISTLE-BLOWERS. The whistle blowers are protected from
being harmed by the person who is being accused for wrongdoing (e.g. nurse,
sweeper, attender, doctor). The accused person is answerable to the law for
his/her actions.

DEPENDENT VS. INDEPENDENT FUNCTIONING (Some issues faced by a Nurse

Administrator)
1. A NURSE ADMINISTRATOR is never allowed to function independently. He/she
is always dependent on the management authorities in taking any decision.
Though a nurse administrator is trained theoretically to function independently,
he/she is not allowed to practice it in real situations, such as staffing.
2. One of the main functions of a nurse administrator is STAFFING, which means
selecting and recruiting the staff as per qualification, experience and requirement
in the hospital. However, the nurse administrator cannot decide any appointment
 without involving management authorities. There is no prime importance given to
the nurse administrator in decision-making regarding the appointment of staff or
fixing the salary.
3. Apart from the nurses, so many others are involved in the planning of policies,
rules, and regulations about nursing activities. A nurse needs to totally depend
upon the management authorities to carry out the functions. Nurses are
considered inferior and are thought to not make any difference by becoming a
nurse leader or administrator.
4. In delegation of any responsibilities to other co-workers, a nurse administrator or
leader needs the approval of higher authorities, which degrades his/her respect
among the co-workers. Most of the times, only the quantity of work is valued and
not the quality of nursing care.
5. The nurse administrator is supposed to coordinate the work of the health team
and take decisions regarding holidays, offs, and duty schedules. However, there
is some interference from the hospital management. If they prefer the work of
certain staff they ask personally to appoint the same nurse for continuous duty or
night shifts. A nurse administrator should shuffle the staff and classify the duty
schedule as per patient classification system, but he/she is forced to give
preference to somebody over others in order to fulfill the wishes of the
management authorities.
6. The reports given by the nurse administrator is not valued by the management
authorities, for example, action is not taken regarding the reports of staff
inadequacy in the ward, need of supplies and equipment, staff salary or
increment, or improving the working environment. These reports reach the
management authorities’ desk but are never considered or welcomed and
sometimes are thrown as trash without even being opened.
7. In the case of budgeting, only the plan is given by the nurse manager but he/she
has not control over its implementation. The nurse administrator is not allowed to
handle any money. The management authorities never consider a nurse to be
skilled enough to implement budgeting activities.

ETHICAL ISSUES FACED DURING RECRUITMENT

1. Procuring registration by false means
2. Procuring the certificate in another person’s name
3. Use of fake name and registration number by a nursing person
4. Representation of registrant as a medical practitioner

RIGHTS OF A NURSE (according to the English Law in India)

1. Right to sue for salary or fees.
2. Right of a nurse to add title and degree to show his/her qualification in nursing
and the position.
3. Right to get respect from members of health team.
4. Right to participate in all health events in the hospital.
5. Right to whistle-blow or complain about unethical practice to the concerned
authorities with evidence.
6. Right to get all facilities to provide good nursing care.
7. Right to take rest, holidays, and offs as per the duty roster.
8. Right to participate in in-service and continuing education.

FUNDAMENTAL DUTIES OF A NURSE

1. Use adequate knowledge and skill to treat the patients.
2. Continue the therapeutic relationship with a patient effectively until the patient is
discharged.
3. Never ignore a call and pay attention to all the needs of the patients.
4. As per INDIAN PENAL CODE, keep all poisonous drugs safely labelled and
marked.
5. Keep all documents regarding the patient safe and confidential.
6. Report and record the abnormalities of a patient on time; this prevents incidence
of legal and ethical issues and protects the nurse.

ROLE OF NURSE ADMINISTRATORS

1. PREPARE SUCCESS MODEL (Good Quality Patient Care, Good Patient
Satisfaction, and Job Satisfaction)
2. ACCREDITATIONS
3. NURSING AUDIT. A nurse should organize the nursing audit for evaluating the
total functioning of the nursing activities; this will help to check and ensure the
quality of care given to the patients. Based on the audit, feedback is given to
improve the nursing activity of the nurses.
4. IMPROVING NURSING SKILLS THROUGH EVIDENCE-BASED PRACTICE.
5. BE A GOOD ADMINISTRATOR by following the Code of Ethics and Ethical
Principles and must inculcate to all nurses and those in the administration and
management.
6. EARN THE RESPECT OF THE SOCIETY by planning excellent modes and
strategies to improve the patient care unit in the hospital and community and
should set up emergency and disaster management unit.
7. STANDARDIZE NURSING PRACTICE AND PROFESSION. Improve the
nursing care by applying the principles of human resource management,
recruiting staff with good experience and qualification, ensuring continuance of
such good staff by giving promotions, increment, and positive reinforcement with
good plans for superannuation, and providing standardizing protocol for selected
nursing staff at different levels as per the requirements and demands based on
the patient classification system. The staff should be given standard job
description to carry out nursing care responsibilities. Staff welfare department
must also be maintained; this should take care of staff welfare activities to
ensure that the nurse is satisfied with his/her job and strives to provide high
quality care.
8. CONTROL AND MANAGE THE CO-WORKERS WITH FULL COORDINATION.
The manager should control the activities of the subordinates by doing regular
nursing rounds and should exchange nursing knowledge with other staff to
improve patient care. A NURSE MANAGER must supervise, direct and lead the
subordinates to ensure a unity of command and direction with a goal to improve
quality care. The talented subordinates who are good at their work must be
appreciated and they must be sustained by giving them rewards, good words of
appreciation in front of others, increment, etc.
9. RESPECT THE SUBORDINATES RIGHTS (e.g. right to be informed about rules
and regulations of hospital management, right to take decision in provision of
patient care, right to refuse the job, and right to have personal privacy and
confidentiality).
10. BENEFICENCE AND NON-MALEFICENCE TO THE STAFF AND THE
PATIENTS (e.g. planning proper duty schedule; no staff is overloaded or
underloaded with work and has adequate offs).
11. JUSTICE AND VERACITY. A nurse administrator should be fair and treat all the
nurses and subordinates equally without any discrimination or difference, without
giving preference to only certain nurses. He/she must be truthful, honest,
punctual, polite, and humble and at the same time assertive, but not passive or
aggressive.
12. FIDELITY AND CONFIDENTIALITY. The nurse administrator needs to behave
in such a way that he/she gains the trust of and develops a faithful relationship
with the management, subordinates and patients. He/she plans the standards
 and protocols for the staff, does staffing, plans patient care strategies, organizes
the human resource management process, does budgeting for the entire
management process focusing on cost-benefit analysis, which plays an
important role in the material management, to coordinate and manage the
equipment and supplies needed for the hospital and patient care, does the
supervision to control the staff, retains good-working staff, and provides training
for the staff whose performance is not up to the expected standards.
13. ACCOUNTABILITY AND RESPONSIBILITY. A nurse administrator is
responsible and answerable for not only his/her mistakes but also for that of the
subordinates. He/she cannot just blame the subordinate but is also answerable
to such kind of nursing action by the subordinates. Hence, controlled supervision
of the subordinates, frequent nursing rounds and patient visit schedules, and a
good evaluation system help the nurse administrators to be ethically safe and
also be responsible and accountable towards the nursing care.

5.4 MORAL DECISION MAKING

WHAT IS A MORAL PROBLEM?
 (To be distinguished from an ordinary problem) is a moral matter or issue that is
difficult to deal with, solve or overcome and which stands in need of a moral
solution.
 Can range from the relatively ‘simple’ to the extraordinarily complex, and can
cause varying degrees of perplexity and emotional distress in those who
encounter them.
 Nurses must be able to distinguish moral problems from other sorts of (non-
moral) problems (e.g. legal and clinical problems), and to distinguish different
types of moral problems from each other.

HOW ARE WE TO DISTINGUISH A BONA FIDE MORAL PROBLEM FROM

OTHER KINDS OF (NON-MORAL) PROBLEMS?
 It is generally accepted that something involves a (human) moral/ethical problem
where it has as its central concern:
‒ the promotion and protection of people’s genuine wellbeing and welfare
(including their interests in not suffering unnecessarily) » example: palliative
sedation
‒ responding justly to the genuine needs and significant interests of different
people. NEEDS VS. WANTS
‒ determining and justifying what constitutes right and wrong conduct in a
given situation.

IDENTIFYING DIFFERENT KINDS OF MORAL PROBLEMS

A. MORAL UNPREPAREDNESS AND INCOMPETENCE
 The nurse (or other health professional) may lack the requisite moral
knowledge (e.g. of moral theories, codes and guidelines), skills and
experience (e.g. of ethical reasoning and decision-making, how to interpret
and apply ethical principles and standards of conduct), ‘right attitude’ (e.g.
‘excellence in character’, virtue), and moral wisdom (e.g. moral insight,
perception, astuteness) otherwise necessary to be able to deal with the
complexities of the ethical issues in the situation at hand.
 Examples:
1. A nurse who is not educated in the complexities of, say, intensive care
nursing, but who is nevertheless sent to ‘help out’ and care for a
ventilated patient in intensive care, would not only be inadequate in this
role, but could even be dangerous.
 2. Nursing care was negligent that a patient developed severe decubitus
ulcers between her knees, which became ‘glued’ together as though
they had been skin-grafted.

B. MORAL BLINDNESS
 A morally blind nurse (or health professional) is someone who, upon
encountering a moral problem, simply does not see it as a moral problem.
Instead, they may perceive it as either clinical or a technical problem.
 Health professionals (including nurses) are sometimes so conditioned by the
‘CLINICAL IMAGERY’ (context) around them that, when they do encounter
a bona fide moral problem, it tends to be perceived not as a moral problem,
but as a clinical or a technical problem, and, as such, one requiring a clinical
solution, not a moral solution.
 Some health professionals have a healthy perception of the alternating
moral-clinical images depicted by a given scenario; others, however, remain
stuck with a dominant clinical image and do not see the alternative moral
image, which for them is less discernible.
 The best way to achieve a moral shift in perception is by appropriate ethics
education and reflective ethical practice.
C. MORAL INDIFFERENCE AND INSENSITIVITY
 MORAL INDIFFERENCE is characterized by an unconcerned or
uninterested attitude towards demands to be moral; in short, it assumes the
attitude of ‘Why bother to be moral?’
 MORAL INSENSITIVITY is the failure to respond to the suffering of others,
in refusing to understand others, and in ‘the causal turning away of one’s
ethical gaze’ — in other words, assuming the stance of a morally passive
bystander.
 Examples:
1. A nurse is unconcerned about and uninterested in alleviating a patient’s
pain.
2. A nurse is unconcerned about and uninterested in any form of violation
of patient’s rights.
3. Nurses who are ‘conformist’ in their practice and feel hindered by
‘dominance within the medical profession, a stressful work environment,
insufficient resources, time and workload pressures’.
D. AMORALISM
 Amoralism is an absence of moral concern and a rejection of morality
altogether.
 An AMORAL PERSON is someone who refrains from making moral
judgments and who typically rejects being bound by any morality’s
behavioral prescriptions and proscriptions.
 The only recourse in dealing with the amoral health professional would be to
appeal to non-moral censuring mechanisms such as legal and/or
professional disciplinary measures.
 Examples:
1. An amoral nurse rejects that he or she has a moral duty to uphold a
patient’s rights.
2. An amoral nurse claims that it does not make any sense even to speak
of things like a patient’s rights since moral language itself has no
meaning.
E. IMMORALISM
 Immoral conduct (also termed unethical conduct) is any act involving a
deliberate violation of accepted or agreed ethical standards.
 Immoralism can encompass both MORAL TURPITUDE and MORAL
DELINQUENCY.
 MORAL TURPITUDE is anything done knowingly contrary to justice,
honesty, principle, or good morals … [or] an act of baseness, vileness or
depravity in the private or social duties which a man owes to his fellow man
or to society in general. The term implies something immoral in itself.
 MORAL DELINQUENCY refers to any act involving moral negligence or a
dereliction of moral duty.
 Examples:
1. The deliberate theft of patients’ and/or clients’ money for personal use
2. The sexual, verbal and physical abuse of patients/clients
3. Xenophobic behaviors (including racism, sexism, ageism, homophobia
and a range of other unjust discriminatory behaviors)
4. Participation in unscrupulous research practices
5. A nurse who knowingly and recklessly breaches a patient’s
confidentiality could have committed an unethical act even if the breach
in question did not result in any significant moral harm to the patient.
F. MORAL COMPLACENCY
 A general unwillingness to accept that one’s moral opinions may be
mistaken.
 Can be remedied by moral education, moral consciousness raising and
reflective practice in an ethical environment that has organizational support.
G. MORAL FANATICISM
 The moral fanatic is someone who is thoroughly wedded to certain ideals
and uncritically and unreflectingly makes moral judgments according to them.
 Examples:
1. The maintenance of absolute confidentiality, even though harm might be
caused as a result.
2. A doctor or a nurse forcing unwanted information on a patient in the
fanatical belief that all patients ‘must be told the truth’ – even if the
patient in question has specifically requested not to receive the
information, and the imposition of the unwanted information on the
patient can be shown to be a ‘gratuitous and harmful representation of
the moral foundations for respect for autonomy’.
H. MORAL DISAGREEMENTS AND CONFLICTS
 Two fundamental types of Moral Disagreement:
1. Internal Moral Disagreement
2. Radical Moral Disagreement
 THREE FORMS OF INTERNAL MORAL DISAGREEMENT:
1. Involves a fundamental conflict about the force or priority of accepted
moral standards. » DISAGREEMENT IN ATTITUDE. Example: Nurse A
might favor (pro-attitude) telling the truth to patient X about a pessimistic
medical diagnosis and prognosis. Nurse B, on the other hand, might not
favor (con-attitude) telling the truth to patient X about this diagnosis and
prognosis, and prefer a con-attitude to avoid unnecessary suffering.
2. Centers on what are to count as acceptable exceptions and limitations to
otherwise mutually agreed moral standards. » DISAGREEMENT IN
INTERPRETATION. Example: Two nurses agree that patients’ rights
should not be violated. Nurse A, in situations involving violations of
patients’ rights, a nurse should act – even if this means threatening the
nurse’s job security. Nurse B agrees that nurses should in principle act
to prevent a patient’s rights from being violated, but disagree that nurses
should do so if they stand to lose their jobs as a result. What these
nurses are essentially disagreeing about is not the moral standard per
se, but about when morally relevant considerations can be and cannot
be overridden by self-interest.
 3. Centers on the selection and applicability of accepted ethical standards
» DISAGREEMENT ON THE MORAL RELEVANCE. Example: Two
nurses may agree that killing an innocent human being is wrong. They
may disagree, however, that abortion is wrong. Nurse A argues that
since the fetus is not a human being, abortion does not entail the killing
of an innocent human being and therefore is not wrong. Nurse B argues
that the fetus is a human being, and therefore abortion, since it entails
killing an innocent human being, is absolutely morally wrong.
 TWO TYPES OF RADICAL MORAL DISAGREEMENT:
1. PARTIAL RADICAL MORAL DISAGREEMENT dissenting parties might
agree on some criteria of relevance but not all. Example on Partial
Radical Moral Disagreement:
‒ A nurse might argue that directly killing terminally and chronically ill
patients with a lethal injection is morally wrong, whereas merely
letting nature take its course or letting patients die is not morally
wrong.
‒ Another nurse might agree that directly killing terminally and
chronically ill patients is wrong, but thoroughly disagree that merely
letting patients die is less morally offensive.
2. TOTAL RADICAL MORAL DISAGREEMENT disputants do not agree
on any criteria of relevance, and do not share any basic moral principles.
I. MORAL DILEMMAS
 What is a DILEMMA? A situation requiring choice between what seem to be
two equally desirable or undesirable alternatives; it may also be described as
an awful feeling of being stuck.
 What then is a moral dilemma? It can occur in the form of logical
incompatibility between two different moral principles (e.g. respect for the
sanctity of life vs. non-maleficence). It involves competing moral duties and
entails competing and conflicting interests.
 EXAMPLE ON ‘COMPETING MORAL DUTIES’
1. A nurse working in a specialized unit is assigned a patient with a known
history of drug addiction, and is instructed to chaperone the patient
when there are visitors to make sure that illicit drugs are not ‘slipped in’.
The nurse, however, believes that the duty to protect this patient from
harm (such as might occur from receiving illicit drugs) competes with the
duty to respect the patient’s privacy. The question for the nurse in this
scenario is: Which duty should I fulfill?
 EXAMPLE ON ‘COMPETING AND CONFLICTING INTERESTS’
1. A clinical teacher on clinical placement at a residential care home was
informed by a student that an elderly demented resident had been
physically and verbally abused by one of the ward’s permanent staff
members, as witnessed by the student. The clinical teacher was
temporarily undecided about what to do. It was a very serious matter –
and, indeed, a very serious accusation – but it would be difficult to prove.
If the incident was not reported to the home’s nursing administrator, the
staff member concerned would probably continue to abuse the home’s
residents. If the incident was reported, there was a risk that the interests
of both students and the school of nursing could be undermined (The
home’s administrator might, for example, refuse to continue allowing
students to be placed at the home for the purposes of gaining clinical
experience).
J. ‘MORAL DISTRESS’
 INITIAL MORAL DISTRESS is characterized by feelings of frustration, anger,
anxiety and guilt when faced with perceived institutional obstacles and
interpersonal conflict about values, and
  REACTIVE MORAL DISTRESS (also called moral residue) occurs when an
individual fails to act on their initial moral distress and is left with ‘residue’ or
lingering distress.
 Three (3) root cause of moral distress in nursing:
1. CLINICAL SITUATIONS (e.g. controversial end-of-life decisions;
inadequate informed consent; working with incompetent practitioners);
2. INTERNAL CONSTRAINTS (e.g. nurses’ lack of moral competencies;
perceived lack of autonomy and powerlessness to act; lack of
knowledge and understanding of the full situation); and
3. EXTERNAL CONSTRAINTS (e.g. hierarchies within the health care
system; inadequate communication among team members; hospital
policies and priorities that conflict with patient care needs)
 CONSEQUENCES:
1. threat to the integrity of nurses and the quality of care
2. nurse job dissatisfaction
3. burnout
4. untimely abandoning of their positions and even their profession
altogether

MAKING MORAL DECISIONS

 DECISION is a judgment, conclusion or resolution reached or given; it may also
be defined as the making up of one’s mind.
 MORAL DECISION is a moral judgment, moral conclusion or moral resolution
reached or given about what constitutes ‘right’ and ‘wrong’ conduct.
 MORAL DECISION-MAKING is fundamentally concerned with reconciling moral
disagreements between disputing parties, each of whom may hold equally valid
moral viewpoints and may reach different yet reasonable conclusions on what
constitutes ‘right’ and ‘wrong’ conduct in a given context.

3 ELEMENTS OF GOOD INDIVIDUAL DECISION-MAKING

1. SELF-KNOWLEDGE (feelings, motives, inclinations and interests both enlighten
and obscure moral understanding)
2. KNOWLEDGE OF MORAL THEORIES AND TRADITIONS (self-understanding
and reflectiveness about the societal and cultural contexts of our decisions)
3. CULTURAL PERCEPTION (the reflective self, the interpreted culture, and the
contributions of moral theory together with an individual and collective [culturally
constructed] vision of human good)

PROCESS FOR MAKING MORAL DECISIONS

1. ASSESS the situation (including making a diligent appraisal of the relevant facts
of the matter and operating values in the situation at issue)
2. DIAGNOSE or identify the moral problem(s) at hand
3. Set moral goals and PLAN an appropriate moral course of action to address the
moral problems identified
4. IMPLEMENT the plan of moral action
5. EVALUATE the moral outcomes of the action implemented

WHAT IS CONSCIENCE?
 The practical judgment that determines that an act is good, therefore to be done,
and evil, therefore to be avoided.
 Etymologically » Latin: con and science = WITH KNOWLEDGE
 An act of conscience is therefore an act that has basis on some knowledge.
1. RIGHT CONSCIENCE is the judgment of a person who—on the basis of
true principles—decides, in conformity with the truth, that a particular action
is licit or illicit.
 2. ERRONEOUS CONSCIENCE is the judgment of a person who—on the
basis of false principles that are thought to be true—mistakenly determines
that a particular action is licit or illicit.
3. CERTAIN CONSCIENCE is the judgment about the goodness or evil of a
particular action that is made without fear of being mistaken. This type of
conscience must always be followed.
4. DOUBTFUL CONSCIENCE Is the suspension of judgment on the moral
goodness or evil of an action because the intellect cannot see clearly
whether it is good or bad. A doubtful conscience cannot be followed if it
entails the possibility of doing something bad; the doubt must be resolved
first.
5. SCRUPULOUS CONSCIENCE decides that an action is sinful based on
weak or insufficient reasons. The symptoms of a scrupulous conscience are:
‒ an excessive anxiety over the sufficiency of good actions and, especially,
over the validity of past confessions,
‒ fastidious scrutinizing of unnecessary circumstances, especially as
regards internal sins (thoughts, desires),
‒ obstinacy in one’s opinion, which leads to mistrust one’s confessor and
to go from one confessor to another.
6. LAX CONSCIENCE judges without sufficient reason that a certain action is
not, or is only slightly, sinful.

FORMATION OF CONSCIENCE
 Diligently learning the laws of the moral life (through spiritual formation), just as
the referee must be interested in knowing well the rules of the game;
 Seeking expert advice in difficult cases (spiritual direction), just as doctors hold
consultations when the diagnosis of a serious illness is not clear;
 Asking God for light (prayer);
 Removing the obstacles to right judgment, such as habitual moral disorder, or
bad habits (ascetical struggle); and
 Personal examination of conscience

THE PRINCIPLE OF WELL-INFORMED CONSCIENCE

 This principle states that “to have a good judgment of conscience, one is obliged
to form it diligently in accordance with some reasonable processes so that one
arrives at a right moral decision.”
a. Inform themselves as fully as possible about the facts of the case and about
the attendant ethical norms (Principles of Bioethics).
b. Form a morally certain judgment of conscience on the basis of this
information.
c. Act according to this well-formed judgment of conscience.
d. Be responsible for actions performed.
 Nurses will encounter many complex moral problems in the course of their work.
To be effective in dealing with these problems and preventing the kinds of moral
harms that can follow as a consequence of them, it is imperative that nurses
have an informed knowledge and understanding of the nature of moral problems,
the various forms in which they can manifest, and the kinds of processes that
can be used for dealing with them effectively (e.g. conscientious objection,
whistleblowing, etc.).

5.5 MEANING AND SERVICE VALUE OF MEDICAL CARE

DEFINITION OF JUSTICE
 Three (3) Essential Properties of Justice
a. Justice always refer TO ANOTHER PERSON. Strictly speaking, there are no
obligations of justice toward oneself.
 b. The object of justice is not a free gift, but something that is STRICTLY DUE.
c. Justice does not demand an approximate compensation, but only what is
EXACTLY DUE, neither more nor less.
SUBJECTIVE PARTS OF JUSTICE
 Division according to Aristotle and Saint Thomas. The proper way to classify
virtues is according to their primary end, not according to the persons to whom
they are directed.
1. LEGAL, GENERAL, or SOCIAL JUSTICE. Directly and primarily aimed at
the common good. These terms are taken here as equivalent. » taxes,
cooperation in public affairs
2. PARTICULAR JUSTICE. Directed to the private good.
a. COMMUTATIVE JUSTICE (duties of an individual toward other
individuals) » buying and selling
b. DISTRIBUTIVE JUSTICE (duties of the community toward the individual)
» allocation of health resources
 Division according to Modern Authors
1. LEGAL JUSTICE (duties of the individual toward the community)
2. DISTRIBUTIVE JUSTICE (duties of the community toward the individual)
3. COMMUTATIVE JUSTICE (duties of an individual toward other individuals)

5.6 MICRO- AND MACRO-ALLOCATION OF HEALTH CARE

 MACRO-ALLOCATION is usually the state legislatures, insurance companies,
private foundations, and health organizations as society attempts to determine
how much should be expended and what kinds of goods and services will be
made available.
‒ What kinds of health care will be available?
‒ Who will get it, and on what basis?
‒ How will the costs be distributed?
‒ Who will deliver the services?
‒ Who controls these issues?
 MICRO-ALLOCATION is the more personal determination of who will receive
scarce resources, such as intensive-care beds, advanced technology, or organ
transplants.

CH. I SEC. 2 - DECLARATION OF PRINCIPLES AND POLICIES

a. An integrated and comprehensive approach to ensure that all Filipinos are health
literate, provided with healthy living conditions, and protected from hazards and
risks that could affect their health;
b. A health care model that provides all Filipinos access to a comprehensive set of
quality and cost-effective, promotive, preventive, curative, rehabilitative and
palliative health services without causing financial hardship, and prioritizes the
needs of the population who cannot afford such services;
c. A framework that fosters a whole-of-system, whole-of-government, and whole-of-
society approach in the development, implementation, monitoring, and
evaluation of health policies, programs and plans; and
d. A people-oriented approach for the delivery of health services that is centered on
people’s needs and well-being, and cognizant of the differences in culture,
values, and beliefs.

CH. I SEC. 3 - GENERAL OBJECTIVES

a. Progressively realize universal health care in the country through a systemic
approach and clear delineation of roles of key agencies and stakeholders
towards better performance in the health system; and
b. Ensure that all Filipinos are guaranteed equitable access to quality and
affordable health care goods and services, and protected against financial risk.
CH. II SEC. 5 ~ UNIVERSAL HEALTH CARE (UHC): POPULATION COVERAGE
a. Every Filipino citizen shall be automatically included into the National Health
Insurance Program (NHIP), hereinafter referred to as the PROGRAM.

CH. II SEC. 6 ~ UNIVERSAL HEALTH CARE (UHC): SERVICE COVERAGE

a. Every Filipino shall be granted immediate eligibility and access to preventive,
promotive, curative, rehabilitative, and palliative care for medical, dental, mental
and emergency health services, delivered either as population-based or
individual-based health services: Provided, That the goods and services to be
included shall be determined through a fair and transparent HEALTH
TECHNOLOGY ASSESSMENT (HTA) process;
b. Within two (2) years from the effectivity of this Act, PHILHEALTH shall
implement a comprehensive outpatient benefit including outpatient drug benefit
and emergency medical services in accordance with the recommendations of the
HEALTH TECHNOLOGY ASSESSMENT COUNCIL (HTAC)…
c. The DOH and the LGUs shall endeavor to provide a health care delivery system
that will afford every Filipino a primary care provider that would act as the
navigator, coordinator, and initial and continuing point of contact in the health
care delivery system: Provided, That except in emergency or serious cases and
when proximity is a concern, access to higher levels of care shall be coordinated
by the primary care provider; and
d. Every Filipino shall register with a public or private primary care provider of
choice. The DOH shall promulgate the guidelines on the licensing of primary
care providers and the registration of every Filipino to a primary care provider.

CH. II SEC. 7 ~ UNIVERSAL HEALTH CARE (UHC): FINANCIAL COVERAGE

a. Population-based health services shall be financed by the NATIONAL
GOVERNMENT through the DOH and provided free of charge at point of service
for all Filipinos. The National Government shall support LGUs in the financing of
capital investments and provision of population-based interventions.
b. Individual-based health services shall be financed primarily through prepayment
mechanisms such as social health insurance, private health insurance, and
Health Maintenance Organization (HMO) plans to ensure predictability of health
expenditures.

CH. III SEC. 8 ~ NATIONAL HEALTH INSURANCE PROGRAM: PROGRAM

MEMBERSHIP
a. DIRECT CONTRIBUTORS. Refer to those who have the capacity to pay
premiums, are gainfully employed and are bound by an employer-employee
relationship, or are self-earning, professional practitioners, migrant workers,
including their qualified dependents, and lifetime members.
b. INDIRECT CONTRIBUTORS. Refer to all others not included as direct
contributors, as well as their qualified dependents, whose premium shall be
subsidized by the national government including those who are subsidized as a
result of special laws.

CH. III SEC. 9 ~ NATIONAL HEALTH INSURANCE PROGRAM: ENTITLEMENT

TO BENEFITS
a. Every member shall be granted immediate eligibility for health benefit package
under the Program: Provided, That PhilHealth Identification Card shall not be
required in the availment of any health service: Provided further, That no co-
payment shall be charged for services rendered in basic or ward accommodation:
Provided furthermore, That co-payments and co-insurance for amenities in
public hospitals shall be regulated by the DOH and PhilHealth: Provided, finally,
That the current PhilHealth package for members shall not be reduced.
b. PhilHealth shall provide additional Program benefits for direct contributors,
where applicable: Provided, That failure to pay premiums shall not prevent the
enjoyment of any Program benefits: Provided, further, That employers and self-
employed direct contributors shall be required to pay all missed contributions
with an interest, compounded monthly, of at least three percent (3%) for
employers and not exceeding one and one-half percent (1.5%) for self-earning,
professional practitioners, and migrant workers.

CH. IV SEC. 17 ~ HEALTH SERVICES DELIVERY: POPULATION-BASED

HEALTH SERVICES
a. The DOH shall endeavor to contract province-wide and city-wide health systems
for the delivery of population-based health services. PROVINCE-WIDE and
CITY-WIDE HEALTH SYSTEMS shall have the following minimum components:
‒ Primary care provider network with patient records accessible throughout the
health system;
‒ Accurate, sensitive, and timely epidemiologic surveillance systems; and
‒ Proactive and effective health promotion programs or campaigns.

CH. IV SEC. 18 ~ HEALTH SERVICES DELIVERY: INDIVIDUAL-BASED HEALTH

SERVICES
a. PhilHealth shall endeavor to contract public, private, or mixed health care
provider networks for the delivery of individual-based health services: Provided,
That member access to services shall not be compromised: Provided, further,
That these networks agree to service quality, co-payment/co-insurance, and data
submission standards: Provided, furthermore, That during the transition,
PhilHealth and DOH shall incentivize health care providers that form networks:
Provided, finally, That apex or end-referral hospitals, as determined by the DOH,
may be contracted as stand-alone health care providers by PhilHealth.

CH. IX SEC. 37 ~ APPROPRIATIONS: APPROPRIATIONS

The amount necessary to implement this Act shall be sourced from the following:
a. Total incremental sin tax collections as provided for in RA 10351 (“SIN TAX
REFORM LAW”);
b. Fifty percent (50%) of the National Government share from the income of the
PHILIPPINE AMUSEMENT GAMING CORPORATION (PAGCOR) as provided
for in PD1869, as amended: Provided, That the funds raised for this purpose
shall be transferred to PhilHealth at the end of each quarter subject to the usual
budgeting, accounting and auditing rules and regulations: Provided, further, That
the funds shall be used by PhilHealth to improve its benefit packages;
c. Forty percent (40%) of the Charity Fund, net of Documentary Stamp Tax
Payments, and mandatory contributions of the PHILIPPINE CHARITY
SWEEPSTAKES OFFICE (PCSO) as provided for in the RA 1169, as amended:
Provided, That the funds raised for this purpose shall be transferred to
PhilHealth at the end of each quarter subject to the usual budgeting, accounting,
auditing rules and regulations: Provided, further, That the funds shall be used by
PhilHealth to improve its benefit packages:
d. Premium contributions of members;
e. Annual appropriations of the DOH included in the GENERAL
APPROPRIATIONS ACT (GAA); and
f. National Government subsidy to PhilHealth included in the GAA.