Healthcare Ethics [NCM108]

Module 2 Bioethical Principles & Core Behavioral Norms

Engage involved in decision
 As much as there are determinants of morality  Possibility of a ‘right’
which include the act, the motive and the choice with bad
circumstances (as we have learned in the consequence
previous module), there are also differences in  Possibility of conflict in
impact on how these determinants are given duties
emphasis when appraising a situation.
 At the same time, depending on how we are Teleological approach
morally developing (as an effect of the various
Other terms  Consequence approach
development theories and psychosocial
 Practical approach
factors), there are specific approaches which
have been established through time:
deontological, teleological, and virtue ethics.
 Alongside these approaches are the equally Origin in Greek  Telos = ‘end’
significant principles which you have heard of word
or studied previously. Definition  Places value on the end
 In as much as values can turn into virtues or result
vices, finding the right balance on the
application of these principles and behavioral Moral questions  Will this action produce
norms will aid each of us in our aim towards good or bad results?
morality.  Is my action making the
world a better place?
Explore  Utilitarianism: What will
There are 3 approaches to ethics and each one is result in the greatest good?
vital.
Deontological ethics
Other terms  Command approach

Origin in Greek  Deon = ‘duty’ or ‘rule’

word
Application  Making a decision based
Definition  Places value on the act
whether inherently right or on the end result
wrong  E.g. assessing costs &
benefits of an intervention
Moral questions  Is this action right or wrong
in itself?
 What are the ethical
principles telling me to do? Possible issues  Disagreement of principles
 What are my duties? involved in decision
Application  Identifying one’s duty and  Possibility of a ‘right’
acting accordingly choice with bad
 E.g. telling the truth even if consequence
it can lead to negative  Possibility of conflict in
consequences duties

Possible issues  Disagreement of principles

1
 Healthcare Ethics [NCM108]

Virtue Ethics
Other terms  Character approach
 Aretaic ethics

Origin in Greek  Arete = ‘excellence of

word character’ or ‘virtue’

Definition  Places value on the PRINCIPLES OF HEALTH CARE ETHICS

motives of the moral 1. Autonomy
character of actor o The respect for a patient's self-
 No vices determination.
Moral questions  How do I live my life? o Patients have the right to accept or reject
 What kind of person do I recommendations for health care if they
want to be? have an appropriate decision-making
 Is the actor a good person capacity.
with good motives? o Patients are autonomous agents having the
ability to decide for themselves.
o This premise is the main basis for informed
consent.
o We know that each patient has the capacity
to act intentionally, with understanding, and
without controlling influences.
o Legally, informed consent shall be obtained
Application  Making a decision in light
from a patient concerned if he is of legal age
of those favored virtues
and of sound mind.
 E.g. doing what is good
o In cases where a patient is incapable of
from within, not being
giving consent, a third-party consent is
pretentious
required.
o The order of priority is stated as:
Possible issues  May miss importance of 1. Spouse
obligations to client and 2. Son or daughter or legal age
the public 3. Either parent
 Possibility of conflict in 4. Brother or sister of legal age
virtues 5. Guardian

If the above substituted judgment is unavailable

Any one of the above is inadequate by itself. It is in then, best interest standard is applied based on the
bringing these approaches together that we can clinical expertise of the physician or even the nurse
live morally to the fullest. as the situation presents.

Explain Another legal approach in the health care proxy is

the use of advance directive.
- Advance directive is a document where a
person gives instructions about future
medical care should he or she be unable to

2
 Healthcare Ethics [NCM108]
participate in medical decisions due to
incapacity.
- Examples of advance directives are the
living will, the durable power of attorney
for health care (sometimes known as the
medical power of attorney) and Do not
resuscitate (DNR) orders.
One concept that is usually discussed alongside
autonomy is paternalism.
- Paternalism is acting in a fatherly manner.
- A term usually linked to the physician’s
assumption of authority in medical care.
- It is also said that the role of nurse as
patient’s advocate is related to the concept
of paternalism.
- These terms must be clearly delineated to
avoid violation of autonomy.
2. Beneficence
o Doing “what is best” for the patient.
o The definition of “what is best” may be
derived from the nurse’s judgment or the
patient’s wishes.
o This provision of benefit is applied to both
the welfare of the client and the society.
Example: Recommending to a mother who is 40
years old and who is hypertensive and obese the
use of IUD (intrauterine device) instead of estrogen
containing pills as contraception because ECPs
(estrogen-containing pills) increase the risk of
venous and arterial thromboembolic events.
More Examples:
1. Resuscitating a drowning victim
2. Providing vaccinations
3. Encouraging a patient to quit smoking
4. Taking to community about STD
preventions.
3. Non-maleficence
 “Doing no harm.”
 Non-maleficence can be enforced by abiding
by the legal requirements of duty and
accountability.
3
 Nurses do this by not intentionally creating a
needless harm or injury to the patient, either
through negligent acts of commission or
omission.
Example: The institution where a nurse works has
an ethical obligation to provide a working
environment that is safe and does not harm the
employees. This environment should be free from
harassment and discrimination.
Harm by an act of omission means that some
action could have been done to avoid harm but was
not done.
 Example: Omission would be failing to raise
the side rails on the patient’s hospital bed,
upon which the patient fell out and was
injured.
An act of Commission is something done that
resulted in harm.
 Example: Delivering a medication in the
wrong dose or to the wrong patient.
4. Justice
 The fair allocation of resources.
 Stated simply, patients in similar situations
should have access to the same care.
 This requires that social benefits and social
burdens be distributed in accordance with
the demands of the patients.
 Nurses must, therefore, render nursing care
to the best of our ability to every patient
regardless of religion, sex, race, economic
status, political beliefs, among others.
Justice may be having two types: distributive and
comparative.
a. Distributive justice
1. Addresses the degree to which
healthcare services are distributed
equitably throughout society.
2. Within the logic of distributive justice,
we should treat similar cases similarly—
but how can we determine if cases are
indeed similar?
3. Beauchamp & Childress (2013) identify
six material principles that must be
considered, while recognizing that
 Healthcare Ethics [NCM108]
there is little likelihood all six principles
could be satisfied at the same time.
4. Principles of Justice
5. To each person:
i. To each person an equal share
ii. To each person according to need
iii. To each person according to
effort
iv. To each person according to
contribution
v. To each person according to merit
vi. To each person according to free
market exchanges
b. Comparative justice
1. It determines how healthcare is
delivered at the individual level.
2. It looks at disparate treatment of
patients based on age, disability,
gender, race, ethnicity, and religion.
3. Of particular interest are the disparities
that occur because of age.
4. Bias because of age compared to
gender and race discrimination is
referred to the practice as ageism
(Chrisler et al., 2016).
5. In our society, equal access to
healthcare does not exist due to
variations in health insurance, third-
party payers, socioeconomic levels, and
even availability of transportation to
care facilities.
6. There is valid concern about the
distribution of resources, particularly as
the population ages and the demand
for services increases.
Core Behavioral Norms:
1. Veracity: honesty, truthfulness, candor.
Parts:
a. Duty to disclose information: example is
informed consent process
 Informed Consent:
4
i. The first application of the
principle of veracity relates to
informed consent and the
autonomy of the patient to make
decisions based on all available
information.
ii. Patients need to know the truth
about their medical situation and
their options.
iii. However, some patients or their
families may not want the full
truth disclosed to them. (the best
way to tell the clients are “ask the
physician”)
 Therapeutic privilege
i. The legal exception to the rule of
informed consent, which allows
the caregiver to proceed with care
without consent in cases of
emergency, incompetence, and in
which due to depression or
instability, the patient could be
harmed by the information.
ii. Decisions about withholding
information involve a conflict
between veracity and deception.
iii. There are times when the legal
system and professional ethics
agree that deception is legitimate
and legal.
iv. Therapeutic privilege is invoked
when the healthcare team makes
the decision to withhold
information believed to be
detrimental to the patient.
v. Such privilege is by its nature
subject to challenge and is taken
very seriously by ethics
committees.
c. Duty not to lie:
 Example: not revealing a diagnosis or
change in condition when asked
d. Duty not to deceive:
 Example: the use of placebos (where
the patient believes they are receiving a
medication versus in a clinical trial
where they are informed that they may
 Healthcare Ethics [NCM108]
receive the experimental medication or
a placebo) or benevolent deception
such as not revealing Alzheimer's
diagnosis.
Arguments for veracity or truthfulness:
1. We owe respect to others and that
requires being truthful
2. We have an obligation to fulfill our
patients’ expectations of honesty and
to keep our promises
3. Honesty and candor are necessary in
health care for good patient outcomes
– both on the part of the patient and
the clinician
Possible reasons to override veracity:
1. The patient may be harmed by the truth
either by increasing anxiety, sorrow or
potentially causing suicide. (iniiwasan
natin, lalo na if yung patients may
suicidal thoughts already)
2. The patient will not agree to therapy if
they are fully informed.
2. Privacy: loss of privacy occurs if others use
several forms of access to a person
inappropriately. For example, access to
physical body, access to personal information,
access to solitude
a. TYPES OF PRIVACY
1. Bodily privacy
 An ethical concept of bodily
privacy can be derived from
respect for autonomy, where
autonomy includes the freedom
to decide what happens to one's
body.
 Bodily privacy is recognized in
law: actions in assault, battery
and false imprisonment may be
available to the person who does
not consent to health care.
2. Decisional privacy
 Decisional privacy is distinguished
as control over the intimate
decisions one makes (e.g., about
5
contraception, abortion, and
perhaps health care at the end of
one's life).
3. Informational privacy: This type of
privacy underlies the notion of
confidentiality.
Note: There is a difference between loss of privacy
versus a sense of privacy. Most patients do not
have a sense of privacy while being cared for, but
their privacy can still be protected.
Arguments for privacy:
1. Respect for autonomy -- sovereignty over
self and right to protect access to self
2. Respectful care – patient characteristics
that don’t affect care should not be
discussed or otherwise shared
unnecessarily
Potential reasons to override privacy:
1. Risks to others such as some
communicable diseases
2. Learning of future clinicians
3. Confidentiality: holding disclosed information in
confidence
 Difference between confidentiality and
privacy: breach of confidentiality occurs if
you disclose information from a patient to
another without their authorization (e.g.,
your nurse discloses that you are COVID 19
positive to other people not involved in
your care).
 Breach of privacy occurs if you look at the
medical chart of a hospitalized co-worker
that you are not caring for
Arguments for confidentiality:
 Necessary to achieve best outcomes
 To protect privacy
 To be trustworthy (to every patient)
Between the health care provider and the client,
there exists privilege communication. Privileged
communication (Edge & Groves, 2019) is an
interaction between two persons which is legally
recognized as a private and protected relationship.
 Healthcare Ethics [NCM108]
Therefore, patients have a legal right to believe
that their conversation with the nurse will be kept
confidential.
However, the privilege permits disclosure when
there is: threat to themselves or to others, patient’s
consent, court order or if information is needed for
patient care.
Justified breaches of confidentiality:
1. Obligatory:
 Some contagious diseases
 Child/vulnerable adult abuse
 Gunshot wounds
2. Permissible:
Elaborate
 Telling a patient that their partner, who
is also your patient, is HIV positive.
To further understand the principles discussed, let
us analyze the given case.
4. Fidelity: trust; to act in good faith; loyalty
 Nurses and other professionals have a
‘social contract’ with the public to provide
their professional services
 Examples of breaches of fidelity include:
1. Abandonment
 Examples might include leaving the
care of your patients without
turning care over to another nurse,
refusing to care for a particular
patient when there is no other
nurse to assume that care, strikes
2. Putting other interests above patient's
interests
 Examples might include situations
reported in managed care systems
where care providers are rewarded
for ‘saving money’. Hence, their
own interests may or your own
interests
3. Reasons for fidelity:
 The public has a right to expect a
standard of behavior from a health
care professional – such as to
expect gentle, non-judgmental care
6
 Example: caring for a patient who
committed abortion - the patient
should be care for not because of
the belief in a relationship based on
fidelity is necessary for patients
and their families to entrust their
health care to a nurse or other
health care professional
4. Possible reasons to override fidelity:
 Going on strike to improve working
conditions
 Personal safety (such as in a fire
where personal life is in danger)
 Maria is a registered nurse who recently
lost her husband after he suffered a
massive stroke. One of her patients is a 42-
year-old male with a left hemisphere
cerebrovascular accident (CVA).
 She notes on his history that he is married
with three young children. Currently, his
only form of communication is by slowly
writing with his left, non-dominant hand.
 He has requested a do-not-resuscitate
(DNR) order and asked that his feeding
tube be removed. Maria finds the patient
alert and oriented to time, place, and
person.
 After spending time with the patient during
rehabilitation therapy, she also determines
that he is competent to make health care
decisions.
 During their interaction, the patient asks
that his wife not be informed of his wishes
concerning the feeding tube and the DNR
status.
 Maria has trouble acknowledging the
patient's wishes because they go against
her value of human life and belief in the
patient's ability to recover with
compensation for deficits.
 Healthcare Ethics [NCM108]
Try answering the following questions:
1. Describe how Maria's values and recent
personal experience influence her care of this
patient.
2. Identify how the principles of autonomy,
beneficence, non-maleficence, fidelity, justice,
and veracity apply to this case.
3. Do Maria's values conflict with any of the
moral/ethical principles of nursing care
(autonomy, beneficence, non-maleficence,
fidelity, justice, veracity)? If so, explain.
4. Were the principles mentioned in no. 3 upheld
or violated?
5. Which ethical principle is the most important in
this case study?
To answer the question no. 1, Maria values life, no
matter what the form. Her recent loss of her
husband might make her sympathetic to the wife
and make it difficult for her to adhere to the
patient's wishes for his health care.
As for question no. 2, this is how the different
principles apply to this case:
 Autonomy: The patient has the freedom to
make decisions and choices about health
care without interference.
 Beneficence: Provide interventions
designed to assist the patient to achieve
the highest level of functioning.
 Non-maleficence: Provide nursing care that
is designed to prevent harm to the patient.
 Fidelity: In this case, the patient requests
confidentiality of information and that his
choices be kept confidential concerning his
DNR status and removal of his feeding
tube.
 Justice: In this case, there is no reference to
socioeconomic status or other variables
that might influence patient care.
 Veracity: The duty to tell the truth to the
patient about the health status appears to
be met in that the patient seems to
understand his condition.
With regards to question 3 on the nurse’s values,
Maria's values conflict with autonomy and fidelity.
If the patient's family is considered an extension of
the patient, then there is a problem with veracity—
telling the truth to the patient's wife.
For question no. 4:
 Autonomy: If the patient was given the
freedom to make decisions and choices
about health care without interference,
then it is upheld.
 Beneficence: this principle was upheld since
there was provision of interventions
designed to assist the patient to achieve
the highest level of functioning in the form
of rehabilitation therapy.
 Non-maleficence: Provide nursing care that
is designed to prevent harm to the patient.
 Fidelity: If the patient’s request that his
choices be kept confidential concerning his
DNR status and removal of his feeding tube
will be granted, then it is upheld.
 Veracity: The patient seems to understand
his condition so it is presumed that the duty
to tell the truth to the patient about the
health status appears to be met, hence, this
principle is upheld.
In this case, we put forward the principles of
autonomy and non-maleficence as the most
important. In the principle of autonomy, it is
imperative that we often stress that individual
autonomy should be promoted and respected at all
times except in some instances as discussed
previously in this module. In this exemplar, the
patient is able to make decisions on his own and for
himself as he is of sound mind, so, his decision
should be respected. With regards to principle of
non-maleficence, the nurse still provided a standard
of care to the patient avoiding risk or minimizing it,
as it relates to medical competence.