INTRODUCTION TO BIOETHICS

BIOETHICS- is a field of study concerned with the ETHICS and philosophical implications of certain biological
and medical procedures, technologies, and treatments, as organ transplants, genetic engineering, and
care of the terminally ill.
A science that deals with the study of the morality of human conduct concerning human life in all its aspects from
the moment of its conception to its natural end.

HEALTHCARE ETHICS-is the field of applied ethics that is concerned with the vast array of moral decision-
making situations that arise in the practice of medicine in addition to the procedures and the policies that are
designed to guide such practice. Health ethics is employed to regulate human conduct in the practice of health
care so that the good may be done and evil may be avoided thereby ensuring the purpose of health care.

NURSING ETHICS- can be defined broadly as the examination of all kinds of ethical and bioethical issues
from the perspective of nursing theory and practice which, in turn, rest on the agreed core concepts of nursing,
namely: person, culture, care, health, healing, environment and nursing itself

PROFESSIONAL ETHICS - Is the division of ethics that relates to professional behavior

ETHICS- It is a PRACTICAL science of morality of human conduct that implies direction;

Science – deals with complete and systematic body of factual and empirical data and reasoning;
Moral – dictates of reason on how things should be
Human conduct – deliberate, free and how one person SHOULD ACT
Ethics - concerns the needs and values of human persons in all matters of human concern including HEALTH;
nothing is more human and personal than HEALTH; Ethics is concern with the study of social morality and
philosophical reflection on its norms and practices; Moral issues deals with respect for life, freedom, love, issues
that provokes conscience; issues that responds to ought, should, right, wrong, good, bad and complicated

The Human Being

 The PERSON
• (Biblical) Created in the image and likeness of God; differing from animals due to possession of spiritual
intelligence and free will;
• God produces the human body through the cooperation of human parents; the creation of the human
soul is direct act of God;
• Each person is unique and irreplaceable; and are called not only to maturity but to eternal life

HUMAN ACTS & ACTS OF MAN

• Human act is an act which proceeds from the deliberate free will of man. Man knows what he is doing and
freely chooses to do what he does;
• Not all acts are Human Acts; for an act to be human it must have:
• KNOWLEDGE and FREEDOM

HUMAN ACTS & ACTS OF MAN

• KNOWLEDGE – of what it is about and what it means. Facts, information, and skills acquired by a person
through experience or education; the theoretical or practical understanding of a subject: Awareness or
familiarity gained by experience of a fact or situation
 • FREEDOM – to do or leave it undone without coercion or constraint; it implies voluntariness which is to
rationally choose by deliberate will the object.
An idea of reason that serves an indispensable practical function. Without the assumption of freedom, reason
cannot act.

• CONSCIENCE – spiritual discernment;

- The capacity to make practical judgement in matters involving ethical issues;
- It is person’s most secret sanctuary where he/she is alone with God;
- Hence the more a correct conscience prevails the more do persons and groups turn aside from blind
choice and try to be guided by the objective standards of moral conduct (SVC 1965)

Ethical Philosophers/Bioethicists
Immanuel Kant
• (1724-1804)
• A German philosopher
• was an opponent of utilitarianism

• Our emotional preferences which provides us with values, must be checked against certain rational
standards of a PURELY formal kind;
• Supreme principle of morality referred to as The Categorical Imperative (CI);
• Any choices we make must be such that we would be willing for everyone else to make the same choices
(universality).

John Bordley Rawl

• Born: February 21, 1921
• an American moral and political philosopher;
• Professorship at Harvard University, University of Oxford;
• His magnum opus, A Theory of Justice (1971
• According to English philosopher Jonathan Wolff, John Rawls was the most important political philosopher
of the 20th century
• Social Contract as a solution to Distributive Justice (the socially just distribution of goods in a society);
• Resultant theory known as "Justice as Fairness”:
• Society should be structured so that the greatest possible amount of liberty is given to its members,;
• Inequalities either social or economic are only to be allowed only if the worst will result under an equal
distribution;
• Finally, if there is such a beneficial inequality, this inequality should not make it harder for those without
resources to occupy positions of power, for instance public office.
St. Thomas Aquinas

• Born 1225; Sicily, Italy

• Proclaimed Doctor of the Catholic Church  Joined the Dominican Order
• (Order of Preachers – OP)
• Thomas's ethics - "first principles of action.“  Summa theologiae , he wrote:
• Virtue denotes a certain perfection of a power;
• Now a thing's perfection is considered chiefly in regard to its end;
• But the end of power is act. Wherefore power is said to be perfect, according as it is determinate to its
act.[82] St. Thomas Four Cardinal Virtues
• Prudence
• Temperance
• Justice
 • Fortitude
• The object of the theological virtues is GOD Himself, Who is the last end of all, as surpassing the
knowledge of our reason;
• On the other hand, the object of the intellectual and moral virtues is something comprehensible to human
reason. Wherefore the theological virtues are specifically distinct from the moral and intellectual virtues

William David Ross

• Born: April 15, 1877; Thurso, Scotland

• Scottish philosopher
• Education: University of Edinburgh
• The moral order...is just as much part of the fundamental nature of the universe (and...of any possible
universe in which there are moral agents at all) as is the spatial or numerical structure expressed in the
axioms of geometry or arithmetic;
• "moral intuitionist" theory,
• According to W. D. Ross (1877-1971), there are several prima facie duties that we can use to determine
what, concretely, we ought to do.
• A prima facie duty is a duty that is binding (obligatory)
• "Unless stronger moral considerations outweigh, one ought to keep a promise made."

THEORIES AND PRINCIPLES OF HEALTH ETHICS AND VIRTUE ETHICS IN NURSING

Moral philosophy is the branch of philosophy that examines beliefs and assumptions about certain human values.
Ethics is the practical application of moral philosophy; that is, given the moral context of good or bad, right or
wrong, “What should I do in this situation?” The philosopher reveals an integrated global vision in which elements,
like pieces of a puzzle, have a logical fit. By developing theories of ethics, the philosopher hopes to explain
values and behavior related to cultural and moral norms. Each theory is based upon the particular viewpoint of
the individual philosopher, and maintains, within itself, philosophical consistency.

1. Deontology- Deontological theories of ethics are based upon the rationalist view that the rightness or
wrongness of an act depends upon the nature of the act, rather than its consequences. The term deontology is
taken from the Greek word for duty. Occasionally, deontology is called formalism; some writers refer to this type
of ethical theory as Kantianism. Kantianism is based upon the writings of the German philosopher Immanuel
Kant, who shaped many deontological formulations.

• Act only according to that maxim by which you can at the same time will that it should become a universal
law.
• Act so that you treat humanity, whether in your own person or that of another, always as an end and never
as a means only.

Deontology also implies that ethics are derived from fulfilling duties. One must act for the sake of duty or
obligation. Most professional codes of ethics are based upon Kantian principles. Nurses’ codes of ethics stress
both the importance of fulfilling duties that are inherently owed to patients and the importance of preserving the
dignity and autonomy of each individual patient. For example, section 1.2 of the ANA Code of Ethics for Nurses
(Appendix A) notes that, “The nurse establishes relationships and delivers nursing services with respect for
patient needs and values, and without prejudice.” This statement presumes that the nurse has a duty to respect
and care for the patient in terms of the patient’s own needs and values. It demonstrates the principles of respect
for person, beneficence, and autonomy. These principles are so pervasive in the profession that they often go
unnoticed. When you maintain confidentiality, when you advocate for a patient, when you keep your promises,
when you tell the truth, and when you practice with expert skill, you are utilizing deontic principles.
2. Utilitarianism- Utilitarianism is a pivotal form of moral philosophy for health care delivery. Sometimes
called consequentialism, utilitarianism is a type of teleological theory. Telos comes from the ancient Greek
language and literally means end: Utilitarianism is the moral theory that holds that an action can be considered
good or bad in relation to its end result. Utilitarianism is an important ethical philosophy that has its basis in
naturalism. According to the utilitarian school of thought, the right action is that which has the greatest utility or
usefulness. No action is, in itself, either good or bad. Utilitarian hold that the only factors that make actions good
or bad are the outcomes, or end results, that are derived from them.

• The end justifies the means

Utilitarianism is widely used in the health care system. It is the basis for many policy-level decisions about the
distribution of health care services and can be integral to medical emergency triage decisions. Policy makers
attempt to wisely appropriate public funds. The debates about funding are often in the news and include topics
on a variety of public programs, such as Medicare, Medicaid, managed care, family planning, pediatric services,
mental health, and others. As these programs focus on delivering cost-effective health care to large numbers of
people, they serve very specific narrow populations (denying resources to others) and provide or deny very
specific services—all based upon utilitarian principles. In emergency situations such as war or natural disasters,
utilitarianism may become the default method of making these types of decisions.

3. Consequentialism/Teleology- Consequentialist moral theories evaluate the morality of actions in terms

of progress toward a goal or end. The consequences of the action are what matter, not their intent. This is in
contrast to previously noted theories (e.g., deontology, virtue ethics, and natural law) that consider intent.
Consequentialism is sometimes called teleology, using the Greek term telos, which refers to “ends.” Thus, one
finds that the goal of consequentialism is often stated as the greatest good for the greatest number.

Virtue Ethics in Nursing

Virtue ethics, sometimes called character ethics, represents the idea that individuals’ actions are based upon a
certain degree of innate moral virtue. First noted in the writings of Plato, Aristotle, and early Christian thinkers,
there has been a contemporary resurgence of interest in virtue ethics. Western moralism emerged with the idea
of the cardinal virtues of wisdom, courage, temperance, justice, generosity, faith, hope, and charity (Kitwood,
1990). Modern and contemporary writers also include such virtues as honesty, compassion, caring, responsibility,
integrity, discernment, trustworthiness, and prudence. Though nearly absent in nursing ethics texts in the past
20 years, virtue ethics is re-emerging as an important framework for examining moral behavior.

Focal Virtues

In the discussion of virtue as related to biomedical ethics, Beauchamp and Childress (2008) define character as
being made up of a set of stable traits that affect a person’s judgment and action. Like Aristotle, these authors
suggest that although people have different character traits, all have the capacity to learn or cultivate those that
are important to morality. Beauchamp and Childress propose that there are four focal virtues that are more pivotal
than others in characterizing a virtuous person: compassion, discernment, trustworthiness, and integrity.

Virtue Ethics in Nursing

How does the concept of virtue or character ethics fit with nursing as a principled profession? It is likely that
principled behavior, while not the sole domain of a good moral character, is more likely to occur in the presence
of one. Certainly Florence Nightingale thought virtue was an important trait of the good nurse. Nightingale learned
Greek as a child. She was inspired by Plato and translated parts of Phaedo, Crito, and Apology. Nightingale was
intrigued by Plato’s description of elite people with rare gifts who command many kinds of knowledge. The
characteristics, or virtues, of these people resonated with Nightingale and were reflected in her writings
throughout her life (Dossey, 2000). She believed that one of the aims of philosophy was to cultivate in gifted
people their potential intellectual and moral qualities. The Nightingale Pledge, composed by Lystra Gretter in
1893 and traditionally recited by graduating nurses, implies virtue of character as nurses promise purity, faith,
loyalty, devotion, trustworthiness, and temperance. It is reasonable to say that good character is the cornerstone
of good nursing, and that the nurse with virtue will act according to principle. If Aristotle was correct in his belief
that virtue can be practiced and learned, then we can learn, through practice, those acts that, by their doing,
create a virtuous person.

Core Values of a Professional Nurse

Nursing is a caring profession. Caring encompasses empathy for and connection with people. Teaching and role-
modeling caring is a nursing curriculum challenge. Caring is best demonstrated by a nurse's ability to embody
the five core values of professional nursing. Core nursing values essential to baccalaureate education
include human dignity, integrity, autonomy, altruism, and social justice. The caring professional nurse
integrates these values in clinical practice. Strategies for integrating and teaching core values are outlined and
outcomes of value-based nursing education are described. Carefully integrated values education ensures that
the legacy of caring behavior embodied by nurses is strengthened for the future nursing workforce.

ETHICAL PRINCIPLES AND RELEVANT PRINCIPLES IN HEALTH CARE

Ethical Principles
Ethical issues are commonly examined in terms of a number of ethical principles Ethical principles are basic and
obvious moral truths that guide deliberation and action. Major ethical theories utilize many of the same principles,
though either the emphasis or meaning may be somewhat different in each. For example, respect for autonomy
is a dominant principle in deontological theory but is less important in utilitarian theory. It is vital for nurses to
understand ethical principles and be adept at applying them in a meaningful and consistent manner.

A. Respect for persons

All of the principles discussed in this module presuppose that nurses have respect for the value and uniqueness
of persons. Occasionally viewed as an ethical principle in its own right, respect for persons implies that 1
considers others to be worthy of high regard. Certainly, genuine regard and respect for others is the moving force
behind all caring professions. Codes of nursing ethics explicitly state that respect for persons is a cornerstone of
professional ethics. Discussion of the ethical principles in this chapter is based upon the belief that nurses value
the principle of respect for persons.

B. Autonomy

As you would expect, the ethical principle of respect for autonomy denotes the ethical obligation to honor the
autonomy of other persons. The word autonomy literally means self-governing.
Autonomy denotes having the freedom to make choices about issues that affect one’s life, free from lies, restraint,
or coercion. Respect for autonomy is closely linked to the notion of respect for persons, and is an important
principle in cultures where all individuals are considered unique and valuable members of society.

Implied in the concept of autonomy are four basic elements.

1. Autonomous person is respected

2. Autonomous person must be able to determine personal goals
3. Autonomous person has the capacity to determine personal goals
4. Autonomous person has the freedom to act upon choices

Patient’s bill of rights.

Magna Carta of Patient’s Rights and Obligations Act of 2017

1. Right to Good Quality Health Care and 12. Right to Medical Records
Humane Treatment 13. Right to Health Education
2. Right to Dignity 14. Right to Leave Against Medical Advice
3. Right to be informed of His Rights and 15. Right to Express Grievances
Obligations as a Patient 16. Right to Health
4. Right to Choose His Physician / Health 17. Right to Access to Quality Public Health Care
Institution 18. Right to a Healthy and Safe Workplace
5. Right to Informed Consent 19. Right to Medical Information and Education
6. Right to Refuse Diagnostic and Medical Programs
Treatment 20. Right to Participate in Policy Decisions
7. Right to Refuse Participation in Medical 21. Right to Access to Health Facilities
Research 22. Right to an Equitable and Economical Use of
8. Right to Religious Belief and Assistance Resources
9. Right to Privacy and Confidentiality 23. Right to Continuing Health Care
10. Right to Disclosure of, and Access to. 24. Right to Be Provided Quality Health Care in
Information Times of Insolvency
11. Right to Correspondence and to Receive
Visitors
Obligations of Patients

1. Know Rights
2. Provide Adequate, Accurate and Complete Information
3. Report Unexpected Health Changes
4. Understand the Purpose and Cost of Treatment
5. Accept the Consequences of Own Informed Consent
6. Settle Financial Obligations
7. Respect the Rights of Health Care Providers, Health Care Institutions and Other Patients
8. Obligation to Self
9. Provide Adequate Health Information and Actively Participate in His/Her Treatment
10. Respect the Right to Privacy of Health Care Providers and Institutions
11. Exercise Fidelity on Privileged Communication
12. Respect a Physician's Refusal to Treat Him
13. Respect the Physician's Decision on Medical Reasons based on his/lier Religious Belief
14. Ensure Integrity and Authenticity of Medical Records
15. Participate in the Training of Competent Future Physicians
16. Report Infractions and Exhaust Grievance Mechanism.

Informed consent

Relates to the process by which the patients are informed of the possible outcomes, alternatives, and the
risks of treatments, and are required to give their consent freely. It assures the legal protection of a patient’s right
to personal autonomy in regard to specific treatments and procedure that may be complex or simple. This is
usually discussed in relation to surgery or complex medical procedures. Common intervention like immunization
and certain methods of contraceptive need informed consent .This concept means the patient is given the
opportunity to choose a course from alternative of action-to refuse or to accept.

Exemption to informed consent.

Emergencies when there is no time to disclose the information, waivers of patients who do not want to know their
prognosis or risk of treatment.
Ethical and Legal Elements of informed Consent.
Ethically valid consent is a process of shared decision making based upon mutual respect and
participation , not a ritual to be equated with reciting the contents of a form that details the risks of particular
treatment.

Major legal elements of informed consent;

Information- Includes disclosure and understanding of the essential information: the nature of health concern
and prognosis if nothing is done.

Consent- Implies the freedom to accept or reject it, it means that consent to health care intervention
must be voluntary, without coercion, force or manipulation from health care provider and family. Coercion
and manipulation may be overt or subtle and may include threats, rewards, deception, or inducing excessive
fear. The voluntary nature of the consent does not prohibit the health care provider from making
recommendations or attempting to persuade patient to accept their suggestion but must be alert to situation
which persuasion takes on qualities of coercion and manipulation

Paternalism

A gender biased term that literally means acting in fatherly manner, that denotes leadership, benevolent
decision making, protection and discipline. In nursing it carries negative connotations, particularly related to
implied dominant male and submissive female roles. Patient’s autonomy was frequently violated in the name
of beneficence. Professionals often make dangerous assumption that they are unique ly qualified to make health
care decision by the virtue of their knowledge. This kind of thinking ignore other factors like economic,
consideration, values, role, culture and spiritual belief.

Parentalism

Translates to professionals who restricts other autonomy to protect the person form perceived or anticipated
harm. This is appropriate when the patient is judged to be incompetent or have diminished decision making
capacity; unconscious post op patient, older client, children, and teen agers. We can consider parentalism as
an advocacy if we combine genuine concern for the patient with well founded belief that the patient is
unable to make autonomous decisions

Noncompliance

Denoting unwillingness of the patient to participate in health care activities; taking medications as
scheduled, maintaining therapeutic or weight loss diet, exercising regularly, and quitting smoking

C. Confidentiality

The terms confidentiality and privacy are interrelated. Privacy refers to the right of an individual to control the
personal information or secrets that are disclosed to others. Privacy is a fundamental right of individuals
(O’Keefe, 2001). The ethical principle of confidentiality demands nondisclosure of private or secret information
about another person with which one is entrusted. That is, confidentiality requires that one maintain the privacy
of another. When the nurse learns private information about a patient, the nurse must keep that information
confidential, sharing only that information necessary to provide patient care (ANA, 2001).

Nursing codes of ethics require that we maintain the confidentiality of patient information. According to the ICN
Code of Ethics for Nurses (2006), “The nurse holds in confidence personal information and uses judgement in
sharing this information.” Similarly, the ANA Code of Ethics for Nurses (2001) and the CNA Code of Ethics for
Registered Nurses (2008) direct nurses to maintain confidentiality.
Confidentiality is the only facet of patient care mentioned in the Nightingale Pledge. This oath has been recited
for decades by graduating nurses: “I will do all in my power to elevate the standard of my profession and will hold
in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the
practice of my profession.”

E. Fidelity

The ethical principle of fidelity relates to the concept of faithfulness and the practice of keeping promises. Society
has granted nurses the right to practice nursing through the processes of licensure and certification. “The
authority for the practice of nursing is based on a social contract that acknowledges professional rights and
responsibilities as well as mechanisms for public accountability” (ANA, 1995, p. 3). The process of licensure is
one that ensures no other group can practice within the domain of nursing as defined by society and the
profession. Thus, to accept licensure and become legitimate members of the profession mandates that nurses
uphold the responsibilities inherent in the contract with society. Members are called to be faithful to the society
that grants the right to practice—to keep the promise of upholding the profession’s code of ethics, to practice
within the established scope of practice and definition of nursing, to remain competent in practice, to abide by
the policies of employing institutions, and to keep promises to individual patients. To be a nurse is to make these
promises. In fulfilling this contract with society, nurses are responsible to faithfully and consistently adhere to
these basic principles.

F. Justice

Justice is the ethical principle that relates to fair, equitable, and appropriate treatment in light of what is due or
owed to persons, recognizing that giving things to some will deny receipt to others who might otherwise have
received those things. Within the context of health care ethics, the most relevant application of the principle
focuses on distribution of goods and services. This application is called distributive justice. Unfortunately, there
is a finite supply of goods and services, and it is impossible for all people to have everything they might want or
need. One of the primary purposes of governing systems is to formulate and enforce policies that deal with fair
and equitable distribution of scarce resources.

Decisions about distributive justice are made on a variety of levels. The government is responsible for deciding
policy about broad public health access issues, such as children’s immunization and Medicare for the elderly.
Hospitals and other organizations formulate policy on an institutional level and deal with issues such as how
decisions will be made concerning who will occupy intensive care beds and which types of patients will be
accepted in emergency rooms. Nurses and other health care providers frequently make decisions of distributive
justice on an individual basis. For example, having assessed the needs of patients, nurses decide how best to
allocate their time (a scarce resource).

There are three basic areas of health care that are relevant to questions of distributive justice. First, what
percentage of our resources is it reasonable to spend on health care? Second, recognizing that health care
resources are limited, which aspects of health care should receive the most resources? Third, which patients
should have access to the limited health care staff, equipment, and so forth (Jameton, 1984)?
In making decisions of distributive justice, one must ask the question, “Who is entitled to these goods or
services?” Philosophers have suggested a number of different ways to choose among people.

G. Beneficence

The principle of beneficence means to do good. It requires nurses to act in ways that benefit patients. Beneficent
acts are morally and legally demanded by the professional role (Beauchamp & Walters, 2007). The objective of
beneficence provides nursing’s context and justification. It lays the groundwork for the trust that society places
in the nursing profession, and the trust that individuals place in particular nurses or health care agencies. Perhaps
this principle seems straightforward, but it is actually very complex. As we think about beneficence, certain
questions arise: How do we define beneficence—what is good? Should we determine what is good by subjective,
or by objective, means? When people disagree about what is good, whose opinion counts? Is beneficence an
absolute obligation and, if so, how far does our obligation extend? Does the trend toward unbridled patient
autonomy outweigh obligations of beneficence? Veatch (2002) asks whether the goal is really to promote the
total well-being of the patient or to promote only the medical well-being of the patient. We must keep these
questions in mind as we practice.

The ethical principle of beneficence has three major components: do or promote good, prevent harm, and remove
evil or harm. Beneficence requires that we do or promote good (Beauchamp & Childress, 2008). Even with the
recognition that good might be defined in a number of ways, it seems safe to assume that the intention of nurses
in general is to do good. Questions arise when those involved in a situation cannot decide what is good. For
example, consider the case of a patient who is in the process of a lingering, painful, terminal illness. There are
those who believe that life is sacred and should be preserved at all costs. Others believe that a natural and
peaceful death is preferable to an extended life of pain and dependence. The definition of good in any particular
case will determine, at least in part, the action that is to be taken. The principle of beneficence also requires us
to prevent or remove harm (Beauchamp & Childress, 2008). In fact, some believe that doing no harm, and
preventing or removing harm, is more imperative than doing good. All codes of nursing ethics require us to
prevent or remove harm. For example, the
International Council of Nurses (ICN) Code of Ethics for Nurses (2006) says, “The nurse takes appropriate action
to safeguard individuals, families and communities when their care is endangered by a co-worker or any other
person.” Similarly, the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses (2008) says,
“Nurses question and intervene to address unsafe, non-compassionate, unethical or incompetent practice or
conditions that interfere with their ability to provide safe, compassionate, competent and ethical care to those to
whom they are providing care, and they support those who do the same”

H. Non Maleficence

The principle of nonmaleficence is related to beneficence. Whereas beneficence requires us to prevent or

remove harm, nonmaleficence requires us to avoid actually causing harm. Included in this principle are deliberate
harm, risk of harm, and harm that occurs during the performance of beneficial acts. Most ethicists today tend
toward the Hippocratic tradition that says to first do no harm (the principle of nonmaleficence), placing this
principle above all others. It is obvious that we must not commit acts that cause deliberate harm. This principle
prohibits, for example, experimental research when it is fairly certain that participants will be harmed, and the
performance of unnecessary procedures for economic gain or solely as a learning experience.

Non maleficence also means avoiding harm as a consequence of doing good. In such cases, the harm must be
weighed against the expected benefit. For example, sticking a child with a needle for the purpose of causing pain
is always bad—there is no benefit. Giving an immunization, on the other hand, while causing similar pain, results
in the benefit of protecting the child from serious disease. The harm caused by the pain of the injection is easily
outweighed by the benefit of the vaccine. In day-to-day practice, we encounter many situations in which the
distinction is less clear, either because the harm may appear to be equal to the benefit gained, because the
outcome of a particular therapy cannot be assured, or as a result of conflicting beliefs and values. For example,
consider analgesia for patients with painful terminal illness. Narcotic analgesia may be the only type of
medication that will relieve very severe pain. This medication, however, may result in dependence and can
hasten death when given in amounts required to relieve pain.
Principle of double effect

The first principle that proposes to distinguish between a good and an evil is the theory of double effect. Derived
from Summa Theologica, the principle has four key points:

• The act must be good, or at least morally neutral, independent of its consequences.
 • The agent intends only the good effects, not the bad effect.
• The bad effect must not be a means to the good effect. If the good effect were to be the causal result of the
bad effect, the agent would intend the bad effect in pursuit of the good effect
• The good effect must outweigh the bad effect.

The theory of double effect has use in medical ethics when dealing with abortion, euthanasia, and other decisions
where there is a conflict between a good and an evil. For example, under this view, abortion is an evil, but saving
the life of a mother is a good. Under this view, euthanasia is an evil, but relieving pain by the use of morphine is
a good. If the person dies and the death was not intended, then is it acceptable? Major issues arise in the
application of the theory concerning how to determine a person’s intent.

Principle of Legitimate Cooperation

To achieve a well-formed conscience, one should always judge it unethical to cooperate formally with an immoral
act (that is, directly to intend the evil act itself), but one may sometimes judge it to be an ethical duty to cooperate
materially with an immoral act (that is, only indirectly intend its harmful consequences) when only in this way can
a greater harm be prevented, provided:

• That the cooperation is not immediate and

• That the degree of cooperation and the danger of scandal are taken into account

Types of cooperation

• Formal cooperation - occurs when a person or organization freely participates in the actions of a
principal agent. Implicit formal cooperation occurs when even though the cooperator denies intending the
object of the principal agent , the cooperator participates in the action.

• Immediate material cooperation - occurs when the cooperator participates in circumstances that are
essential to the commission of an act, such the act could not occur without this participation. A debate on about
duress wherein an act was done at gun point.

• Mediate material cooperation - occurs when the cooperator participates in circumstances that are not
essential to the commission of the action, such that the action could occur even without cooperation.

Principle of common good and subsidiarity

The Common Good

The term the "common good" has been used in various contexts to identify actions or outcomes that have some
definable benefit that extends beyond individual gain. The common good has been addressed in professional
literature pertaining to ethics, political action, the environment, nursing, and health care.

The literature examining the relationship of the common good to nursing and other health professions mainly
cites the common good as an impetus for action; literature exploring the common good as a concept of use to
nursing and health care is very limited. However, nursing is viewed as promoting the common good.8 In addition,
the development of nursing as a discrete profession reflects societal recognition that the constellation of services
provided by nurses is supportive of the common good. Although nursing literature does not address the common
good from a theological perspective, it clearly addresses related concepts such as concern for the whole person
in the community and outcomes associated with the common good, such as distributive justice.9 Consistent with
the Catholic perspective of the common good,10 nursing also addresses the need to balance the preservation
of individual dignity and respect against societal integrity. The "added value" of the common good to existing
nursing concepts may be illustrated by examining instances of ethical misconduct in clinical research and the
evolution of the health care delivery system.

PRINCIPLE OF STEWARDSHIP. PRINCIPLE OF TOTALITY AND INTEGRITY. PRINCIPLE OF

ORDINARY AND EXTRAORDINARY MEANS. PRINCIPLE OF PERSONALIZED SEXUALITY
Principle of Stewardship

Requires us to appreciate 2 great gifts that a wise and loving God has given; the earth, with all the
natural resource and out own human nature, with its biological, psychological, social and spiritual
capacities. This principle is grounded in the presupposition that God has the absolute domain over creation and
that in so far as man are made in God’s image and likeness, we have given the limited dominion over creation
and are responsible for care. Gifts of human life and environment be used with profound respect. Human
creativity should be used to cultivate nature, recognizing our limitation and the risk of destroying these
gifts. The principles of stewardship includes but not reducible to concern scarce resources.

Role of nurses as stewards

Personal - Although the nurse steward ought to structure educational opportunities that encourage nurses to
shift their epistemology of practice, integrating a virtue-based practical reasoning, a gap remains to be filled by
the steward’s theoretical lens. MacIntyre’s theory of virtue ethics, which is founded in Aristotle’s concept of
phronesis, provides such a lens. This theory extends understanding of virtue-based practical reasoning, due to
its explanation of how character qualities - or self-identity - influence practical reasoning, specifically how a moral
insight may be evoked through a critical appraisal of situations generating conflict and ambiguity. The nature of
lived experiences may be appraised through drawing on experience, understanding and values, as well as a
continuous dialogue between the experience and theory and practice. This theory finds itself dual premised: it
embraces a form of realism, specifically, that human experience and sensitivity can yield a knowledge of moral
reality whose properties exist outside subjective awareness; and secondly, it is grounded in a teleological form
of understanding that accepts the end’s or goal’s primacy.

Social- Nurses advocate for the health promotion educate patients and public on the prevention of illness and
injury, provide care and assist in cure, participate in rehabilitation and provide support. Nurses help families
become healthy by helping them understand the range of emotional, physical, mental and cultural experiences
they encounter during health and illness. Nurses help people and their families to cope with their illness and deal
with it and if necessary live with it, so that their normal life can continue.

Ecological – Nurses can help with waste management. Health care sectors generates tons of waste from the
hospitals and since nurses are the frontlines of care, they can be helpful in coming up with policies about hospital
waste segregation and recycling. Nurses can lead a way for communities to have a more sustainable way of
living.

Biomedical – Over the past decades, the nursing profession has faced a tremendous advancement in
technology and medical practice, a nurse should be familiar and well versed with new equipment and tools that
are being used in the hospital and other clinical setting. According to the theory of Locsin, entitled Technological
competency as caring in nursing, a nurse can be a steward of patients if they know how to use technology to
their advantage.

Principle of Totality and Its Integrity

The principle of totality states that all decisions in medical ethics must prioritize the good of the entire person,
including physical, psychological and spiritual factors. The principle of totality is used as an ethical guideline by
Catholic healthcare institutions.
 Ethico-moral responsibility of nurses in surgery

Though often difficult, ethical decision making is necessary when caring for surgical patients. Perioperative
nurses have to recognize ethical dilemmas and be prepared to take action based on the ethical code outlined in
the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements.
Perioperative nurses often find ethical decisions difficult to make, but necessary when caring for surgical patients
in practice. Perioperative nurses need to be able to recognize ethical dilemmas and take appropriate action as
warranted. They are responsible for nursing decisions that are not only clinically and technically sound but also
morally appropriate and suitable for the specific problems of the particular patient being treated. The technical
or medical aspects of nursing practice answer the question, “What can be done for the patient?” The moral
component involves the patient's wishes and answers the question, “What ought to be done for the patient?”

SUPPORTING PATIENT RIGHTS AND CHOICES

Perioperative nurses are obligated morally to respect the dignity and worth of individual patients. Perioperative
nursing care must be provided in a manner that preserves and protects patient autonomy and human rights.
Nurses have an obligation to be knowledgeable about the moral and legal rights of their patients and to protect
and support those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account
both individual rights and interdependence in decision making. By doing so, nurses can recognize situations in
which individual rights to self‐ determination in health care temporarily should be overridden to preserve the life
of the human community. For example, during a bioterrorism attack, victims infected with transmissible
organisms (eg, small pox) require infection control measures to prevent transmission to others. These infection
control measures may require isolation, resulting in restricting a patient's right to freedom of movement to protect
others. Perioperative nurses preserve and protect their patients' autonomy, dignity, and human rights with specific
nursing interventions, including supporting a patient's participation in decision making, confirming informed
consent, and implementing facility advance directive policies.7 Perioperative nurses explain procedures and the
OR environment before initiating actions, and they respect patients' wishes in regard to advance directives and
endof‐life choices. Perioperative nurses help patients make choices within their scope of care as applicable.
They also provide patients with honest and accurate answers to their questions, especially related to
perioperative teaching, and formulate ethical decisions with help from
available resources (eg, ethics committee, counselors, ethicists). Patients have the right to selfdetermination (ie,
the ability to decide for oneself what course of action will be taken in various circumstances). The nurse, as a
moral agent for the patient, must be ready and able to advocate for the patient's rights and needs whenever
necessary while providing care. Assuming such a stance involves acting on ethical principles and values. Nurses
must be prepared to identify advocacy issues and take action on them as needed. The nurse‐patient relationship
not only allows the nurse to support the patient, but it also supports the nurse. Nurses can empower patients by
providing opportunities for them to make autonomous decisions about their health care. They can support patient
empowerment through education about appropriate administrative protocols (eg, patients' rights, hospital
policies, procedures) that best meet individual patient's needs. When dealing with informed consent, the nurse's
role is to validate that the patient has been given the information and understands as much as is possible about
the surgical intervention. The nurse's assessment includes determining whether the patient has any additional
questions that might require another discussion with the physician. The nurse also assesses the level of decision
making the patient is able to demonstrate. The principle of autonomy provides for patients to make decisions
freely, even if those decisions are against medical advice. The criterion that must be met is that the patient is an
adult who is capable of making decisions and has been given the information necessary to make an autonomous
choice. Even if a surgeon and nurse believe that surgery is in the best interest of the patient, the patient has the
right to refuse the procedure at any time, regardless of whether he or she signed a surgical consent form. Nurses
ethically should support patients in their choices, regardless of whether they agree with the patient's decision.
Nursing assessment and care also applies to situations in which patients identify advance directive choices or
decisions related to do‐not‐resuscitate orders. It is the nurse's role to ensure that surgical team members are
aware of a patient's wishes in these matters. It is important that all team members and the patient discuss and
identify a plan of care before beginning the surgical procedure.
ETHICAL DILEMMAS
Perioperative nurses often are faced with an ethical dilemma when a patient is anxious because he or she does
not understand fully what is going to happen in surgery and the nurse is being pressured for a fast turnover time.
The nurse is faced with conflicting expectations (ie, the patient's emotional needs, expectations to be efficient).
Nurses following the ethical principles of compassion and respect would place a patient's emotional needs above
expediting the surgical schedule. In addition, there may be times when a perioperative nurse is told to get the
patient's signature on a consent form. Nurses must realize that they are not being asked to provide informed
consent for the patient. In cases such as these, the nurse merely is acting as a witness to the identity of the
patient and to the patient's signature on the consent form. If a nurse is present at the time the patient signs the
consent, it is a good opportunity to once again assess the patient's level of understanding and see if he or she
wishes to further discuss the proposed intervention with the physician.

Sterilization and Mutilation

Sterilization refers to any process that eliminates, removes, kills, or deactivates all forms of life and other
biological agents.

Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external
female genitalia, or other injury to the female genital organs for non-medical reasons.

Preservation of bodily functional integrity

Principle of integrity refers to every individual’s duty to preserve the view of the human person in which the
order/function of the body and its systems are respected and not duly compromised by medical interventions.
Anatomical- material or physical integrity of the body
Functional- systemic efficiency or functionality of the body

These principle 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 of the patient.

For example:
If one person is missing from the person’s body = lack of anatomical integrity
But is one kidney is healthy, present and functioning well =functional integrity is preserved

Issues on Organ Donation

Organ donation is when a person allows an organ of their own to be removed and transplanted to another person,
legally, either by consent while the donor is alive or dead with the assent of the next of kin. Donation may be for
research or, more commonly, healthy transplantable organs and tissues may be donated to be transplanted into
another person.

Common transplantations include kidneys, heart, liver, pancreas, intestines, lungs, bones, bone marrow, skin,
and corneas. Some organs and tissues can be donated by living donors, such as a kidney or part of the liver,
part of the pancreas, part of the lungs or part of the intestines, but most donations occur after the donor has died.

Principle of ordinary and extraordinary measures

Ordinary measures are those that are based on medication or treatment which is directly available and can be
applied without incurring severe pain, costs or other inconveniences, but which give the patient in question
justified hope for a commensurate improvement in his health

Principle of Personalized Sexuality

Sex is a social necessity for the procreation of children and their education in the family so as to expand the
human community and guarantee its future beyond the death of individual members. Teaches that God created
persons as male and female and blessed their sexuality as a great and good gift.

HUMAN SEXUALITY AND ITS MORAL OBLIGATION AND MARRIAGE

Bioethics and Its Application in Various Health Care Situations

Human Sexuality and its moral evaluation

Human sexuality refers to people’s sexual interest in and attraction to others, as well as their capacity to have
erotic experiences and responses. People’s sexual orientation is their emotional and sexual attraction to
particular sexes or genders, which often shapes their sexuality. Sexuality may be experienced and expressed in
a variety of ways, including thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles,
and relationships.

HUMAN SEXUALITY
• Human sexuality is the capacity to have erotic experiences and responses.
• A person's sexual orientation may influence their sexual interest and attraction for another person.
• Sexuality is a multidimensional phenomenon that includes feelings, attitudes, and actions. It has both biologic
and cultural components. It encompasses and gives direction to a person’s physical, emotional, social, and
intellectual responses throughout life.
• Sexuality may be experienced and expressed in a variety of ways, including through thoughts, fantasies,
desires, beliefs, attitudes, values, behaviors, practices, roles and relationships, which may manifest by way
of biological, physical, emotional, or spiritual aspects.

TYPES OF SEXUAL ORIENTATION:

• Heterosexual: attracted to individuals of the opposite sex (straight) A person who finds sexual fulfillment with
a member of the opposite gender.
• Homosexual: attracted to individuals of the same sex. A person who finds sexual fulfillment with a member
of his or her own sex. Many homosexual men prefer to use the term “gay.” “Lesbian” refers to a homosexual
woman. More recent terms are “men who have sex with men” (abbreviated as “MWM”) and “women who
have sex with women” (WWW)
• Bisexual: attracted to both sexes. People are said to be bisexual if they achieve sexual satisfaction from both
homosexual and heterosexual relationships.
• Queer: attracted to the same or both sexes and/or transgendered individuals Asexual: not experiencing
sexual attractions
• Transexuality: molded to be the opposite sex. A transsexual or transgender person is an individual who,
although of one biologic gender, feels as if he or she is of the opposite gender. Such people may have sex
change operations so that they appear cosmetically as the gender they feel that they are.

Moral issues and the public aspect of human sexuality

1. Rape, child molestation and sadism considered harmful to the public and controlled by law
2. Pornography, homosexuality, sex outside marriage, prostitution, masturbation, and ‘unnatural’ or ‘perverted’
sex areall activities considered by some to be against public interest.
3. Premarital Sex -is sexual activity practiced by persons who are unmarried. Historically, premarital sex was
considered a moral issue which was taboo in many cultures and considered a sin by a number of religions,
but since about the 1960s, it has become more widely accepted, especially in Western countries.
4. Same-Sex Marriage -(also known as gay marriage) is marriage between two people of the same sex. Legal
recognition of same-sex marriage or the possibility to perform a same-sex marriage is sometimes referred
to as marriage equality or equal marriage, particularly by supporters.
5. Masturbation -is the sexual stimulation of one's own genitals for sexual arousalor other sexual pleasure,
usually to the point of orgasm.
6. Pornography -is the portrayal of sexual subject matter for the purpose of sexual arousal. Pornography may
be presented in a variety of media, including books, magazines, postcards, photographs, sculpture, drawing,
painting, animation, sound recording, film, video, and video games.
7. Prostitution -is the business or practice of engaging in sexual relations in exchange for payment or some
other benefit. Prostitution is sometimes described as commercial sex.

Marriage
Marriage is defined differently, and by different entities, based on cultural, religious, and personal factors.
A commonly accepted and encompassing definition of marriage is the following: a formal union and social and
legal contract between two individuals that unites their lives legally, economically, and emotionally. The
contractual marriage agreement usually implies that the couple has legal obligations to each other throughout
their lives or until they decide to divorce. Being married also gives legitimacy to sexual relations within the
marriage. Traditionally, marriage is often viewed as having a key role in the preservation of morals and civilization.

Fundamentals of marriage

Husband- A married man considered in relation to his spouse.

Wife- A married woman considered in relation to her spouse
Marriage License- A license that a couple must obtain before getting married
• Monogamy - one man, one woman. All 1st world countries are monogamous.
• Polygamy - more than one wife or husband. Example: Islam & Fundamental Mormons
• Bigamy – Marrying another person while still married to someone else. It is against the law.
• Serial Monogamy or Modified Polygamy – Succession of marriages over time. Typical of US marriages.

Issues on sex outside marriage

Premarital sex- Premarital sex is sexual activity which is practiced by people before they are married.
Historically, premarital sex has been considered a moral issue which is taboo in many cultures and it is also
considered a sin by a number of religions, but since the sexual revolution of the 1960s, it has become accepted
by certain liberal movements, especially in Western countries.

Extra Marital Sex- occurs when a married person engages in sexual activity with someone other than their
spouse.

Where extramarital sexual relations do breach a sexual norm, it may be referred to as adultery or non-monogamy
(sexual acts between a married person and a person other than the spouse), fornication (sexual acts between
unmarried people), philandery, or infidelity. These terms imply moral or religious consequences, whether in civil
law or religious law.

Adultery and Concubinage

Philippines' law criminalizes adultery and concubinage. Both are deemed “crimes against chastity” under the
Revised Penal Code of the Philippines and are treated as sexual infidelity in the Family Code.

The law discriminates against wives. The crime of adultery can be committed only by a wife and her paramour.
The husband need only prove that his wife had sexual intercourse with a man other than him.

The crime of concubinage can be committed only by a husband and his concubine, but it requires that the wife
must prove that her husband has kept a mistress in the conjugal dwelling, or has had sexual intercourse under
“scandalous circumstances” or lived together with his mistress in any other place.
The penalties are also quite different. For adultery the guilty wife and her paramour may be imprisoned for up to
6 years

For concubinage, the husband may be imprisoned for up to 4 years and 1 day, while his concubine may be
merely “banished” but may not be imprisoned.

The laws work to the great disadvantage of women. There is no divorce in the Philippines and abandoned wives
are often accused of adultery in order to force them to agree to their husband's petitions to nullify the marriage.
The Philippine Commission on Women reports that, “In many cases, women who are faced by these threats are
forced to forego legitimate custodial claims of their children while some are forced to give up their claims over
conjugal properties, assets and the like.”

Contraception Methods of Contraception

1. Folk methods Precoital/Poscoital Douche Prolonged Lactation Withdrawal- coitus interruptos, coitus
reservatus
2. Mechanical methods condom Diaphragm Sponge
3. Chemical methods Vaginal suppositories and tablets Vaginal jellies, creams, and foams
4. Hormonal methods Contraceptive pills Injections and implants
5. Abortifacients Intrauterine Device DES( diethylstilbestrol Prostaglandin Antipregnancy vaccine Low-dose of
contraceptive pills
6. Surgical methods Tubal ligation Vasectomy Hysterectomy
7. Natural or behavioral methods Rhythm or calendar method Temperature method Ovulation (Mucus) Method
Sympto-thermal method Sex relations during menstruation

The controversy questions around are

1. Whether individuals have a right to control parenthood?
2. Which type of contraceptive method is best?
3. Who should practice contraceptives?
4. At what age contraception would be used?

Age of consent
• Children who are under the age of eighteen years may be sexually active and require health care because
of pregnancy or sexually transmitted diseases.
• Some students ask the physician or school nurse for birth control devices.

Application of ethical theories

Natural law ethics had two division
• Only rhythm method and abstinence
• Voluntary sterilization as WRONG
Utilitarianism
• Justify contraception and sterilization for the greatest happiness and benefits
Pragmatism
• Contraception and sterilization is practical, useful, and beneficial.
ISSUES ON ARTIFICIAL REPRODUCTION AND ITS MORALITY. MORALITY ON ABORTION AND
RAPE

Artificial Insemination
Artificial insemination (AI) consist of depositing a man’s semen in the vagina, cervical canal or uterus through
the use of instruments to bring about conception unattained or unattainable by sexual intercourse.

2 types of artificial insemination

1. Homologous insemination or artificial insemination by husband (AIH)
 2. Heterologous insemination or artificial insemination by donor

Justification for AIH

1. Husband;s impotence
2. Anatomical defects of a husband’s urethra
3. Oligospermia
4. Spinal injury
5. Underwent vasectomy
6. Anatomical problem of the wife

Justification for AID

1. Azoospermia
2. Husband is carrier of a hereditary disease
3. Wife’s oocytes are defective
4. Wife’s anatomical problem

In Vitro Fertilization
• In vitro fertilization and embryo transplant (IVF-ET)
• One or more eggs are surgically removed from a woman’s ovary, fertilized with her husband’s sperm in a
laboratory dish and developed in the dish for a few days after which tiny embryo is transferred into the
woman’s uterus in the hope that pregnancy will proceed normally.
• There is complete separation of unitive and procreative concepts
• It does not show the burden of the procedure such as expenses, emotional frustrations, child defects, other
serious problems;
• It promotes the wrong attitude of the child being a product and not a gift

Fundamental ethical concern

• Any intervention in the reproductive process is that the child be brought into existence by the NATURAL
love act of married couple

Other ethical issues

• Bypassing the natural method of conception;

• The creation of life in the laboratory;
• Fertilization of more embryos than will be needed;
• Discarding of excess embryos;
• Unnatural environment for embryos;
• Use of untested technology;
• Not affordable for many;
• Misallocation of medical resources
• Creation of embryos, then freezing them, and keeping them "in limbo“;
• Exposure of embryos to unnatural substances;
• Destruction of embryos in research;
• Potential to create, select and modify embryos;
• Facilitation of the idea that embryos are commodities;
• Financial rewards for IVF doctors dissuade them from recommending other methods to couples;
• Infertility is treated as a disease and not as a symptom of underlying medical problems.

Surrogate Motherhood
SURROGACY
▪ A surrogacy arrangement or surrogacy agreement is the carrying of a pregnancy for intended parents.
SURROGATE
A surrogate is a substitute or deputy for another person in a specific role and may refer to:
1. Surrogate pregnancy is a type of pregnancy in which a woman carries and gives birth to a baby for a
person who is not able to have children.
2. Sexual surrogate, sometimes referred to as surrogate partners, are practitioners trained in addressing
issues of intimacy and sexuality. A surrogate partner works in collaboration with a therapist to meet the
goals of their client.
3. Surrogate marriage, describes the arrangement where a woman is infertile or dies young and her family
substitutes another woman to bear children for the husband.

Surrogate Mothers
▪ A surrogate mother is a woman who agrees to carry a pregnancy to term for a subfertile couple.
▪ The surrogate may provide the ova and be impregnated by the man’s sperm. In other instances, the ova and
sperm both may be donated by the subfertile couple, or donor ova and sperm may be used.
▪ Surrogate mothers are often friends or family members who assume the role out of friendship or compassion,
or they can be referred to the couple through an agency or attorney and receive monetary reimbursement for
their expenses.

TYPES OF SURROGACY
1. Gestational surrogacy - the child is not biologically related to the surrogate mother, who is often referred to
as a gestational carrier. Instead, the embryo is created via in vitro fertilization (IVF), using the eggs and sperm
of the intended parents or donors, and is then transferred to the surrogate This form of surrogacy is sometimes
also called “host surrogacy” or “full surrogacy.” In most cases, at least one intended parent is genetically related
to the child, and the surrogate is not. This makes gestational surrogacy less legally complicated than other forms
of surrogacy because stepparent or second-parent adoption is not required.

How does gestational surrogacy work?

Intended parents may locate a surrogacy opportunity on their own and pursue an independent surrogacy with an
attorney specializing in assisted reproductive law.

Once a match has been identified, the surrogate and intended parents will each work with an attorney to discuss
each party’s legal risks and responsibilities, as well as surrogate compensation. Once everyone is in agreement
and the contracts are signed, a fertility clinic will handle the IVF and embryo transfer process. An embryo will be
created and transferred to the surrogate using one of the following:

1. The eggs and sperm of the intended parents, in which case both intended parents will be genetically
related to their child
2. A donated egg fertilized with sperm from the intended father, in which case the intended father will be
genetically related to the child
3. The intended mother’s egg fertilized with donor sperm, in which case the intended mother will be
genetically related to the child
4. A donor embryo or an embryo created using donor eggs and donor sperm, in which case neither intended
parent will be genetically related to the child
5. From there, the surrogate will carry the baby as if it were any other pregnancy, and the intended parents
will welcome their child and have full legal custody when he or she is born.

Pros and Cons of Gestational Surrogacy

PROS CONS
 Gestational surrogacy permits infertile couples, single Surrogacy is generally a legally complex and costly
parents and members of the LGBT community to process.
complete their families.

Gestational surrogacy consents intended parents to Gestational surrogacy requires intended parents to
maintain a genetic link to their child. abandon some control as someone else carries the
pregnancy for them.

Surrogacy gives proposed parents the opportunity to If the proposed mother is using her own eggs in the
create a meaningful relationship with their surrogate. surrogacy process, she will have to undergo fertility
treatments and other medical procedures.

2. Traditional surrogacy - the surrogate mother uses her own egg and is artificially inseminated using sperm
from the intended father or a donor. The surrogate carries and delivers the baby, and then, because she is the
child’s biological mother, must relinquish her parental rights so that the child can be raised by the intended
parents.
Traditional surrogacy is sometimes also called partial surrogacy or genetic surrogacy because of the surrogate’s
biological link to the child she carries

How Does Traditional Surrogacy Work?

• First, the intended parents will not need to identify an egg donor because the surrogate’s eggs will be used
instead. This means the family only needs to be matched to a surrogate who is willing to complete a traditional
surrogacy.
• Once the intended parents have found a traditional surrogate they would like to work with, legal contracts must
be drafted and signed.
• Traditional surrogacy uses intrauterine insemination (IUI) to artificially inseminate the surrogate mother using the
intended father’s sperm. IUI is less complicated, less expensive and involves fewer medical procedures than
IVF, and this process can be repeated several times until a pregnancy is achieved.
• From there, the surrogate will carry the baby as if it were any other pregnancy. When the baby is born, the
surrogate will be the biological mother and therefore has parental rights.

Pros and Cons of Traditional Surrogacy

PROS CONS
Traditional surrogacy is usually less expensive than A traditional surrogate is the biological mother of her child,
gestational surrogacy. meaning she has parental rights and the power to change
her mind and keep the baby. The intended parents would
then need to go to court to gain custody of the child.

Intended mothers do not need to undergo medical In some cases, intended parents will need to complete a
procedures because their eggs will not be stepparent adoption to both be recognized as the child’s
harvested to create the embryo. legal parents.
Intended mothers do not have the option of being
biologically related to their children in traditional
surrogacy.

ROLE OF MOTHER
New definition of a Mother
• Genetic mother - a woman whose contribution to the child was the ovum, and hence genes.
 • Gestational mother - a woman whose uterus was used for the nurturing and development of an embryo
into a baby.
• Social mother - a woman who rears the baby after birth.

2 types of surrogacy arrangements

• Altruistic surrogacy - In this type of surrogacy, the surrogate mother is not paid for her 'service'. She 'offers
her womb' as an act of 'altruism'. Often there will be a pre-established bond between the surrogate mother
and the expecting couple. Typically the surrogate mother is a friend or a relative.
• Commercial surrogacy - In commercial surrogacy the surrogate mother receives compensation for carrying
the child. Often there will be a mediating party, a surrogacy agency that deals with all the practical
arrangements for the commissioning couple: finding a suitable surrogate mother and dealing with all the
paperwork etc.

CONFLICTS OF SURROGATE MOTHERHOOD

• The idea of surrogate motherhood is morally wrong
• Degrade the role and value of mother
• Put the unborn children into dangerous circumstance

ETHICAL ISSUES
• What if the surrogate decides to maintain her privacy?
• What if the surrogate and the spouse violate the abstention clause?
• What if the surrogate decides to keep the baby?
• What if the surrogate with genetic ties demands to visit her child?
• Is handing over a child after delivery for a fee baby-selling?
• Do women participate in surrogacy to save their marriage?

Abortion

What is Abortion?
Abortion (from Latin abortāre, from aboriri to miscarry, from ab — wrongly, badly) has been defined simply by the
Collins Australian Dictionary as the ‘premature termination of a pregnancy by either spontaneous or induced
expulsion of a nonviable fetus from a uterus’.

Value-neutral (objective) definitions:

Opposed to abortion - ‘artificially causing the miscarriage of an unborn child’, or ‘killing an innocent human being’.
Support abortion - ‘terminating pregnancy’ or ‘ridding the products of unwanted/unviable conception’.
Is Abortion Morally Permissible?
Anthropological studies suggest that abortion has been widely practised across cultures and throughout human
history:
Chinese, Egyptian and Greek text - describes abortion tecniques
Muslim culture - permit abortion, so long as it is procured while ‘the embryo is unformed in human shape’.
Japan - did not introduce anti-abortion laws until the Meiji Restoration (1869–1912).

Philippine Law on Abortion

• According to Article 2, Section 12 of the 1986 Philippine Constitution “The state recognizes the sanctity
of life and shall protect and strengthen the family as a basic autonomous social institution. It shall equally
protect the life of the mother and the life of the unborn from conception.”

• Revised Penal Code of the Philippines (enacted in 1930 and remains in effect today.) Articles 256, 258
and 259 of the Code mandate imprisonment for the woman who undergoes the abortion, as well as for
any person who assists in the procedure, even if they be the woman's parents, a physician or midwife.
Types of Abortion
• Natural/Spontaneous or Accidental Abortion - The removal of the product of conception through natural
or accidental causes.
• Direct or Intentional Abortion - planned removal of the product of conception before it has become viable
or survived.
• Therapeutic Abortion - planned removal of a living fetus inorder to save the mother from death or harm
caused by medical problems.
• Eugenic/Selective or Abortion on Fetal Indications - this is done once they discovered that the fetus has
anatomical defects and cannot live outside the utero once delivered.
• Indirect Abortion - the fetus will be removed as a secondary effect of a procedure done to save the life of
the mother.

Viewpoints on Abortion
● Conservative Viewpoint - It declares that abortion is never permissible, or atmost, is permissible if and only
it is required to save thepregnant woman’s life, as in the case of the removal of a cancerous uterus or the removal
of the fallopian tube,or a part of it, because of ectopic pregnancy. (Edge, R. S. and Groves, J. R. 2018)
● Liberal Viewpoint - States that abortion is always permissible, whateverthe state of fetal development may
be. If women are truly to be liberated, this view contends, they must ultimately have full freedom to control their
own reproductive capacities.
“The fetus has no ontological status; it is neither an individual, human, nor a person, but only a tissue in a
woman’s uterus; therefore, it possesses no rightsand no moral status.” (Edge, R. S. and Groves, J. R. 2018)

● The moderate or intermediate Viewpoint - It holds that abortion is morally permissible up tocertain stage of
fetal development, or for some limitedset of reasons sufficient to justify the taking of life inthis or that special
circumstances. As far as the moderates are concerned, the fetus obtains ontological status at quickening or
viability. (Edge, R. S. and Groves, J. R. 2018)

Methods of Abortion
1. PLANTS AND PLANT PREPARATIONS
a. Ruta chalepensis/graveolens
b. Lycopodium saururus),
c. Parsley (Petroselinum hortense),
2. PHYSICAL METHODS
a. Massage and abdominal pressure are applied by the hilot
3. INSERTION OF CATHETERS
4. DILATION AND CURETTAGE- Usually, this is performed for pregnant women who had already been
bleeding, in which case it is called completion curettage.
5. DRUGS These include medicines such as quinine, an anti-malarial;
a. methylergometrin, a uterine stimulant methotrexate, an anti-cancer drug.
b. Misoprostol (Cytotec)
6. SALT POISONING - A needle is inserted through the mother’s abdomen and 50-250 ml of amniotic fluid
is withdrawn and replaced with a solution of concentrated salt.
7. HYSTEROTOMY - is a form of abortion in which the uterus is opened through an abdominal incision and
the fetus is removed, similar to a caesarean section, but requiring a smaller incision. (Abortion. (2007). MSN
Encarta. Retrieved July 1, 2007. Archived 2009-10-31)

DIGNITY OF DEATH AND DYING, ADVANCE DIRECTIVES AND DO NOT RESUSCITATE (DNR)
Euthanasia and prolongation of life
Etymologically euthanasia means “easy death” from the Greek words eu which means easy and Thanatos which
means death. More strictly it means painless and peaceful death: it is deliberate putting to death in an easy,
painless way, of an individual suffering from an incurable and agonizing disease.

Cases of euthanasia may be grouped into self-administered and other administered. The selfadministered may
be either active (positive) euthanasia in which the terminally ill patient will deliberately, directly terminate his/her
life by employing painless methods- it is an act of commission as it is voluntary and deliberate. Passive (negative)
euthanasia in which one allows oneself to die without taking any medications or by refusing medical treatment it
is an act of omission as one simply refuses to take anything to sustain life.

Classification of euthanasia

1. Active and voluntary euthanasia- is one in which either a physician, a spouse or a friend of a patient
will terminate the patient’s life upon his/her request. It is voluntary as it is requested by the patient and
active as some positive means is used to terminate the patient’s life.

2. Passive and voluntary euthanasia- is one in which the terminally ill patients is simply allowed to dies
by the physician, spouse or an immediate relative upon the patient’s request. It is passive as no positive
method is employed; the patient is permitted to pass away. It is voluntary as this is done upon the patient’s
request.

3. Active and non-voluntary euthanasia- occurs when it is the physician, spouse, friend or relative who
decides that the life of the terminally ill patient should be terminated. It is active as some positive method
is utilized to terminate the patient’s life it is non voluntary as the termination of the patient’s life is decided
by an individual other than the patient

4. Passive and non-voluntary euthanasia- is one in which a terminally ill patient is simply allowed to die,
as requested to immediate family members or the attending physician. It is passive in as much as no
positive means is employed to end the patient’s life; it is non voluntary as other person make the moral
decision to terminate the patient’s life.

Suicide
Suicide is the direct and willful destruction of one’s own life. It is direct insofar as the primary object of thee act
is the killing of oneself; it is willful insofar as it is deliberate, voluntary and intentional. And it is destructive insofar
as the means of terminating one’s own life is, more often than not, violent, brutal or very harsh. In some respects,
the concept of active voluntary euthanasia and suicide overlap, but there are several differences, people who
resort to euthanasia do so for the medical reasons, hence, it is referred to as an easy and painless death.

Suicide, on the contrary, is usually the destructive and violent termination of one’s life. As a rule, suicide
presupposes incurable ailment or terminal condition. Hence, the former is a sudden interruption or destruction
of the life process, while the latter is an easy, painless, and quiet acceleration of imminent or certain death for
one to rid of prolonged suffering. Furthermore the individual who commits suicide for non-medical reasons is
solely responsible for his or her death.
Application of Ethical Theories

Natural law ethics, with its principle of stewardship, considers suicide as self-murder. An individual has no right
to murder himself/herself as he/she has no right to murder someone else. Life is a gift of God, A person is only
a steward, a caretaker at most.

The utilitarian’s principle of utility seems to be in keeping with the argument that an individual may deliberately
terminate his/her own life if and when suffering becomes too much to bear. Besides, whenever one has become
a financial burden and a liability due to a prolonged, incurable disease, then an appeal to the greatest happiness
for the greatest number principle becomes justifiable. This is arguable, however.

Kant’s ethics, within the context of the categorical imperative’s not using oneself only as a means but always as
an end. May be taken as a rejection or prohibition of suicide. On the other hand, advocates of the principle of
autonomy and self-regulating will to support and justify their argument that an individual not only has a duty to
preserve his/her life, but also to die with dignity if and when the situation warrants such a moral decision.

Dysthanasia

The timeline of humanity shows us evolution in almost every field of arts and science. In science, the advances
have come through the knowledge and technology, which is itself the result of applied knowledge.

In medicine, the aftermath of this evolution has contributed, together with social improvement of many societies,
to a progressive and sustained increase in life expectancy.
The increase in life expectancy owes much of its accomplishments, so far as Medicine is concerned, to the
technological achievements which can directly influence the natural history of end of life.

In terms of concept, the end of life or death has two moments: The process of death and the moments of death.
While the latter is the moment of irreversibility, the former―the process of death―can be swayed in either way;
in fastening―euthanasia or in retarding―dysthanasia.
Dysthanasia from Greek, dysthanatos, turning death difficult. In a broad sense it can be understood as medical
stubbornness or a futile treatment. In good medical practice the treatment should be proportional to the expected
prognosis. If the treatment provided clearly overcomes the expected prognosis retarding the process of dying
and prolonging the agony and suffering of the patient, than it seems clear that it is a case of dysthanasia.

Orthothanasia

The word orthothanasia was used for the first time in the 1950s. It means correct dying, or allowing to die or
letting die.

It is vital to note the difference between allowing death to occur and intending death to happen. While in
euthanasia the death of the patient is directly intended and caused, in allowing to die his death is directly caused
by a grave pathology: the morphine administered to the patient in pain directly causes the relief of his pain and
indirectly and unintendedly may perhaps advance his death, which is merely foreseen and tolerated.

Let us underline that in the case of letting die, what is directly intended is the relief of the acute pain of the patient.
In allowing to or letting die, therefore, death is neither directly caused nor intended or postponed. It merely
happens. It is an event, part of the temporal life of every human being. Hence, allowing to die is anti-euthanasia,
which unethically anticipates death, and antidysthanasia, which unduly postpones it.

ALLOWING TO DIE: POSSIBILITIES

Allowing to die includes, in particular, three possibilities.

First possibility: when the treatment to prolong life is useless or futile for the patient, and therefore ought not to
be given. We remember the world of the poet: For man to want to live when God wants him to die is madness.
 Second possibility for letting die: when the prolongation of life or the postponement of death is unduly
burdensome in the first place for the patient – also for the family. On this point, the Catechism of the Catholic
Church summarizes the traditional teaching of the magisterium:
“Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the
expected outcome can be legitimate; it is the refusal of ‘over-zealous’ treatment. Here one does not will to cause
death; one’s inability to impede it is merely accepted” (CCC, 2278).

Third possibility for allowing to die: when the patient needs painkillers or medical sedation, which does not intend
the death of the patient. These painkillers directly mitigate suffering and indirectly may shorten life. Physicians
and significant others are committed to relieve pain and suffering, which is their professional commitment, or
moral duty limited only by the prohibition against direct killing. Summing up the traditional teaching of the Church,
the Catechism states: “The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening
their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but
only foreseen and tolerated as inevitable”

Administration of drugs to the dying

In medicine, specifically in end of life care, palliative sedation is the practice of relieving distress in a terminally
ill person in the last hours or days of the dying patient’s life, usually by means of a continuous intravenous or
subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable
and discreet administration of ongoing medications via rectal route. Palliative sedation is an option of last resort
for patients whose symptoms cannot be controlled by any other means. It is not a form of euthanasia, as the
goal of palliative sedation is to control symptoms, rather than to shorten the patient’s life.

Advance Directives

An advance decision (or Advance Directive, a Living Will, or Healthcare Directive) allows an individual to provide
instructions for future medical care and treatment while still capable of making decisions for themselves and
provides an opportunity for an individual to discuss treatment opportunities with healthcare professionals,
including medical staff as well, as to discuss and resolve difficult issues with family and friends.
Some medical conditions permit the extension of life for many years through artificial means. But many patients
and their families question the significance of doing so where there is little hope of recovery.
The value of life during and after recovery from an illness is often an essential issue. Consider quality-of-life
issues in making decisions about accepting, rejecting, or stopping medical treatment. Advance directives were
created in response to the increasing complexity and prevalence of medical technology. Numerous studies have
documented critical discrepancies in the medical care of the dying; it has been found to be unnecessarily
sustained, painful, expensive, and emotionally burdensome to both patients and their families.

Advance directives
Is a legal document in which a person specifies what actions should be taken for their health if they are no longer
able to make decisions for themselves because of illness or incapacity.
Advance directives are written, legally-recognized documents that state your choices about healthcare treatment
or name someone to make such choices for you if you are not able to do so (Reyes, 2010).
Purpose of Advance directives
• Appointment of health care proxy
• Make decision and guide doctors about life sustaining procedures in the event of terminal condition,
persistent vegetative state and end stage condition i.e DNR, Pain management, Organ Donation,
Euthanasia.

ADVANCE DIRECTIVES : FORMS.

1. Living will (Health-care directives)
• A living will is a more restricted type of advance directive because you only make decisions about life
sustaining procedure in the event that your death from a terminal conditions is impending.
• This is a living document that allows a person to state whether he or she wants his or her life artificially
prolonged under certain conditions. The Health-Care Directive would only be followed if the patient is
diagnosed in writing by the attending physician to be in a terminal condition or in a permanent unconscious
situation by two doctors, and where the application of life-sustaining treatments would serve only to artificially
prolong the process of dying.
• The Health-Care Directive must be signed by the patient and witnessed by two persons. The witnesses
cannot be related to the patient or expect to inherit anything from the patient and they cannot be hospital
employees, staff, attending doctors or employees of the attending doctor.

2. Health care proxy

• Is a document (legal instrument) with which a patient appoints an agent to legally make health care
decisions on behalf of the patient, when he or she is incapable of making and executing healthcare
decisions stipulated in the proxy.
• This is a legal document in which an individual designates another person to make healthcare decisions
if he or she is rendered incapable of making their wishes known. The healthcare proxy has, in essence,
the same rights to request or refuse treatment that the individual would have if capable of making and
communicating decisions.
• Most people pick a spouse, partner, or child as their health care proxy. Obviously, you want someone
who knows you and your preferences well.

3. Power of attorney
• Written authorization to represent or act on another ‘s behalf if private affairs, business, or some other legal
matter, sometimes against the wishes of the other.
• Not limited to healthcare but also other matters, such as finance

ADVANCE DIRECTIVES: ADVANTAGE

• unnecessarily prolonged painful hospitalization
• Prevents unnecessary prolonged comatose or vegetative state
• Prevents burden of rising Medical costs
• Releases responsibility of love ones of difficult decisions

ADVANCE DIRECTIVES : DISADVANTAGE

• Family or loved ones may disagree with your medical decisions.
• Difficulty in predicting what treatments will be available and preferred in a “future” crisis.
• Uncertainty over who can/should be a health care agent, especially for individuals without available (or
willing) family.

Do not resuscitate (DNR)

In decisions regarding cardiopulmonary resuscitation (CPR), nurses have an active role in initiating or withholding
life-sustaining treatment. Considering whether to initiate CPR with a patient requires attention to professional,
ethical, legal, and institutional considerations. Principles utilized to justify decisions regarding resuscitation
include autonomy, self-determination, non-maleficence, and respect for persons.

The general practice regarding CPR is that it must be initiated unless: (1) it would clearly be futile to do so, or (2)
the practitioner has specific instructions not to do so. The legal definition of do not resuscitate (DNR) is not to
initiate CPR in the event of a cardiac or pulmonary arrest. As noted previously, DNR orders are written directives
placed in a patient’s medical record indicating that the use of cardiopulmonary resuscitation is to be avoided.
DNR orders should be documented immediately in a patient’s health care record, noting the reason the order
was written, who gave consent and who was involved in the discussion, whether the patient was competent to
give consent or who was authorized to do so, and the time frame for the DNR order (American Nurses Association
[ANA], 2003). In situations of medical futility, decisions to withhold or stop CPR are appropriately made by
physicians in consultation with patients and families and need not be offered as an option for patients. DNR
decisions require open communication among the patient or surrogate, the family, and the health care team. This
communication needs to include explicit discussion of the efficacy and desirability of CPR, balanced with the
potential harm and suffering it may cause the patient. People often overestimate the effectiveness of CPR, and
do not understand that CPR is not always medically indicated. Many people derive their concept of CPR from
what they see in the media. Diem, Lantos, and Tulsky (1996) conducted an interesting study that indicated that
rates of survival after CPR in television dramas were much higher than the most optimistic survival rates in the
medical literature. In order to make informed decisions regarding CPR, patients and families need to understand
the patient’s clinical condition and prognosis People rarely appreciate that CPR is a harsh and traumatic
procedure, and that patients with multiple, severe, chronic health problems who receive CPR rarely survive to
be discharged (Cadogan, 2010; Feen, 2010).

The relevance of considering the patient’s or family’s values in justifying DNR orders may vary, depending on
the rationale given for the decision (ANA, 2003; Cadogan, 2010; Feen, 2010; Hayes, 2004; Hickman et al., 2009).
In situations in which CPR would be medically ineffective, patient autonomy and consent are considered less
relevant. However, when the rationale for the decision is based on the patient’s quality of life, either after or
before CPR, determination of whether the benefit of continued life outweighs the risk of harmful consequences,
such as debility or suffering, must flow from the values of the patient or the patient’s surrogate. Competent
patients have the right to refuse CPR and may request DNR orders after they have been informed of the risks
and benefits involved. Good communication is the most critical factor in assuring that any DNR decision is
acceptable to all parties involved.

DNR orders apply only to resuscitation. The fact that CPR might be considered futile does not necessarily imply
that other life-sustaining interventions are futile or that other treatments will not be used. Health care providers
often fail to make this distinction, thus causing confusion for patients as well. Many institutions require more
specific instructions regarding what is and is not to be done for a patient. These interventions might include
treatment of physiological abnormalities such as fever or cardiac arrhythmias, nutrition, or use of mechanical
ventilation and CPR. Plans for and parameters of DNR orders need to be discussed with all members of the
health care team so that the goal of care is clear. The presence of DNR orders requires nurses to become even
more focused on providing supportive and comfort interventions, and to ensure that there is no reduction in the
level of care for the patient and family. A DNR order means only that, in the event of cardiac or respiratory arrest,
there are to be no attempts to resuscitate. Presuming no arrest occurs, the patient may recover from the problem
necessitating hospitalization and return home.

Many years ago Scofield suggested that decisions to not resuscitate ask us “individually and collectively, to arrive
at a consensus on how to integrate death and decisions about it into the legitimating values of our moral universe.
Deciding what kind of life we want involves deciding what kind of death we can face” (1995, p. 184). He noted
that death, which was once considered fate, is now often a matter of a choice that we do not want to have to
make. His comments are still relevant today because those involved in DNR decisions face this dilemma.