BASIC ETHICAL PRINCIPLES

HEALTH CARE ETHICS

(BIOETHICS )

Compiled by:
LNP
1. PRINCIPLE OF STEWARDSHIP
 Life comes from God, and humans are "stewards"
responsible for the care of the body.

This principle is grounded in the presupposition that God has absolute Dominion over
creation, and that, insofar as human beings are made in God’s image and likeness (Imago
Dei), we have been given a limited dominion over creation and are responsible for its
care. The principle requires that the gifts of human life and its natural environment be
used with profound respect for their intrinsic ends. Accordingly, simply because
something can be done does not necessarily mean that it should be done (the fallacy of
the technological imperative). (When means become ends: technology producing values)

As applied to Catholic-sponsored health care, the principle of stewardship includes but is

not reducible to concern for scarce resources; rather, it also implies a responsibility to see
that the mission of Catholic health care is carried out as a ministry with its particular
commitment to human dignity and the common good.
 Stewardship- refers to the expression of one’s responsibility to take care of, nurture and cultivate what has
been entrusted to him.
 In health care practice, STEWARDSHIP refers to the execution of responsibility of the health care practitioners
to look after, provide necessary health care services, and promote the health and life of those entrusted to
their care.

Traditional definitions of stewardship

 In the Book of Genesis, God appoints humanity as the steward of all creation. The Old Testament tells the
story of Joseph, who is sold by his brothers into slavery and becomes Potiphar’s steward and ultimately the
Pharaoh’s. From this parable, a steward is a selfless servant who manages assets and possessions without
owning them, foresees future trends and creates plans and interventions.

 The parable of ‘talents’ in the New Testament describes another aspect of stewardship in which a master
divides his worldly goods between his three servants. The moral portrayed in this parable is that when one is
entrusted with something of value, there is an obligation to improve on it.

 The Islamic institution of Hisba is responsible for organising public administrative functions within the
dimensions of morality, normality and technology. The head of the Al Hisba is called the Muhtasib, who was
first appointed in Medina in the 9th century. The Muhtasib in the pre-colonial Arab civilisation was
responsible for the regulation of medical practice and pharmaceuticals, which incorporated equitable
provision of services to the public.
Stewardship of nursing

The leadership potential of stewardship in nursing requires new models of delivery of care, and we need to address the
ever-changing nature of the work of a nurse. With evolving new roles in the nursing profession, collaboration with nursing
research colleagues will be required to develop mechanisms of evaluation and assessment which further refine evidence
that supports the essential and exclusive contributions of the professional nurse in outcomes of care and prevention.
Development and enhancement of the evidence in research call for nursing stewards who will embark on such issues to
design new financial models in order to constantly build the business side of nursing care delivery models. Such leadership
will become synergistic with the work in the area of stewardship of the health care system.

Future nurse leaders or stewards will be directly centered on working with nurse practitioners and nurse educators to
transform the practice environments in which they work. The intended outcome is to make practice environments more
positive, healthy and engaging. Areas for dialogue may be within:

• patient-population centeredness
• safety for patients and health care personnel
• the needs of an ageing workforce
• increased autonomy for advanced nurse practitioners
• increased respect for the contributions made by professional nurses
• clarification of the caring work of the nurse, and
• enhancement of the collaborative practice of the multidisciplinary health care team.
Stewardship of self
To meet the domains of stewardship in health care and the nursing profession, it is
crucial that nurse leaders engage with the development of self. Succession planning to
develop and nurture a new generation of transformational nurse leaders may be the
only way to achieve this. To meet the concept of lifelong learning, nurse leaders or
stewards will need to use of mentors and personal coaches to assist them in refining
skills and improving competencies.4 Healthy nurse leader stewards will thus become
visible and sound role models within their institutions to maintain the balance
between self and professional fulfilment.4

The future of nursing is rapidly changing. Things are somewhat chaotic at times, but
the opportunities for stewardship are many and varied. We are ideally suited to serve
as nurse leaders or stewards in all aspects of health care. By embracing the six aims of
health care improvement, the leadership of nursing can be both invigorating and
transformational.
2. PRINCIPLE OF INTEGRITY AND TOTALITY

These principles dictate that the well-being of the whole person must be
taken into account in deciding about any therapeutic intervention or use of
technology.

 In this context, "integrity" refers to each individual’s duty to "preserve a

view of the whole human person in which the values of the intellect,
will, conscience, and fraternity are pre-eminent”.”

 Totality" refers to the duty to preserve intact the physical component of

the integrated bodily and spiritual nature of human life, whereby every
part of the human body "exists for the sake of the whole as the
imperfect for the sake of the perfect".
The whole implies the existence of its parts. The existence of its parts
indicates the existence of the whole.
Parts as such should continuously be connected with the whole of
which they are parts without which they cease to be.
The whole is greater than any of its parts.
Suppose a man’s foot is gangrenous, should he consent to an
amputation? Since the amputation will save his life and he can still walk
through the aid of crutches or artificial limbs, he can consent to an
operation.
However, if its state of condition and continuous existence as part pose
a threat to do more harm than good leading to the destruction of the
whole and that there is no other means by which the problem can be
addressed, the principle of totality provides that it be removed and
sacrificed for the sake of the whole.
3. THE PRINCIPLES OF DOUBLE EFFECT
 An action that is good in itself that has two effects--an intended and otherwise not
reasonably attainable good effect, and an unintended yet foreseen evil effect--is
licit, provided there is a due proportion between the intended good and the
permitted evil.
 When there is a clash between the two universal norms of "do good" and "avoid
evil," the question arises as to whether the obligation to avoid evil requires one to
abstain from a good action in order to prevent a foreseen but merely permitted
concomitant evil effect. The answer is that one need not always abstain from a good
action that has foreseen bad effects, depending on certain moral criteria identified
in the principle of double effect. Though five are listed here, some authors
emphasize only four basic moral criteria (the fifth listed here further specifies the
third criterion):
1. The object of the act must not be intrinsically contradictory to one's
fundamental commitment to God and neighbor (including oneself), that
is, it must be a good action judged by its moral object (in other words,
the action must not be intrinsically evil);
2. The direct intention of the agent must be to achieve the beneficial
effects and to avoid the foreseen harmful effects as far as possible, that
is, one must only indirectly intend the harm;
3. The foreseen beneficial effects must not be achieved by the means of
the foreseen harmful effects, and no other means of achieving those
effects are available;
4. The foreseen beneficial effects must be equal to or greater than the
foreseen harmful effects (the proportionate judgment)
5. The beneficial effects must follow from the action at least as
immediately as do the harmful effect.
When a nurse is faced with a situation which may have both good and
bad effects, how should she choose which one to follow? The basis of
action may be the following:

 That the good action must be morally good.

 That the good effect must be willed and the bad effect merely
allowed
 That the good effect must not come from evil action but from the
initial action itself directly
 That the good effect must be greater than the bad effect.
It is not morally good if a boy steals in order to alleviate his
hunger because the action itself is already bad.

On the other hand, if a patient who has cancer of the uterus
submits to hysterectomy she will not be able to bear a child. If
she does not have the operation, she will die. It is the
gynecologist’s intention to help the mother and not harm her.
The surgeon’s action is morally good since saving the mother’s
life is of primary importance. Also the doctor himself did not
will that the patient lose her child-bearing function
4. THE PRINCIPLE OF COOPERATION

 Along with the principles of double effect and toleration, the

principles of cooperation were developed in the Catholic moral
tradition as a way of helping individuals discern how to properly
avoid, limit, or distance themselves from evil (especially intrinsic evil)
in order to avoid a worse evil or to achieve an important good.

 In more recent years, the principles of cooperation have been applied

to organizations or "corporate persons" (the implication being that
organizations, like individual persons, are moral agents). Like the
principle of double effect and some other moral principles, the
principles of cooperation are actually a constellation of moral criteria.
1. Formal Cooperation.
Formal cooperation occurs when a person or organization
freely participates in the action(s) of a principal agent, or
shares in the agent’s intention, either for its own sake or as a
means to some other goal. Implicit formal cooperation
occurs when, even though the cooperator denies intending
the object of the principal agent, the cooperating person or
organization participates in the action directly and in such a
way that it could not be done without this participation.
Formal cooperation in intrinsically evil actions, either
explicitly or implicitly, is morally illicit.
2. Immediate Material Cooperation.
Immediate material cooperation occurs when the cooperator participates in
circumstances that are essential to the commission of an act, such that the act could
not occur without this participation. Immediate material cooperation in intrinsically
evil actions is morally illicit. There has been in the tradition a debate about the
permissibility of immediate cooperation in immoral acts under "duress." When
individuals are forced under duress (e.g., at gunpoint) to cooperate in the
intrinsically evil action of another, they act with diminished freedom.

3. Mediate Material Cooperation.

Mediate material cooperation occurs when the cooperator participates in
circumstances that are not essential to the commission of an action, such that the
action could occur even without this cooperation. Mediate material cooperation in
an immoral act might be justifiable under three basic conditions:
a. If there is a proportionately serious reason for the
cooperation (i.e., for the sake of protecting an important
good or for avoiding a worse harm); the graver the evil the
more serious a reason required for the cooperation;
b. The importance of the reason for cooperation must be
proportionate to the causal proximity of the cooperator’s
action to the action of the principal agent (the distinction
between proximate and remote);
c. The danger of scandal (i.e., leading others into doing evil,
leading others into error, or spreading confusion) must be
avoided
5. THE PRINCIPLE OF SOLIDARITY
 The principle of solidarity invites us to consider how we relate to
each other in community. It assumes that we recognize that we are a
part of at least one family - our biological family, our local
community, or our national community - but then challenges us to
consider the full range of relationships with others.

 In a globalizing economy, we participate in a vast, international

economic community, one in which goods and services are provided
for us by those on the other side of the world. Solidarity requires us
to consider this kind of extended community, and to act in such a
way that reflects concern for the well-being of others.
1. Participation extends the idea of solidarity to make it practical.
The demands of solidarity point us to the principle of participation, so that
those affected by an environmental decision can shape how it is made. Many,
many environmental problems stem from decisions being made by private
individuals or companies that have wide-ranging implications. In some cases,
in this country and others, governments make environmental decisions
without fully securing the consent of the public.

Often, those most affected are unaware of the decisions or the long-term
effects on their health and the well-being of their environment. The ethical
principle of participation requires us to recognize all of the parties - human
and non-human - likely to be affected by a decision, and to recognize that all
parties should have a say in how the decision is made. Genuine participation
requires transparency, meaning that each individual has access to the same
information that everyone else has.
6. THE PRINCIPLE OF SUBSIDIARITY
Means that what an individual, lower or smaller group can achieve
within his / her or its capacity should not be taken away and transmitted
to the custody and performance of a higher or bigger group.
Often considered a corollary of the principle of the common good,
subsidiarity requires those in positions of authority to recognize that
individuals have a right to participate in decisions that directly affect
them, in accord with their dignity and with their responsibility to the
common good.
Decisions should be made at the most appropriate level in a society or
organization, that is one should not withdraw those decisions or choices
that rightly belong to the individuals or smaller groups and assign them
to higher authority.