MODULE 5: OTHER ETHICAL PRINCIPLES AND APPROACHES

 
Objectives: After the discussion, the students will be able to:
a. different ethical principles and approaches in bioethics; and
b. investigate nursing ethical issues or challenges utilizing the different
ethical principles and approaches.
 
 
Module 5 gives an overview of the three bioethical approaches that includes teleological
approach, deontological approach and virtue approach; and also the five common universal
principles of biomedical ethics that includes autonomy, veracity, beneficience, non-maleficence
and justice. The discussion of the concepts focus more on its application in the nursing practice
that will initially help you to investigate ethical issues or challenges in the clinical area.
 
What would a teleological thinker say, is it good or bad?
What about a deontological thinker, is it good or bad?

A nurse allows a granddaughter to see his dying Lola even

though it is not a visiting hour.

A father steals food to be able to feed his starving family.

A patient decided to go home and the doctor ordered MGH

against medical advice.
 A. Teleological Approach
 It originated from the Greek word telos meaning end or purpose/goal
 It stresses the end-result, goal or consequences of an act as the determining factor of its rightness and
wrongness
 It is also called consequential ethics
o If the consequences of my action increase the blood pressure of my patient then it is wrong
o If the consequences of my action give comfort to my patient then it is right
 Focus on issues of fairness
 
Forms
1. Ethical Relativism also known as moral relativism
 No universal or absolute moral principles. Standard of right and wrong are always relative to a particular
culture or society. It depends on the prevailing view of a particular individual, culture, or historical period.
 
 Some examples are:
o Some ethnic group practice cultural activities to cleanse the patient from sickness.
o Some religious group accepts blood transfusion but others do not.
o Abortion is acceptable in other countries like US, Canada but considered as murder in the Philippines.
2. Situation ethics
 The moral norm depends upon a given situation, but whatever this situation may
be, one must always act in the name of Christian love
 Consider the particular context of an act when evaluating it ethically, rather than
judging it according to absolute moral standards.
 Like a situation wherein a patient who insisted to be discharged due to economic
and cultural reasons was ordered by the doctor MGH against medical advice.
Instead of judging the family and the patient, the nurse come up with discharge
plan and discuss with the family and patient.
3. Pragmatism
 It considers the workability, practicality or usefulness of an idea as the criterion of true
knowledge
 A word may have different meaning in a different setting like people react differently to a
symbol in a different setting.
 Pragmatism promotes respect for the individual, as it appreciates that each person has
unique needs. In the health care setting, we have to be aware that clients are recipient of
care and the nurse is a client advocate and provider of care. The usefulness or workability of
our interventions depends on our perceived health needs of our client depends on the
particular environment.
 Like in the use of herbal medicine or acupuncture as an alternative treatment, some patients
accept because they find it effective but others says it is use by quack doctors; and another
example is a dried tree valued by a sculptor as a beautiful furniture but a farmer value it as a
fuel.
4. Utilitarianism
 
 It is a theory of moral philosophy that is based on the principle that an action is morally right if it
produces greater quantity of good or happiness than any other possible actions. It requires to look
into the consequences to determine the morality of an action and claim that the morality of the action
depends on the amount of “goodness” that the action produces (Principle of utility). It emphasizes that
the rightness and goodness of an action is determined by the goodness and badness of their
consequences.

 Usefulness of an act is determined by the extent to which it promotes happiness rather than its
reverse. It emphasize the “The greatest good for the greatest number” , in which they say that
utilitarianism involves “moral calculus”.

 When you will be a Public Health Nurse and will be involved in the planning of the Provincial Health
Board. You will be one of those who will decide to which program should you allot a bigger budget,
would it be the modernization of the hospital or escalating the preventive programs like nutrition and
immunization programs. In this scenario, you will consider the greatest good for the greatest
number.Will promotion of health and prevention of diseases have priority over treatment of illness and
rehabilitation?
 The following are guidelines for making ethical decisions provided by Fletcher:

1. Consideration for people as human beings;

2. Consideration of consequences;
3. Proportionate good to come from the choices;
4. Propriety of action needs over ideal or potential needs;
5. A desire to enlarge choices and reduce chance; and
6. A courageous acceptance of the consequence of the decision.
B. Deontological Approach

 The word deontology derives from the Greek words for duty (deon) and science (or study) of
(logos). Deontology falls within the domain of moral theories that guide and assess our choices
of what we ought to do (deontic theories), in contrast to those that guide and assess what kind
of person we are and should be (aretaic [virtue] theories).
 The morality of an action is determined whether it is done according to an objective principle
which is opposition to consequentialists. It embraces duty-oriented or principle –based
theories.
 A person is morally good if his action are done from a sense of duty and reason.According to
W. D. Ross, to consider the 7 prima facie when other relevant factors in a situation are not
considered.

A nurse is assigned to care for a COVID 19 infected patient. Could

she reasonably refuse to care for the patient on the ground that the
patient’s condition may threaten his health?

As practitioners, nurses are to take care of the sick even if it threaten one’s
heath since it is our sworn duty. The nurse however must observe the
necessary precautions to protect their health.
 Which of the statement would you expect a
deontologist and a utilitarian say?

Promises are meant to be broken.

Promises are meant NOT to be broken

A deontologist might argue that a promise ought to be kept simply because it is right to keep a promise,
regardless whether the doing so will have a good or bad consequences. In contrast, a utilitarian argues
that we should keep our promises only when keeping them results in better consequences than the
alternatives.
C. Virtue Approach
 It is from the Greek 'aretai' meaning 'virtue' or 'excellence'.
 It is also called Normative Ethical Theory and it is a character-based approach to morality that
assumes that we acquire virtue through practice. It articulates that normative evaluations are
rooted in the character of a moral agent rather than the consequences of an action (contra
Consequentialism) or some intrinsic feature of an action itself (contra Deontological Ethics). The
fundamental question of morality, they believe, is not "What should I do?" but rather "What kind of
person do I want to be?"
 Primarily focus on the heart of a person performing the act. It is not only doing the right thing but
also to develop the trait and qualities of a good person such as having right motivation, right
disposition and traits for being good such as courage, justice, honesty, beneficence. In nursing
practice, virtues expected are professional competence, honesty and integrity, caring and
compassion
 A nurse who has developed the virtue of being punctual is often referred to as a punctual person
because she tends to be on time in all circumstances and became an inherent in the character of
the nurse.
D. Universal Principles of Biomedical Ethics

1. Autonomy

 It is from the Greek word “autos” meaning self and “nomos” meaning governance
 It is the expression of self-determination and freedom to choose and implement one’s own
decision free from deceit, duress, constraint and coercion
 Clients and nurses has the right to exercise their autonomy to maintain a quality health
care.
 
  For a client to be able to decide appropriately, the client has the following rights:
 
a. Right to informed consent
 The client has a right to be informed of the appropriate and accurate information about his
condition for him to be able make an informed and voluntary decision about accepting or
declining medical care.
 Information should explained within the level of understanding of the client.
b. Right to informed decision
 Client should be aware of the choices and treatments for his medical care, the potential
outcomes of these choices and treatments and the personal values considered in making
decision which then will help client to decide regarding his health care during deliberation.
 Client who makes decision must be:
 Competent
 has the intellectual capacity to make a rational decision
 legal age 18 yrs. old and above
 decision is of her free will and not coerced
c. Right to informed choice
 After accurate information and understanding genuine deliberation of his health condition, the
client has the right to inform his decision on either to accept or reject a treatment or to transfer to
another hospital for further treatment of diagnosis.
d. Right to refusal of treatment
 A client has the right to reject a treatment even though his life will be in danger. Some clients are
discharged from the hospital against medical advice since it is the right of the client to refuse the
continuity of care.
 4 Major elements of informed consent:

a. Competence: It refers to a patient’s capacity for decision making. The mental and cognitive ability of
the person giving the consent should be assessed to ensure that the person has the intellectual
capacity to make a rational decision.
b. Disclosure- It denotes that accurate content of what a patient is told or informed about during the
consent negotiation. The purpose for such a disclosure is to inform the client of the potential risks
and possible actions to minimize the effects of the vulnerability.
c. Comprehension- It refers to what extend the information given has been understood. Discussion
should be within the level of understanding of the client. Nurses should countercheck and ensure
that the client understood what was explained.
d. Voluntariness- It means that signing a consent to a certain treatment or procedure should be done
with free will, free from coercion. Client can refuse and should be respected by the health team.
Therapeutic privilege:

 This is an exception of the rule of informed consent

 This privilege will allow health care provider to proceed :
a. in case of emergency
b. incompetence
c. waiver
d. implied consent
2. Veracity
 It means that we have the obligation to tell the truth. We as health care provider and the patient/client
are bond to tell the truth for us to be able to accurately assess, come up with nursing diagnosis, decide
on appropriate intervention and to be able to have a better evaluation of the health care.
 
In the International Council of Nurses Code of ethics and in the Code of ethics for Filipino Nurses, point out
that nurses should practice veracity as stated in the following:
 
International Council of Nurses code of ethics:
https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally
appropriate manner of which to base consent for care and related treatment.
 
Code of Ethics for Filipino Nurse ARTICLE III Sec 9 b:
https://www.prc.gov.ph/uploaded/documents/Board%20of%20Nursing-CE.pdf
The nurses to provide the patients or their families with all pertinent information except those
which may be deemed harmful to their well-being
 Patient’s or clients also has obligations to practice veracity .They have also the responsibilities to tell
the truth to be able to help in their effective and efficient health care. The following are the patient’s
responsibilities (Venzon, 2005):
 
a. Providing information
The patient has the responsibility to provide truthful, accurate and complete information about
his chief complain, history of present and past illness, hospitalization, medication and other
matters related to his health condition. If the patient cannot provide the information, the
immediate member of the family or significant others are responsible for doing so in his behalf.
If the patient is a toddler, the mother is the best person to give the information.
b. Complying with instructions
A patient is responsible for complying with the treatment plan, keep his appointments, abide by
the hospital policies and also has the responsibility to inform those concern if not able to
conform with it.
c. Informing the physician of refusal of treatment
A patient who refuses treatment or to be compliant with the treatment plan has the obligation
to inform the physicians and nurses.
d. Paying hospital bills
Patients are also responsible for ensuring that financial obligations related to his/her health care
are fulfilled. They have also the responsibility to communicate to the concern offices in-case of
financial limitation.

e. Following hospital rules and regulations

The patient is responsible for following the hospital’s rules and regulations and shall advise his
/her family or watcher to do so also. Uneasiness on the hospital rules and regulations should be
communicated to the concern person/offices such as financial limitations so that clients maybe
referred to the DSWD.

f. Show respect and consideration

The patient must be considerate of the rights of other patients and hospital personnel. They must
also respect the property of other person and that of the hospital. They shall assist in the control of
noise, smoking, playing loud music and maintaining clean environment. Since the nurses are the
closest health care provider to the patients, they are the most logical guardians of the patient’s rights.
The nurse has the duties to inform the patients and their relatives/guardian upon admission of the
responsibilities expected from them.
Benevolent Deception
Benevolent Deception is the withholding temporarily
information base on sound medical judgement that to divulge
the information might potentially harm a depressed and
unstable client
 

Ethical concern:
Case #1 If informed… would it not be more advantageous?
Wife would be examined, protected or treated
Wife would be able to do precautionary measures for herself
Wife would be able to understand the husband’s illness and participate in the care
 
Case #2 If informed….. Would it not be advantageous?
Gently telling her the truth would help convince her to participate in the treatment plan, spiritual
preparation towards peaceful death.
Confidentiality

 It refers to the non-disclosure of personal information that has been

communicated within the nurse–patient relationship. The nurse has a
duty to maintain confidentiality of all patient information, both personal
and clinical in the work setting and off duty in all venues, including
social media or any other means.
 The duty to maintain confidentiality is not absolute and may need to be
modified in order to protect the patient, other innocent parties, and in
circumstances of required disclosure such as mandated reporting or
for safety or public health reasons. (ANA, 2014)
 Confidentiality of information may be revealed (5 C) on the following circumstances:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2922345/
 
a. Consent : The patient permits such revelation as in the case of for hospitalization, insurance benefits,
among others;
b. Comply with existing law and regulations like in the case of medico-legal to comply with mandatory
reporting such as in attempted suicide, gunshot wounds which have to be reported to the police
c. Communicate a threat such as patient who is ill of communicable disease and public safety may be
jeopardize as stipulated in RA # 11332: Mandatory Reporting of Notifiable Diseases and Health Events of
Public Health Concern Act
https://www.officialgazette.gov.ph/downloads/2019/04apr/20190426-RA-11332-RRD.pdf
d. Care: Information is given to members of the health team if information is relevant to his continued care.
We have to abide with what is stated in the Phil constitution Art IV Sec 4.
The privacy of communication and correspondence shall be inviolable except upon lawful order of
the court or when public safety and order requires otherwise.
e. Court Order: May release confidential information upon the receipt of an order by a court.
For further information, you read Republic Act 10173 Data Privacy Act of 2012
https://www.privacy.gov.ph/data-privacy-act/

Section. 13. Sensitive Personal Information and Privileged Information :The processing of
sensitive personal information and privileged information shall be prohibited, except in the f
following cases:
(a) The data subject has given his or her consent, specific to the purpose prior to the
processing
(b) The processing of the same is provided for by existing laws and regulations: Provided that
such regulatory enactments guarantee the protection of the sensitive personal information and
the privileged information
 (c) The processing is necessary to protect the life and health of the data subject or
another person, and the data subject is not legally or physically able to express his or
her consent prior to the processing;
(d) The processing is necessary to achieve the lawful and noncommercial objectives of
public organizations and their associations:
(e) The processing is necessary for purposes of medical treatment, is carried out by a
medical practitioner or a medical treatment institution
(f) The processing concerns such personal information as is necessary for the
protection of lawful rights and interests of natural or legal persons

Bridge of Confidentiality
 Occurs when patient’s information is disclosed to a 3rd party without his consent or
court order
 Disclosure maybe through oral, written, by telephone, fax, or electronically such as
posting photos or information in the social media like facebook and messenger.
3. Beneficence
 It refers to the act of kindness and mercy. The emphasis that health care provider like nurses
should to do good for the patient.
 All the statement of beneficence involved positive action toward preventing or removing harm and
promoting the good.
Ex: administer the right drug, right dose of medicine at the right time to the right patient
 For us health care provider to do good to our patient/clients, we have to uphold the patient’s bill of
right. The following are the patient’s bill of right:

a. The patient has the right to considerate and respectful care;

b. The patient has the right to relevant, current and understandable information concerning diagnosis,
treatment prognosis, specific procedures, treatment risks involved, medically reasonable alternative
benefits needed to make informed consent;
c. The patient has the right to make decisions regarding his plan of care; in case of refusal, he is entitled
to other appropriate care and service or be transferred to another hospital;
d. The patient has the right to have advance directive (such as living will) concerning treatment or
designating a surrogate decision maker;
e. The patient has the right to every consideration of his privacy such as in case discussion ,
consultation and treatment;
f. The patient has the right to confidentiality of communications and records;
g. The patient has the right to review his records concerning his medical care and have these
explained to him except when restricted by law;
h. The patient has the right to be informed of business relationship among the hospital educational
institution, health care providers that may influence the patient’s treatment and care;
i. The patient has the right to consent or decline to participate in experimental research affecting
his care;
j. The patient has the right to reasonable continuity of care when appropriate and be informed of
other care options when hospital care is no longer appropriate; and
k. The patient has the right to be informed of hospital policies and practices that relate to patient
care.
You will notice that in some hospitals, the patient’s bill of right is posted in the
walls of the hospital wards and other hospitals also had it printed and include
it as part of the patient’s kit. It is the responsibility of the nurse to orient the
patients /clients on their rights especially when they are admitted in the
hospital.
4. Nonmaleficience

 Stated as an admonition (warning/caution) in the negative form to remind Health Practitioners to

do no harm

 Avoid inflicting evil , injury or harm upon others as we would avoid doing so to ourselves,
avoiding pain, suffering, disability and death

 Some interventions that may also give harm to patient:

 Chloramphenicol for typhoid fever with side effect of aplastic anaemia
 Analgesic such as morphine given for moderate to severe pain may lead to a suppression
of respiration
 Ibuprofen for pain given may also upset stomach
 
 To maintain the ethical position of nonmaleficence, mostly practitioners explained their action
through the principle of double effect.
 5. Justice
 It refers to the right to demand to be treated justly, fairly and equally. The hospital management
ensure that a nurse is treated justly (equity) by giving her merit like promotion and certificate of
recognition base on his significant effort, skills and contribution in the effective and efficient
health care implementation that help in the decrease of patient affected by COVID-19 virus.
Likewise, all health workers assigned to patient affected by COVID 19 virus regardless of
position are treated equally and fairly by giving them complete personal protective equipment
(PPE) in recognition that it is their need and benefit as frontliners.
 
 For the Filipino Citizen to have an equal access to the services of Philhealth, the Philippine
government approved the National Health Insurance Act of 1995 which ensures the Universal
compulsory health insurance program in the country. Recognizing also the unique need of the
Senior Citizen, the Philippine government also approved the Republic Act 7432- Senior Citizen
Act which is the legal basis for giving 20% discount to the elderly.
 Health is a basic human right. The DOH ensure quality health services available
and affordable by mobilizing resource, providing means to better health, and
arousing community participation.
 
 In advocating justice, we have to support our clients by respecting their right and
at the same time as nurses, we also have to assert our right.
 
 Bills of rights for registered nurses ( Venzon, 2005)

a. Nurses have the right to practice in a manner that fulfils their obligations to society and to
those who receive nursing care;
b. Nurses have the right to practice in an environment that allows them to act in accordance with
professional standards and legally authorized scopes of practice;
c. Nurses have the right to a work environment that supports and facilitates ethical practice, in
accordance with the Code of ethics for nurses and its interpretive statements;
d. Nurses have the right to freely and openly advocate for themselves for their patients, without
fear of retribution (revenge);
e. Nurses have the right to fair compensation for their work consistent with their knowledge,
experience, and professional responsibilities;
f. Nurses have the right to a work environment that is safe for themselves and their patients;
and
g. Nurses have the right to negotiate the conditions of their employment, either as individuals or
collectively in all practice settings