NCM 108: Health Care Ethics

the rational analysis of it.” - Joseph

Fletcher
OBLIGATIONS OF A PROFESSIONAL
Morality refers to codes of conduct actually put
Characteristics of a Profession forward by distinct groups or societies.
Ethics - is a process of reflection in which
- Competence in a specialized body of
people’s decisions are shaped by their values,
knowledge and skill.
principles, and purpose. A generic term for the
- The provision of a particular service to
study of how we make judgments in regard to
study.
right and wrong.
- Standards of education and practice.
Code of Ethics for Nurses
- Self-regulation - an acknowledgment of
specific duties and responsibilities
toward our patients, colleagues, and
society.

Code of Ethics - binding together as a group of

practitioners and expressing the aims and
aspirations of that group.
Legal Practice Act - outlines the activities the
providers perform in the delivery of patient care.
Fiduciary Relationship - acting primarily in the
best interests of those they serve.

Professional Etiquette
- Involves issues such as the need to
avoid talking badly about another
practitioner, maintenance of
appropriate relationships at the
workplace, or the need to stay within
the role boundaries of our specialty.
- The professional etiquette requirements
of our roles in health care are usually
based on the traditions of good practice
and good manners.
- It also helps in maintaining order and
civility in our practices.

Health Care Ethics - are designed to promote

order and maintain civility.

Ethics and Morality

- “Morality was what people believed to
be right and good, while ethics is the
critical reflection about morality and

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 NCM 108: Health Care Ethics

Foundations of Law
- Law - is a body of rules of action or
conduct prescribed by controlling
authority and having binding legal
force. Law can also be considered as
the minimum standard of expected
performance between individuals in the
society.
- Obligations of law and ethics are
closely aligned with ethical obligations
typically exceeding legal duties.
- The basic sources for modern law are
common law, which emanates from
judicial decisions; statutory law, which
arises from legislative bodies; and
administrative law, which flows from
rules and regulations and decisions of
administrative agencies.
- Stare decisis which translates to “let the
decision stand”. The use of this
principle provides the system with
needed stability, and yet it has allowed
for the creation of new principles as
changing patterns of facts have
emerged.
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 NCM 108: Health Care Ethics

Fundamental Principles of Law The Complaint and Answer

- A concern for justice and fairness - A plaintiff files a complaint or petition
- Plasticity and change with the court that addresses the
- Doctrine of Individual Rights and elements of the prima facie case.
Responsibilities - Prima facie means that it is legally
sufficient to establish a case.
Common Misunderstandings about the - The plaintiff needs to provide proof and
Nature of Law it requires that he or she present
- There is a feeling that law is evidence for all the essential facts in
all-inclusive and that if you need a the case, and the number of offenses
legal determination, all you need to do that the defendant is guilty of violating.
is to apply the correct legal precedent.
In fact, the law is complete and always The Common Elements of a Complaint:
growing. It is possible in these
currently unexplored areas for
something to be neither legal nor
illegal.
- The belief that if one does this, the law
will do that is a misunderstanding - The notification explains to the
based on the idea that law is defendant the nature of claims. The
prescriptive and certain. In fact, there defendant usually has a statutory
are areas where we have no previous required period of time in which a
legal rulings, and even where we have complaint must be answered.
legal precedence to guide us, growth - Pleadings is the formal presentation of
and changes occur. claims and defenses by parties to a
- The law tells you what to do. In this lawsuit.
way of thinking, legal acts are those - Pro se is a Latin phrase meaning ‘for
things you should do. It is wise to view oneself’, or ‘on one’s own behalf’. In
the law as a guide to proper behavior. legal context it is used when an
individual acts without the assistance of
Public Law - the part of the law that governs legal counsel.
relationships between individuals and the - After the answer has been filed, the
government. defendant may file a motion for
Private Law - a branch of law that deals with summary judgment or a motion to
the relations between individuals or institutions, dismiss.
rather than relations between these and the - If there is a dispute of the facts of the
government. case, then a motion for summary
judgment will not stand.
Lawsuit - The defendant’s answer must address
each of the plaintiff’s allegations. The
- A plaintiff is a person who brings an defendant has three choices: admit,
action in a court of law. deny, or plead ignorance to each
- A defendant is a person against whom allegation in the complaint.
an action is brought. - Affirmative defenses are a fact or a set
of facts other than those alleged by the
plaintiff or prosecutor, that, if proven,
defeats or mitigates the legal
consequences of the defendant’s
otherwise unlawful conduct.
- Filing an answer moves the case into
the pretrial phase.

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 NCM 108: Health Care Ethics

Discovery presented, reviews the evidence, and

- Often the longest part of the lawsuit. proposes a compromise settlement.
- It is the fact-finding phase meant to - It can either be binding or nonbinding.
eliminate surprises, clarify what the - In binding, the decision is final and not
lawsuit is about, and make the parties appealable.
decide if they should settle or drop - If nonbinding, the door is open for
claims and/or offenses. appeal or refusal to comply.
- Major elements of discovery are - Arbitration is chosen because the
interrogatories, document requests, and process is less time consuming and less
depositions. expensive than a suit and trial
- Interrogatories are a series of questions proceedings.
sent by one side to the other. Hippocratic Oath
- Depositions are the opportunity for
each side to question witnesses and
parties to a suit to elicit information
about the case. It is also the most
common and effective method of
discovery as it allows both parties to be
aware of the arguments or claims that
are going to be made in the trial.
Trial and Judgement
- A case may be tried before a judge only
or before a judge and jury.
- During the trial, each side presents
witnesses, and the evidence collected is
placed on record.
- After they have presented and Nightingale’s Pledge
examined the witnesses each party is
allowed time for a closing argument.
- The jury’s decisions are not put into
effect until the judge makes a
judgment, which is the approval to
have the trial’s information to be filed
in public records.
- Civil Case - the judge is allowed at this
time to make changes to the jury’s
verdict by either adding to or reducing
the punishment.
- Criminal Case - the judge does not
have the authority to change the jury
decision.
Appeal
- Losing party may appeal a trial court
decision to a higher court in that
particular jurisdiction, however, only a
final judgment may be appealed.
Arbitration
- Involves a neutral third party that both
sides have agreed will have the power
to decide the outcome and render a
binding decision.
- The arbitrator listens to statements
from both sides, reads documents
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 NCM 108: Health Care Ethics

specific form of consequentialism and

DECISION MAKING IN VALUE ISSUES
utilitarianism.
AND PRIVATE LAW
- Consequence-oriented theories judge the
rightness or wrongness of decisions based
on outcomes or predicted outcomes.
- Teleological theory is taken from the
Greek word telos that means end.
- Joseph Fletcher said that human need
determines what is or is not ethical.
- Agape: can be defined as general goodwill
or love for humanity. If an act helps
people, it's a good act; if it hurts, it's a bad
act.

Deontological (Duty-Oriented) Theories

- Associated with duties and rights that
encourages the judgements on the
rightness of actions based on the duty of
those involved, irrespective of any real or
predicted consequences or outcomes.
- Utilitarianism is where the good resides in
the promotion of happiness or the greatest
net increase of pleasure over pain.
Act Utilitarianism
- The decision is based on listing the
possible alternatives for action, weighing
each in regard to the amount of pleasure or
utility it provides, and selecting the course
of action that maximizes pleasure.
Rule Utilitarianism
- An action can be deemed to be right if it
- The rightness or wrongness of an act is conforms to a rule that has been validated
essentially independent of its by the principle of utility.
consequences , what matters is that the
actor acts out of moral duty. Virtue Ethics
- Immanuel Kant who is, generally
considered the first proponent of - Aristotle
duty-based ethics. - The heart of the moral agent making the
- He proposed these rational agents: decision rather than the reasoning to a
- The agent should act only on a principle right action.
or a maxim that can be regarded as a - Primarily about personal character and
universal law and agreed by everyone. moral habit development rather than a
- No one should be treated merely as particular action.
‘means’ but always an end.

Teleological (Consequence-oriented) Theories

- More concerned with the goals and
consequences of actions when making
judgements on their appropriateness.
Examples of it are consequentialism and a

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 NCM 108: Health Care Ethics

Private Law violates the right to be free from restraint

of movement.
- Concerned with the recognition and
○ Invasion of privacy
enforcement of the rights and duties of
○ Breach of contract - there is failure,
private citizens and organizations. Torts
without legal excuse, to perform any
and contract law are basic types of private
promise that comprises the whole or part
law.
of the contract. Contractual duty can
Basic objectives of tort law are:
occur as the result of signing documents
● Preservation of peace between individuals
or can arise out of implication.
● Determining of fault
● Compensation of injury
Torts are classified into 3 broad categories:
● Negligent torts CORE BIOETHICAL PRINCIPLES
● Intentional torts
• Bio –– life.
● Tort in which liability assessed irrespective
• Ethos –– customs or norms.
of fault (strict liability)
Negligent Torts
❶ STEWARDSHIP
● Negligence is the unintentional
● A principle in Christian ethics.
commission of an act that a reasonably
● A human life comes from God, and no
prudent person would or would not do
individual is the master of her own body.
under the same circumstances.
● Take care of our life and to the life of other
○ Malfeasance - the execution of an
people.
unlawful act
○ Nurses are responsible to someone’s life
○ Misfeasance - improper performance of
○ Avoid harm in human body
an act that lead to injury
○ Nonfeasance - the failure to perform an
❷ TOTALITY
act when there is duty to act.
● Refers to the whole body.
● 4D’s of negligence: duty, dereliction of
● Every person has the duty to develop, use,
duty, direct cause, and damage.
care for and preserve all body parts.
● Res ipsa loquitur - the thing speaks for
○ You should not disregard any part of the
itself.
body
● Respondeat superior - let the master
○ Suggest also that an individual has the
answer.
right to cut off body parts that is no
Intentional Torts
longer functioning
● Willful act that violates another’s interest.
○ Example: diabetic foot
● Assault and battery, defamation of
character, false imprisonment, invasion of
❸ SOLIDARITY
privacy.
● Being one with the other.
○ Assault and battery: unlawful touching
● In practice, we should always be with our
without justification.
patients if they are incapable of doing
■ Assault - verbally
things.
■ Battery - physical contact (bodily
injury or offensive touching.
❹ RESPECT FOR PERSON
○ Defamation of Character: occurs when
● Every person has the responsibility to treat
one person communicates to a second
a person always as an end and never as a
person about someone in such a manner
means.
that the reputation of the person is
● Unique, worthy, rational, self-determining
harmed.
creature, and having the capacity to decide
■ Libel - written
what is best for him.
■ Slander - verbal
● Respect every decision they have: but
○ False Imprisonment - illegal confinement
nurses have the responsibility to explain
of an individual against their will by
the pros and cons of the decision.
another individual in a manner that
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 NCM 108: Health Care Ethics

❺ NON-MALEFICENCE THREE BASIC ELEMENTS OF AUTONOMY

● The non-infliction of evil, harm, or injury
to others and of course, to one’s self. 1. Ability to decide
○ Do no harm 2. Power to act on your decisions
○ Reason why nurses put handrails in the 3. Respect for the individual autonomy of
hospital others

❻ BENEFICENCE PATIENT’S RIGHTS

● Is the practice of doing acts of goodness, ● It is another consideration and decision
kindness and charity. making.
○ To do good ● Greater attention was paid to the rights of the
○ Think always of what is best for patient patient.
● Patients may expect to be informed of all
❼ JUSTICE alternatives for treatment and often want to
● The act of giving one what she deserves or participate in selecting a type of treatment,
what is due to her. weighing the possible benefits and risks of the
○ Fairness or equality. treatment methods presented.
Example: patient has right for decision making;
the nurse has the role to provide the right of THE PATIENT’S BILL OF RIGHTS
patient 1. Right to Appropriate Medical Care
and Humane Treatment.
❽ AUTONOMY ● Without any discrimination and within
● It is the right of every person to have the limits of resources.
control over their lives and decisions ● Good quality.
regarding their care. ● Human dignity, convictions, integrity,
individual needs and culture shall be
respected.
● Be informed of the reason for delay.
AUTONOMY
● Patients in emergency shall be extended
● One of the most important of health immediate medical care and treatment
care ethics. without any deposit, pledge, mortgage or
● The word comes from the Greek words any form of advance payment for
autos and nomos, which means self treatment.
and governance, respectively.
● It is a form of personal liberty, where 2. Right to Informed Consent.
the person is free to select and ● Right to a clear, truthful and substantial
implement her own decisions, free explanation in a manner and language
from deceit, pressure, constraint, or understood to the patient.
coercion. ● Written agreement between patient and
● Involves the right of self-determination, health care provider.
● Exemption:
independence, and freedom.
○ Emergency cases
● Other words often associated with
○ When health population is at risk
autonomy: dignity, inherent worth,
(epidemic)
self-reliance, and individualism.
○ When law makes it compulsory for
EXAMPLE: The nurse having difficulty supporting everyone to submit a procedure
the decision of a new mother, who is a Jehovah's ○ When patient is either a minor, or
Witness and whose life is in danger because of legally incompetent, in which case, a
blood loss, refuses to have a blood transfusion. third party consent is required
○ When the patient waives his right in
writing

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 NCM 108: Health Care Ethics

○ Emancipated: They can already make ○ His decision will not prejudice public
their own decision because they are health and safety.
financially independent or capable of
doing actions 7. Right to Religious Belief.
● In case a person is incapable of giving ● Shall not be imposed by parents upon their
consent and a third party consent is children who have not reached legal age in
required. life threatening situations.
○ Spouse
○ Son or daughter of legal age 8. Right to Medical Records.
○ Either parent ● Summary of medical history and
○ Brother or sister of legal age condition.
○ Guardian ● Has the right to view contents of his
medical records, except psychiatric notes
3. Right to Privacy and Confidentiality. and other incriminatory information
● Be free from unwarranted public obtained about 3rd parties.
exposure, except when his mental or ● Medical certificate and other documents
physical condition is in controversy and ● Within 45 days from request
the appropriate court orders him to
submit to a physical or mental 9. Right to Leave.
examination by physician. ● Right to leave the hospital.
● No patient shall be detained against his or
4. Right to Information. her will.
● Result of evaluation of the nature and extent ○ Only allowed to leave the hospital
of disease. provided appropriate arrangements have
● Other additional or further contemplated been made to settle the unpaid bills.
medical treatment on surgical procedures.
● Itemized bill of the hospital and medical 10. Right to Refuse Participation In
services rendered in the facility. Medical Research.
● The benefits and of the procedure and others ● Right to be advised if the health care
options in which the patient must be informed. provider plans to involve him in the
medical research.
5. Right to choose health care provider and
facility. 11. Right to Correspondence and to Receive
● Except when he is under the care of a Visitors.
service facility or when public health and ● Subject to reasonable limits prescribed by
safety so demands or when the patient the rules and regulations of the health care
expressly waives this right in writing. institution.
● Right to seek 2nd opinion and ● Limitations:
subsequent opinions. ○ If the patient is immunocompromised.
● Patient has the right to choose his or her ● General rule:
health practitioner. ○ Children below 12 years old are not
allowed in the hospital.
[Link] to Self-determination ○ Patient visitors should visit during
● Right to avail of any recommended visiting hours.
diagnostic and treatment procedures.
● Advance written directive –– advance 12. Right to Express Grievances.
directions (e.g. DNR waiver) ● Right to express complaints and
○ Informed of the medical consequences grievances about the care and service
of his choice. received.
○ Releases those involved in his care from
any obligation relative to the
consequences of his decision.

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 NCM 108: Health Care Ethics

13. Right to be Informed of His Rights and GUIDELINES FOR INFORMED CONSENT
Obligations as a Patient.
● The person(s) giving consent must fully
● It shall be the duty of the health care
comprehend:
institution to inform of their rights as well
1. The procedure to be performed
as of the institution’s rules and regulations
that apply to the conduct of the patient 2. The risk involved
while in the care of such institution. 3. Expected or desired outcomes
○ Upon admission, patients and relatives 4. Expected complications or side effects
are informed of their rights and that may occur as a result of treatment
obligations. 5. Alternative treatments that are available
○ To know all their rights. Informed consent is a process where you approach
○ Shall be posted on a bulletin board but the client and you explain the procedure, risk,
some are posted in the patient room. outcomes, complications and
other treatments.
INFORMED CONSENT
● It requires that clients be provided clear CONSENT MAY BE GIVEN BY:
and sufficient information about their 1. A competent adult
situation to make a rational decision for 2. A legal guardian or individual holding
themselves. durable power of attorney.
● It covers elements of: ● Authorization letter
○ Disclosure –– discuss the risks, benefits 3. An emancipated or married minor
and limitations of the procedure. 4. Mature minor (varies by state)
○ Understanding –– agreement between 5. Parent of a minor child
the patient and the health care provider. 6. Court order
○ Voluntariness –– patient is not coerced
If an informed consent by someone related to the
to sign and it should be his/her own patient (e.g. friends), the consent will be invalid.
decision. The best choice if the patient does not have anyone
○ Competence –– do not ask the patient to to sign the consent, it is for the hospital policy to
sign a consent if he/she is not an decide for them.
oriented and clear state.
○ Permission giving.
● Legal exceptions to the rules of informed CONSENT FOR MEDICAL TREATMENT
consent under therapeutic privilege have ● It is the responsibility of the medical
been made in cases of emergency, provider (physician, nurse, etc.).
incompetence, waiver, and when there is ● Included in the discussion must be the
implied consent. alternatives for treatment, the risks of any
● Every person has the right to either treatment proposed, the relative value of
consent (agree) to or refuse health care any treatment proposed, and the risks of
treatment. not having treatment.
● Benevolent deception –– the practitioner ● It can be verbal or written.
is permitted to intentionally withhold ○ The written consent is preferred in
information based on his sound medical health care to ensure that a record of
judgment that to divulge the information consent exists.
might possibly harm a depressed and ○ In accordance with the principle, “if it is
unstable patient. not written, it is not done.”
● Voluntary –– means that no coercion ● The form should state the specific
exists. proposed medical procedure or tests.
● Informed –– the person clearly ● The nurse may present a form for a patient
understands the choices being offered. to sign, and the nurse may sign the form as
a witness to the signature.
● The nurse has ethical obligations to assist
the patient in exercising his or her rights
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 NCM 108: Health Care Ethics

and to assist the physician in providing

EXAMPLE: The person who has had a major
appropriate care. surgery and is receiving large doses of narcotics
○ The nurse can relay the questions to the for pain may not be able to reason clearly.
physician.
● The nurse should attempt to present
CONSENT FOR NURSING MEASURES necessary nursing actions in a way that
elicits cooperation and avoids
● Nurses must obtain a patient’s consent for confrontation over decisions.
nursing care measures undertaken.
● Consent for nursing measures may be WITHDRAWING CONSENT
verbal or implied.
● Consent may be withdrawn after it is
EXAMPLE: The nurse may ask, “Are you ready to given.
ambulate now?” The patient answers, “Certainly,” ● People have the right to change their mind.
providing verbal consent.
● The nurse has an obligation to notify the
● The nurse should remember that the physician if the patient refuses a medical
patient is free to refuse any aspect of care procedure or treatment.
offered.
● Good nursing care requires that you use all CONSENT AND MINORS
means at your disposal to help the patient
● The consent of a minor usually is given by
comprehend the value of proposed care.
a parent or legal guardian.
EXAMPLE: The postoperative patient needs to ● The nurse should obtain the minor’s
understand that getting into a chair is part of the consent when he or she is able to give it.
plan of care, not a convenience for the nurse or ● Emancipated minors are minors who live
simply a change to prevent boredom.
apart from their parents and are financially
independent or who are married.
ADVANCE DIRECTIVES ○ Some states have specific laws relating
to the mature minor, allowing sexually
● Futuristic decision
active minors to give personal consent
● It is a legal document attesting to the
for STD or for obtaining birth control
wishes of an individual regarding health
information and supplies.
care in situations in which he or she is no
longer capable of giving personal informed
consent. ADVANTAGES OF INFORMED CONSENT
● They are completed in advance of the ● The patient feels respected when he/she is
situation in which they might be needed informed about all details regarding the
and direct the actions of others. treatment.
○ Feeling of security
COMPETENCE TO GIVE CONSENT ● It helps the patient to prepare his/her mind
● Competence –– it is the person’s ability to and body for the treatment.
make judgments based on rational ● It helps to avoid conflicts and mistrust and
understanding is termed competence. increases the patient’s faith in the
● The patient’s illness, age, or condition treatment.
alone does not determine competence. ● It decreases the fear and anxiety of the
○ Dementia, developmental disabilities, patient about the nature of treatment.
head injuries, strokes, and illnesses
creating loss of consciousness are DISADVANTAGES OF INFORMED
common causes of an inability to make CONSENT
judgements. ● To get informed consent from a depressed
● Competence may change from day to day, patient is difficult. Signing the informed
as a person's physical illness changes. consent sheet may create silent anxiety in
the patient’s minds.

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 NCM 108: Health Care Ethics

● It is challenging to explain the details for 3 PRIMARY ARGUMENTS THAT

getting informed consent during an SUPPORTS THE OBLIGATIONS OF
emergency. VERACITY
● If informed consent is not obtained,
● First argument is based on the respect
hospitals may refuse to provide care and
owed to persons in contexts beyond
the patient may lose his/her life.
informed consent.
● There will be no legal evidence to prove
● Second argument connects to obligations
that the treatment is given.
of fidelity, promise- keeping, and contract.
○ When we communicate with others, we
PATERNALISM
implicitly promise that we will speak
● It is the intentional limitation of the truthfully and that we will not deceive
autonomy of one person by another, in listeners.
which the person who limits autonomy ○ By entering into a relationship in health
appeals exclusively to grounds of benefit care, the patient enters into a contract
to the other person. that includes a right to receive truthful
● Health care professionals have a special information regarding diagnosis,
fiduciary relationship with patients based prognosis, procedures, and the like, just
on the confidence placed in us and the as the professional gains a right to
inequality of our positions with respect to truthful disclosures from patients.
information. ● Third argument is based on the role of trust
in relationships between health
EXAMPLE: The patient with a specific disease
was not offered information about possible professionals and patients.
treatment alternatives even when valid alternatives ○ Its thesis is that adherence to rules of
did exist. The physician decided which treatment veracity is essential to the development
method was preferable and that was the only one and maintenance of trust in these
presented to the patient. relationships.

THE DISCLOSURE OF BAD NEWS TO

PATIENTS
VERACITY & CONFIDENTIALITY
● Different cultural traditions and
VERACITY philosophical accounts have different
● It means telling the truth, which is views of the circumstances under which
essential to the integrity of the nondisclosure or partial disclosure is
client-provider relationship. justified.
● Health care providers obliged to be honest ● From our standpoint, the physician's or
with clients. nurse's fundamental obligation at the
● The right to self- determination becomes beginning of the process of disclosure is to
meaningless if the client does not receive reassure the patient while engaging
accurate, unbiased, and understandable sympathetically with the patient's feelings
information. and being present as a caring,
● Veracity in health care refers to accurate, knowledgeable professional.
timely, objective, and comprehensive ● Some information can be delayed and
transmission of information, as well as to spread over a period of time, and some
the way the professional fosters the may justifiably never be mentioned.
patient's or subject's understanding. ● This is not to deny that the physician or
○ In this regard, veracity is closely nurse also has an obligation to carefully
connected to respect for autonomy. attend to proper forms of disclosure.
● The best approach is to balance the need
for disclosure with careful attention to the
patient's responses.
● An example of these problems is
intentional nondisclosure to patients of a
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 NCM 108: Health Care Ethics

diagnosis of cancer or a similarly serious record of the patient.

medical condition and a prognosis of ● Indiscretion –– it is an action in which
imminent death. confidential information is shared
inadvertently.
CONFIDENTIALITY o There is no bad intent associated with
● It is an important ethical principle in an indiscretion.
nursing. ● Breach of Confidentiality –– it refers to
● It is an important legal and medical sharing information verbally or in
obligation that all health professionals are written form regarding a client with
supposed to obey. someone who is not on his/her care team,
● Matters regarding patients should not be or who does not have a release of
disclosed to others at any cost. information form from him/her.
● Confidentiality, trust and privacy are three ● Private –– it is defined as information
principles that are intertwined; if there is that is not available for public viewing or
no privacy and trust, there is no room for knowledge.
confidentiality. ● Privileged Information –– it is a term
● Both the Hippocrates Oath and the that refers to all information shared
Nightingale Pledge stress the importance between an attorney and his client.
of confidentiality. o This information is considered
● The basic elements of confidentiality confidential and is not admissible in
include respect for autonomy, privacy, court.
beneficence, non-maleficence and the o Applicable for lawyers but not doctors
relationship between patients and
caregivers in any setting. TYPES OF CONFIDENTIALITY

DEFINITION OF CONFIDENTIALITY DOCTOR–PATIENT CONFIDENTIALITY

● This refers to the confidentiality that is
● It is one of the ethical values needed for
maintained between a doctor and his/her
providing good care and is concerned
patient.
with protecting the private information
● The patient trusts that the doctor will not
of the patient that is obtained during the
reveal his/her details to others or discuss it
course of professional practice.
with them.
1. Confidentiality pertains to a situation
● This ethical principle is framed from the
in which information is expected to be
Hippocratic Oath, which states that a
kept secret.
doctor will not disclose anything
2. Confidentiality is both a legal and an
pertaining to the patient to unauthorized
ethical concept; it is legal to keep all
persons.
the records of a patient safe and
secure, and also it is ethical not to
ATTORNEY-CLIENT CONFIDENTIALITY
reveal any matters regarding the
● An attorney who represents a client must
patient to outsiders.
withhold any information disclosed to him
3. Confidentiality means that it is the
by the client or prospective client.
duty of every individual to respect and
● Any information garnered from the client
protect privileged information
during interviews or during representation
must not be released to any other person
IMPORTANT TERMS
without the written consent of the client.
● Informed Consent –– it is a legal
document signed by the patient after CONFIDENTIALITY AGREEMENT
detailed explanation about the procedure ● It is a legal document between two parties
to be done to the patient and its risks, when their relationship involves secrets.
consequences, etc. ● Businesses require that employees
o It is a permanent legal document or working in confidential areas of the
12
 NCM 108: Health Care Ethics

company sign confidentiality agreements is stronger when the third party is

when the company has a secret ingredient, dependent on others or in some way
product in development or new research especially vulnerable.
on existing products in development. ● Vulnerability –– implies risk or
● The protection of sensitive technical susceptibility to harm when vulnerable
information or other vital information that individuals have a relative inability to
if disclosed will harm the company protect themselves.
concerns this type of confidentiality ● Actions that are considered ethical are
agreement. not always found to be legal.
○ Though there is an ethical basis for
PASTORAL CONFIDENTIALITY subsuming the principle of
● This refers to the pastoral duties of a priest confidentiality in special
or a religious leader who is involved in circumstances, and there is some legal
looking after the religious needs of the precedent for doing so, there is legal
people. risk disclosing sensitive information.
● He/she has the responsibility to help the ○ There is dynamic tension between the
people solve their personal problems by patient's right to confidentiality and
means of fulfilling their spiritual needs. the duty to warn innocent others.
■ Health professionals need to
LIMITS OF CONFIDENTIALITY recognize that careful consideration
of the ethical implications of actions
● Should the principles of confidentiality will not always be supported in legal
be honored in all instances? There are systems.
arguments that favor questioning the
absolute obligation of confidentiality in DISCLOSURE OF INFORMATION
certain situations. These arguments
include theories related to the principles ● It is not necessarily an actionable breach of
of harm and vulnerability. confidence.
● Harm principle –– it can be applied when ● Disclosure may be allowed, under
the nurse or other professional certain circumstances, when it is
recognizes that maintaining requested by: the patient, and where it
confidentiality will result in preventable applies, freedom of information can be
wrongful harm to innocent others. used by patients to obtain health care
○ Foreseeability –– an important information;
consideration in situations in which ○ Other health practitioners (with the
confidentiality conflicts with the duty patient's consent, and where the
to warn. information is relevant to the patient's
○ The nurse or other health care care);
professional ○ Relatives in limited circumstances
○ should be able to reasonably foresee (e.g., parents when it is in the interests
harm or injury to an innocent other in of the child);
order to violate the principle of ○ Researchers with ethics committee
confidentiality in favor of a duty to approval (and where the approved
warn. process is followed);
○ The harm principle is strengthened ○ The court;
when one ○ The media, if the patient has
○ considers the vulnerability of the consented; and
innocent. ○ The police, when the health
● Vulnerability principle –– it can be professional has a duty to provide the
applied when the nurse considers the information.
vulnerability of the innocent or other
individual.
○ The duty to protect others from harm
13
 NCM 108: Health Care Ethics

texts call a due care standard.

■ This basically means that you have
taken all necessary action to use the
most appropriate treatment for the
condition and have provided that
treatment with the least amount of pain
and suffering possible.

BENEFICENCE
● In health care, you go beyond avoiding
harm to people.
NONMALEFICENCE & BENEFICENCE ○ Your obligation is to create benefit and
● Two parallel principles of ethics. contribute to optimum health for
● Some ethics writers view these principles individuals and the community at large.
as inseparable cousins. ● This obligation is called beneficence.
● Others argue that nonmaleficence is the ● Includes the obligation to help those in
strongest obligation of the two. trouble, protect patient’s rights, and
● Whatever the relationship, these two areas provide treatment for people who need it.
are central to a trust-based healthcare ● Patients assume that you are there for their
system because they are assumed by benefit and will act with charity and
society and individuals to be its pillars of kindness toward them.
practice. ○ Without this element of trust, it would
be very difficult for individuals to be
NONMALEFICENCE treated by practitioners, especially when
such treatment often requires
● Involves an ethical and legal duty to avoid embarrassing, painful, or even life-
harming others (Beauchamp & Childress, threatening procedures.
2008). ○ However, practicing beneficence means
● It is based on the Latin maxim primum that healthcare personnel must make an
non nocere or “First, do no harm.” active decision to act with compassion.
○ This concept does not mean that you ● This decision requires that they go beyond
cannot ever cause harm to patients in
the minimum standards of care and
order to treat them.
consider the patients’ needs and [Link]
○ Sometimes harmful action is necessary, also requires that they communicate
but it should never be automatic. compassionately with the patient about
■ The benefits that you provide through what is going to happen and why the
your procedure should outweigh the treatment is necessary.
suffering that you cause. ● In healthcare settings, practicing
● This principle involves areas of healthcare beneficence is often challenging.
practice including treatment procedures ○ You must deliver bad news, but you do
and the rights of patients. not have to be brutal.
● It has been upheld in both the ethical and ○ Even a small act of compassion will
legal practices of health care. be remembered.
○ Using utilitarian logic, the benefit of
■ For example, active beneficence can
procedures is balanced against the
be as simple as holding a patient’s
harm.
hand during a painful procedure.
■ If there is greater benefit, the act is ○ It can also require more effort such as
viewed as an ethical one. taking the time to go beyond what is
○ In fact, you have a duty to provide necessary and assure that patients
appropriate care to avoid further harm receive appropriate care post
to the patient under what some legal
14
 NCM 108: Health Care Ethics

discharge. patient, or should the nurse focus only on

● All the statements of beneficence health benefits?
involved positive action toward 3. Should the nurse give special weight to
preventing, or removing harm, and protecting the patient from harm, or do
promoting the good. benefits and harms get the same weight
○ In the nonmaleficence statement, the in calculating net benefits?
guidance is stated in the negative, to 4. Should the nurse try to do what is most
refrain from inflicting harm. beneficial in each individual case, or
should the nurse think in broader
PRINCIPLE OF DOUBLE EFFECT terms—say, by acting on a set of rules
that will produce more good on balance
● The technology of modern health care than any other set of rules?
and therapeutics has made this a difficult
principle to follow, because much of
what we do has unfortunate secondary or FIDELITY
side effects. ● An ethical principle which implies:
○ For example, some of the antibiotics ○
The quality or state of being loyal or
given to fight infections have serious faithful and,
negative side effects. ○ Exhibiting faithfulness to commitments
■ Analgesics such as morphine given or obligations.
for pain may lead to suppression of ● Fidelity is derived from the Latin word
respiration. “fidelis”, which means faithful or loyal.
● In attempting to maintain the ethical
○ Loyalty not only to the profession but
position of nonmaleficence in these
also to the patient and society.
cases, some practitioners have explained
● This principle refers to the act of keeping
their actions through the principle of
the promises.
double effect.
○ A nurse who follows the nursing
○ With this concept, the secondary
standards of practice will keep the
effects may be foreseen, but can never
promises and will be devoted to the
be the intended outcomes.
objective of providing quality care
throughout his/her career.
CRITERIA
1. The course chosen must be good or at
least morally neutral. CHARACTERISTICS OF FIDELITY
2. The good must not follow as a 1. Loyalty –– being truthful to one’s actions
consequence of the secondary harmful and taking effort to provide best care to
effects. the patient.
3. The harm must never be intended but ● It is expected to the nurse to:
merely tolerated as causally connected ○ Give quality care
with the good intended. ○ Be obedient
4. The good must outweigh the harm. ○ Follow hospital rules.
○ Adhere to specific rules of care and
In trying to figure out how to benefit one’s code of ethics for nurses.
patients and protect them from harm, the 2. Trustworthiness –– trust comes out of
following four separate problems arise: good action and selflessness.
1. How does the nurse determine what ● A nurse must develop good
counts as a benefit when there is
communication skills to build trust.
uncertainty or differences of opinion
3. Discipline
among the patient, family and/or other
● Attend duties on time
members of the professional caregiving
● Provide care without showing
team?
negligence or any sign of malpractice.
2. Should the nurse strive to produce the
● Show respect to patients and other
greatest possible general benefit for the
15
 NCM 108: Health Care Ethics

professions. provided without negligence and this

● Proper documentation of nursing care. agreement refers to the care to be
4. Honesty –– if a nurse commits a mistake, provided by the diagnosis.
he/she must admit the mistake.
● Important component of fidelity. ROLE OF NURSES IN
5. Sincerity –– a sincere nurse will always IMPLEMENTATION OF FIDELITY
be faithful to himself and to the nursing
profession. 1. Provision of holistic care.
● Shows compassion and caring attitude. ●
Sincerity, being accountable and so on.
○ A nurse does something because 2. Follow code of ethics.
he/she loves what he/she is doing. 3. Maintain a good nurse-patient relationship.
● Attain professional and personal ● Being honest and giving respect.
satisfaction, not only for the patient, 4. Commitment and dedication to patient care
because a nurse was able to provide ● Sincerity
quality care. 5. Fulfil expectations of patients.
○ Ensures that the patient gets satisfied ● Agreement
and gets the quality care they deserve. 6. Appropriate nursing and medical
6. Accountability –– a nurse needs to be intervention
accountable and responsible for his/her ● You only do what is required to the
actions in nursing care. patient or needed by the patient.
● Try not to escape 7. Fidelity for good patient recovery.
from duties and ● Establishing trusting relationships
responsibilities. with the patient.

PRINCIPLES OF FIDELITY
JUSTICE
● These principles should be applied during ● There should be an element of fairness in
nursing care. all medical decisions:
● Based on the characteristics of fidelity. ○ Fairness in decisions that burden and
1. Basic respect benefit;
● Treat patients with respect and dignity. ○ Equal distribution of scarce resources
● Never call patients by hospital number and new treatments;
or a name they do not dislike or code ○ Medical practitioners to uphold
name. applicable laws and legislation when
● Never discuss a patient's details in making choices.
front of other people or persons not ● Giving each person what he/she deserves
authorized by the patient. which can be measured in terms of
2. Competent nurse fairness, need and any other criterion that
● Care should not be given in trial and is material to justice decision.
error because a nurse must be skilled. ● In nursing, justice often focuses on
3. Adhere to code of ethics. equitable access to care and equitable
● Nurses should follow the code of scarce resource allocation.
ethics every administration of nursing ○ Refers to how a nurse allocates
care. resources to people when there is
4. Follow the principles and policies of the scarcity.
organization. ● Ethics of justice is centered on
● Policies might be different between maintaining obligation, equity and
hospitals. fairness.
5. Staff nurses to honor the agreements ● Through the application of moral
made with patients. principles, rules and established standards,
● Patient should be informed of all the whereas the ethics of care is centered on
procedures. maintaining relationships, through
● The care given to a patient should be
16
 NCM 108: Health Care Ethics

responding to the needs of others and

ETHICAL ISSUES IN RESEARCH
avoiding being hurt.
○ This morality tends to perceive and ● Ethics is concerned with the conduct of a
interpret and solve moral problems in human being.
different ways. ● All scientific activities have an impact on
human beings and on society and
JUSTICE AND THE ALLOCATION OF environment.
SCARCE RESOURCES ● For making an ethical judgment, the
researcher relies upon standards of ethics,
● Formal Justice –– in distribution, equals which could be universal or specific to the
must be treated equally and unequals must cultures or localities.
be treated unequally. ● A researcher should have deep concern for
○ Identifies what to do. human welfare and sensitivity for the
○ Does not attempt to provide any criteria rights of the research subjects.
for determination of equality ● Ethical responsibility to safeguard the
○ Does not state in what respects equals subject’s rights conflicts with the
are to be treated. efficiency with which one progresses with
○ NO SPECIFIC CRITERIA FOR the research; it may affect the ultimate
DISTRIBUTING RESOURCES. quality of the results
● Material Justice –– principles that specify ● The period during the origin of ethical
relevant characteristics or morally relevant research is known as the dark ages of
criteria in regard to treatment are said to ethics. Slaves, prisoners, criminals,
be material principles. children and poor people were forcibly
○ A CRITERIA IS SET TO used as samples or experimentation
DETERMINE WHO WILL RECEIVE subjects for the research activities.
THE HEALTH CARE RESOURCES. ● They were treated like animals and there
was no consideration for their rights,
consent, wishes, or values. This dark
period of ethical concern is considered to
be a big unhealed wound in the initial
period of development of ethical research.
● Between 1932 and 1972, there was a
drastic and contagious spread of a
● Lifeboat Ethics –– who shall be saved sexually transmitted disease called
syphilis.
from drowning, and what will be the
● This disease was studied by researchers as
criteria for our selection?
a kind of retrospective cohort study to
○ Metaphor for resource distribution.
know the natural history of the disease,
○ Practiced in emergency rooms, wars and
which has pre-pathogenesis, pathogenesis,
disasters.
recovery from acute disease or chronic
○ Similar to the principle of triage.
existence of disease leading to terminal
● Prioritizing the patients who are needed to
illness with disability or death.
be treated first.
● The research study titled “The Tuskegee
Study of Untreated Syphilis in Negro
Male” done in Macon County, Alabama,
used 400 Black males as subjects. The
main aim of the study was to determine
the damage caused in the patients affected
by syphilis if it was left untreated.
● The spirochete treponema pallidum,
which caused the disease, was injected
into the subjects without their consent and
they were left untreated. They were not
17
 NCM 108: Health Care Ethics

given any information regarding the ETHICAL ISSUES

disease and were left to die or experience
the course of illness, even though a proven ● Ethical and legal issues play an important
cure was available for the disease. role throughout the process of research
● The Nuremberg trials in 1947 helped activity, right from the selection of the
bring forth many hidden details regarding problem until its application. Research
the ethical issues in the Second World War process must remove the unwanted ethical
and paved the way for the establishment issues and ensure a safe and harmless
of the Nuremberg Code. It became the research process.
foundation for future ethical guidelines
regarding the use of human samples in the SELECTION OF RESEARCH PROBLEMS
research study. AND CONCEPTUAL MODELS
● This is a crucial period during the research
CONSIDERATIONS OF HUMAN RIGHTS process. Initially, it is not possible for the
IN RESEARCH researcher to accurately estimate the
● Nurses are always present with patients expense for the research process when
and are under pressure to deal with all selecting a research statement. He/she
kinds of problems and issues during should select a problem that is free from
patient care. There is a need for each ethical issues, is affordable, is reasonable,
nurse to be well acquainted with the has widely implementable outcomes and
ethical principles and norms, so that they has more benefits to the public. Adequate
act as a shield and protect him/her from all time and expert guidance are needed to
the legal and ethical issues concerning select the conceptual model for the
patient care. Therefore, the nurse should research.
update his/her knowledge about the new
technology as well as the ethical issues ETHICAL RESEARCH CONCERNING
affecting it. RESEARCH METHODOLOGY
● The ethical considerations safeguarding ● There should be truth, honesty, and
the subject’s rights must always be given sincerity in collecting the data for the
the highest priority. Among human research process. Faking or fabricating the
subjects, the rights that must be taken into data is against ethical principles and
consideration are as follows: becomes an ethical issue. The researcher
○ The right to choose whether or not to should be evaluated at each step by the
participate in the research and the guide and co-guide. Duplicating the
option to withdraw without being results may help the researcher to
penalized, in other words, freedom from complete the project easily, but if the
coercion research data is found to be fabricated, it
○ The right to full information about the will ruin his/her future.
research, that is, what is to be expected, ● Methodology means the design of
and the right to raise questions about the research. The core of research should be
research as it progresses clear, the methods should be enjoyable,
○ The right for protection from and the subjects as well as the investigator
unnecessary risk or harm as a result of should have full interest in the research.
participating in the research project
○ The right to be informed of any ETHICAL ISSUES IN PUBLISHING
potential risk or harm that might be RESEARCH REPORTS
incurred as a result of participating in
the research The reports should be original, clear, and
○ The right for privacy, dignity and verified by the experts. The report should be
confidentiality relevant to the research statement and should be
○ The right to be informed about the made known to the public.
results of the research
18
 NCM 108: Health Care Ethics

ETHICAL ISSUES IN APPLICATION OF the researchers should determine from

RESEARCH OUTCOMES prior knowledge the likely effects of the
experiment. Thus, the problem under
It should be possible to apply the findings of a the study will justify the conduct of the
research project in practice. For example, it was experiment on humans.
proved with evidence that changing the position ● Avoidance of Physical and Mental
of an unconscious or bedridden patient every Harm
two hours reduces the incidence of pressure ○ The experiment conducted on humans
sores. Thus, the finding should be constructive, should ensure that it does not harm or
creative, innovative, and useful. It should injure them physically or
benefit the patient and be widely psychologically. The researcher should
implementable. It should be ensured that the justify and prove that the subjects are
findings published in the report are not fake or not made to suffer any harm, injury or
duplicate, because implementing fake findings insult during the research study.
in nursing care may prove harmful. ● Avoidance of Lethal or Disabling
Experiments
THE NUREMBERG CODE (1947) ○ Experiments should not be performed if
It is a code of research-related principles for there is an a priori reason to believe that
doing human experimentation, which has been death or disabling injury will occur. The
framed based on the Nuremberg trials that exception to this rule is if the physicians
happened subsequent to the Second World War. performing the experiment also serve as
This code is framed to protect the humans from subjects.
being forcibly used as experimental subjects ● Limitation of Risk in Study
and to prevent them from being harmed or ○ There should not increase in the degree
injured through human experimental research. of risk mentioned. The degree of risk
should not be more than the benefits
caused by solving the problem through
The Ten Points of Nuremberg Code the research.
● Protection and Facilities for the
● Voluntary Informed Consent
Subjects Involved in Research
○ The voluntary consent of the human
○ Adequate physical facilities should be
subject is absolutely essential. This
provided for each participant to
means that the participant should give
safeguard him/her from any possible
consent wholeheartedly to participate in
injury, disability or death.
the study, and not by force or
● Performance of Experiment by
compulsion. The researcher should give
Qualified and Experienced Persons
complete details about the research to
○ It is important that the research is
be conducted, such as the nature,
conducted by a qualified as well as
duration, purpose, advantages, and
experienced researcher with good skill
problems that participants may have to
and knowledge about the research study
face in the research.
through all the phases of the research
● Beneficial Results
process.
○ The research should yield results that
● Freedom or Liberty for the Subjects to
benefit the society and should not be
Withdraw
random or uncertain in nature. The
○ The participants of the study must have
researcher should anticipate the benefits
the freedom to withdraw from the study
and ensure that the experiment does not
at any time if they feel physically or
harm the humans or society.
mentally unable to continue. This
● Prior Experimentation on Animals and
allows the subjects to choose what
Prior Knowledge of Problem
happens to them and to protect their
○ The experiments should not be
rights.
performed on humans without tests to
determine their safety on animals, and
19
 NCM 108: Health Care Ethics

● Termination of Study at any Stage

VMA DECLARATION OF HELSINKI
○ During the course of the
Finland, June 1964
experimentation, the researcher must be
prepared to terminate the study if there PREAMBLE:
is a cause to believe, after careful 1. The World Medical Association (WMA)
judgement, that the continuation of the has developed the Declaration of Helsinki
experiment might cause injury, as a statement of ethical principles for
disability, or death to the subjects. medical research involving human
subjects, including research on
THE IMPORTANCE OF RESEARCH identifiable human material and data.
ETHICS ● The Declaration is intended to be read
as a whole and each of its constituent
1. They promote the aims of research, such
paragraphs should be applied with
as expanding knowledge.
consideration of all other relevant
2. They support the values required for
paragraphs.
collaborative work, such as mutual respect
● Consistent with the mandate of the
and fairness. This is essential because
WMA, the Declaration is addressed
scientific research depends on
primarily to physicians.
collaboration between researchers and
● The WMA encourages others who are
groups.
involved in medical research involving
3. They mean that researchers can be held
human subjects to adopt these
accountable for their actions. Many
principles.
researchers are supported by public
money, and regulations on conflicts of
GENERAL PRINCIPLES
interest, misconduct, and research
involving humans or animals are ● The Declaration of Geneva of the WMA
necessary to ensure that money is spent binds the physician with the words, “The
appropriately. health of my patient will be my 6rst
4. They ensure that the public can trust consideration,” and the International Code
research. For people to support and fund of Medical Ethics declares that, “A
research, they have to be confident in it. physician shall act in the patient’s best
5. They support important social and moral interest when providing medical care.”
values, such as the principle of doing no ● It is the duty of the physician to promote
harm to others. and
● safeguard the health, well-being and rights
of patients, including those who are
➢ Research is searching for involved in medical research.
something that is unknown. ○ The physician’s knowledge and
➢ Nursing research is the stepping stone
conscience are dedicated to the
for quality care.
➢ Following ethical principles and fulfillment of this duty.
gaining knowledge about ethical issues ● Medical progress is based on research that
in the nursing research are essential and ultimately must include studies involving
will ensure that the outcome of the human subjects.
research is good and valid. ● The primary purpose of medical research
➢ It is the responsibility of a nurse to follow involving human subjects is to understand
ethics in research and apply the relevant
the causes, development and effects of
principles wherever needed, so that he/she
is able to bring out an excellent nursing diseases and improve preventive,
research activity, which leads to quality diagnostic and therapeutic interventions
care. (methods, procedures and treatments).
● Medical research is subject to ethical
standards that promote and ensure respect
for all human subjects and protect their
health and rights.
20
 NCM 108: Health Care Ethics

● While the primary purpose of medical health of the patients who serve as
research is to generate new knowledge, research subjects.
this goal can never take precedence over ● Appropriate compensation and treatment
the rights and interests of individual for subjects who are harmed as a result of
research subjects. participating in research must be ensured.
● It is the duty of physicians who are
involved in medical research to protect the RISKS, BURDENS AND BENEFITS
life, health, dignity, integrity, right to ● In medical practice and in medical
self-determination, privacy, and research, most interventions involve risks
confidentiality of personal information of and burdens.
research subjects. ○ Medical research involving human
○ The responsibility for the protection of subjects may only be conducted if the
research subjects must always rest with importance of the objective outweighs
the physician or other healthcare the risks and burdens to the research
professionals and never with the subjects.
research subjects, even though they ● All medical research involving human
have given consent. subjects must be preceded by careful
● Physicians must consider the ethical, legal assessment of predictable risks and
and regulatory norms and standards for burdens to the individuals and groups
research involving human subjects in their involved in the research in comparison
own countries as well as applicable with foreseeable benefits to them.
international norms and standards. No Measures to minimise the risks must be
national or international ethical, legal or implemented. The risks must be
regulatory requirement should reduce or continuously monitored, assessed and
eliminate any of the protections for documented by the researcher.
research subjects set forth in this ● Physicians may not be involved in a
Declaration. research study involving human subjects
● Medical research should be conducted in a unless they are confident that the risks
manner that minimises possible harm to have been adequately assessed and can be
the environment. satisfactorily managed.
● Medical research involving human ○ When the risks are found to outweigh
subjects must be conducted only by the potential benefits or when there is
individuals with the appropriate ethics and conclusive proof of definitive outcomes,
scientific education, training and physicians must assess whether to
qualifications. continue, modify or immediately stop
○ Research on patients or healthy the study.
volunteers requires the supervision of a
competent and appropriately qualified VULNERABLE GROUPS AND
physician or other health care INDIVIDUALS
professional. ● Some groups and individuals are
● Groups that are underrepresented in particularly vulnerable and may have an
medical research should be provided increased likelihood of being wronged or
appropriate access to participation in of incurring additional harm. All
research. vulnerable groups and individuals should
● Physicians who combine medical research receive specifically considered protection.
with medical care should involve their ● Medical research with a vulnerable group
patients in research only to the extent that is only justified if the research is
this is justified by: responsive to the health needs or priorities
○ its potential preventive, diagnostic or of this group and the research cannot be
therapeutic value carried out in a non-vulnerable group. In
○ if the physician has good reason to addition, this group should stand to bene6t
believe that participation in the research from the knowledge practices or
study will not adversely affect the
21
 NCM 108: Health Care Ethics

interventions that result from the research. ○ After the end of the study, the
researchers must submit a final report to
SCIENTIFIC REQUIREMENTS AND the committee containing a summary of
RESEARCH PROTOCOLS the study’s findings and conclusions.
● Must conform to generally accepted
scientific principles, be based on a PRIVACY AND CONFIDENTIALITY
thorough knowledge of the scientific ● Every precaution must be taken to protect
literature, other relevant sources of the privacy of research subjects and the
information, and adequate laboratory and, confidentiality of their personal
as appropriate, animal experimentation. information.
The welfare of animals used for research
must be respected. INFORMED CONSENT
● The design and performance of each ● Participation by individuals capable of
research study involving human subjects giving informed consent as subjects in
must be clearly described and justified in medical research must be voluntary.
a research protocol. The protocol should Although it may be appropriate to consult
include information regarding funding, family members or community leaders, no
sponsors, institutional affiliations, individual capable of giving informed
potential conflicts of interest, incentives consent may be enrolled in a research
for subjects and information regarding study unless he or she freely agrees.
provisions for treating and/or ● medical research involving human
compensating subjects who are harmed as subjects capable of giving informed
a consequence of participation in the consent, each potential subject must be
research study. adequately informed of the aims, methods,
sources of funding, any possible conflicts
RESEARCH ETHICS COMMITTEES of interest, institutional affiliations of the
● The research protocol must be submitted researcher, the anticipated benefits and
for consideration, comment, guidance and potential risks of the study and the
approval to the concerned research ethics discomfort it may entail, post-study
committee before the study begins. provisions and any other relevant aspects
○ This committee must be transparent in of the study. The potential subject must be
its functioning, must be independent of informed of the right to refuse to
the researcher, the sponsor and any participate in the study or to withdraw
other undue influence and must be duly consent to participate at any time without
qualified. reprisal. Special attention should be given
○ It must take into consideration the laws to the specific information needs of
and regulations of the country or individual potential subjects as well as to
countries in which the research is to be the methods used to deliver the
performed as well as applicable information. After ensuring that the
international norms and standards but potential subject has understood the
these must not be allowed to reduce or information, the physician or another
eliminate any of the protections for appropriately qualified individual must
research subjects set forth in this then seek the potential subject’s
Declaration. freely-given informed consent, preferably
○ The committee must have the right to in writing. If the consent cannot be
monitor ongoing studies. The researcher expressed in writing, the non-written
must provide monitoring information to consent must be formally documented and
the committee, especially information witnessed. All medical research subjects
about any serious adverse events. should be given the option of being
○ No amendment to the protocol may be informed about the general outcome and
made without consideration and results of the study.
approval by the committee. ● When seeking informed consent for
22
 NCM 108: Health Care Ethics

participation in a research study the patient which aspects of their care are
physician must be particularly cautious if related to the research. The refusal of a
the potential subject is in a dependent patient to participate in a study or the
relationship with the physician or may patient’s decision to withdraw from the
consent under duress. In such situations study must never adversely affect the
the informed consent must be sought by patient-physician relationship.
an appropriately qualified individual who ● For medical research using identifiable
is completely independent of this human material or data, such as research
relationship. on material or data contained in biobanks
● For a potential research subject who is or similar repositories, physicians must
incapable of giving informed consent, the seek informed consent for its collection,
physician must seek informed consent storage and/or reuse. There may be
from the legally authorised representative. exceptional situations where consent
These individuals must not be included in would be impossible or impracticable to
a research study that has no likelihood of obtain for such research. In such situations
bene6t for them unless it is intended to the research may be done only after
promote the health of the group consideration and approval of a research
represented by the potential subject, the ethics committee.
research cannot instead be performed with
persons capable of providing informed USE OF PLACEBO
consent, and the research entails only ● The benefits, risks, burdens and
minimal risk and minimal burden. effectiveness of a new intervention must
● When a potential research subject who is be tested against those of the best proven
deemed incapable of giving informed intervention(s), except in the following
consent is able to give assent to decisions circumstances: Where no proven
about participation in research, the intervention exists, the use of placebo, or
physician must seek that assent in addition no intervention, is acceptable; or Where
to the consent of the legally authorised no proven intervention exists, the use of
representative. The potential subject’s placebo, or no intervention, is acceptable;
dissent should be respected. or Where for compelling and scientifically
● Research involving subjects who are sound methodological reasons the use of
physically or mentally incapable of giving any intervention less effective than the
consent, for example, unconscious best proven one, the use of placebo, or no
patients, may be done only if the physical intervention is necessary to determine the
or mental condition that prevents giving eCcacy or safety of an intervention and
informed consent is a necessary the patients who receive any intervention
characteristic of the research group. In less effective than the best proven one,
such circumstances the physician must placebo, or no intervention will not be
seek informed consent from the legally subject to additional risks of serious or
authorised representative. If no such irreversible harm as a result of not
representative is available and if the receiving the best proven intervention.
research cannot be delayed, the study may Extreme care must be taken to avoid
proceed without informed consent abuse of this option.
provided that the specific reasons for
involving subjects with a condition that POST-TRIAL PROVISIONS
renders them unable to give informed ● In advance of a clinical trial, sponsors,
consent have been stated in the research researchers and host country governments
protocol and the study has been approved should make provisions for post-trial
by a research ethics committee. Consent access for all participants who still need
to remain in the research must be obtained an intervention identified as beneficial in
as soon as possible from the subject or a the trial. This information must also be
legally authorised representative. disclosed to participants during the
● The physician must fully inform the
23
 NCM 108: Health Care Ethics

informed consent process.

ETHICAL ISSUES IN REPRODUCTIVE
HEALTH
RESEARCH REGISTRATION AND
PUBLICATION AND DISSEMINATION ABORTION
OF RESULTS ● Expulsion of a living fetus from the
● Every research study involving human mother’s womb before it is viable.
subjects must be registered in a publicly ● Termination of pregnancy,
accessible database before recruitment of spontaneously or by induction,
the 6rst subject. prior to viability.
● Researchers, authors, sponsors, editors ● 14-20 before weeks of viability
and publishers all have ethical obligations
with regard to the publication and ABORTION IN THE PHILIPPINES:
dissemination of the results of research. CRIMINALIZATION AND A GENERAL
Researchers have a duty to make publicly BAN ON ABORTION
available the results of their research on
human subjects and are accountable for ● In the Philippines any form of abortion is
the completeness and accuracy of their illegal
reports. All parties should adhere to ○ FROM Penal Code of 1870 under
accepted guidelines for ethical reporting. Spanish colonial rule, and the criminal
Negative and inconclusive as well as provisions were incorporated into the
positive results must be published or Revised Penal Code passed in 1930
otherwise made publicly available. under U.S. occupation of the
Sources of funding, institutional Philippines.
affiliations and conflicts of interest must ○ Article II, 1987 constitution: Under the
be declared in the publication. Reports of family code
research not in accordance with the ○ Section 12: Recognizes sanctity of life
principles of this Declaration should not and shall protect and strengthen the
be accepted for publication. family.
○ Protect the life of mother and the life of
UNPROVEN INTERVENTIONS IN the unborn from conception.
CLINICAL PRACTICE ● Criminalized by the Philippine law: Art.
● In the treatment of an individual patient, 256, 258(highest prison term on the
where proven interventions do not exist or woman or parents), and 259: Revised
other known interventions have been Penal Code
ineffective, the physician, after seeking ○ mandate imprisonment for women who
expert advice, with informed consent from undergo abortion, as well as those who
the patient or a legally authorised assist in the procedure.
representative, may use an unproven ○ Article 258 further imposes a higher
intervention if in the physician’s prison term on the woman or her
judgement it offers hope of saving life, parents if the abortion is undertaken "in
re-establishing health or alleviating order to conceal [the woman's]
suffering. This intervention should dishonor"
subsequently be made the object of ● Criminalization of abortion has not
research, designed to evaluate its safety prevented abortion, but instead has made
and efficacy. In all cases, new information the procedure unsafe and potentially
must be recorded and, where appropriate, deadly for those try to terminate their
made publicly available. pregnancies.
○ In 2008 alone, the Philippines’ criminal
abortion ban: deaths of at least 1,000
women and complications for 90,000
more.
● HCW who perform abortions in the
Philippines with the consent of a pregnant
24
 NCM 108: Health Care Ethics

woman may face up to 6 years in prison MORAL ISSUES

under the Revised Penal Code.
● Euthanasia and impaired infants
● Separate laws that prescribe sanctions for
● Personhood
HCW for performing abortions or
● Sanctity of life
dispensing abortifacients such as:
● Quality of life
○ Medical Act,
● Autonomy
○ Midwifery Act
● Mercy
○ Pharmaceutical Act
● freedom and social stability.
● According to these laws, HCWs may have
their license to practice suspended or
revoked if caught engaging in TWO POSITIONS
abortion-related activities. ● Pro-life position- anti-abortion, believes
● Women who undergo abortion for any that abortion is murder
reason may be imprisonment for 2-6 ● Pro-choice position- believes that the
years. decision to abort is one of personal liberty
● Misoprostol- drug inserted in the vagina and thus should be legal
used for abortion ● There are two possible sub positions:
● RH Bill/Law- prevention of abortion and ○ One may believe that abortion is wrong
management of post abortion but, for whatever reason, is something
complications. that should be up to every individual to
● Intention: Responsible parenthood, family decide. The issue becomes an individual
planning or personal decision.
● Address cause of abortion, fetal death, and ■ Abortion is wrong but it is an
teenage pregnancy individual autonomy
● Ensures that women needing care for ○ One may believe there is nothing wrong
post-abortion complications shall be with abortion or that, while abortion is
treated and counseled in humane, wrong, it can be outweighed by other
non-judgmental and compassionate considerations.
manner.” ■ Abortion is not wrong but depending
● but “Abortion remains a crime and is on the situation
punishable”
PRINCIPLE OF DOUBLE EFFECT
TYPES OF ABORTION
● Distinguish the intended effect of an
● Natural abortion(spontaneous/accidental) action from the other, the unintended
unintentional and involuntary effects
● Direct or Intentional Abortion- induced ● The intention is to save the mother, not to
expulsion of a living fetus kill the fetus.
● Therapeutic abortion- induced expulsion ● It would be impermissible, to perform an
of a living fetus in order to save the abortion to save a mother from death if the
mother from the danger of death brought procedure involved the direct killing of
on by pregnancy. the fetus
● Eugenic abortion- recommended in cases ● Permissible if the death of the fetus is an
where certain defects are discovered in the indirect cause of the death
developing fetus.
● Indirect abortion- removal of the fetus NURSING ETHICAL DILEMMA:
occurs as a secondary effect of a ETHICAL RIGHTS AND
legitimate action, which is direct and RESPONSIBILITIES IN ABORTION
primary object of the intention.
● Nurses are agreeable if medically
indicated
● Should respect the choices of the mother
for as long as the abortion is legal under
25
 NCM 108: Health Care Ethics

the state of law ● The issues in these areas are sensitive and
● Should provide the information of it is difficult to handle and to provide
alternative and respecting the patient’s quality care.
right to freedom from imposition and the ● Some of the sensitive issues are sexual
right to receive the utmost care in an and physical assault, rape, miscarriage,
environment that provides privacy, surrogate mother, abortion and infertility.
culturally appropriate, and specific ● These issues affect the growth of the
nursing expertise. (ANA, 2011) foetus, adolescent children, women in the
● If abortion is against the personal moral, reproductive age, and the menopausal
ethical, and religious values of the nurse, women.
the nurse has the right to refuse to
participate in a voluntary termination of ETHICAL AND LEGAL ISSUES
pregnancy
○ Except in emergency situations; ● faced by the mother and the child during
patient’s needs should not be subjected various stages
to coercion, censure, or discipline for Antenatal: Mother
reasons of such refusal 1. Regarding pregnant women and mothers
○ Should be aware of abortion laws in antenatal period:
within the state of practice to be more 2. Sexual abuse of pregnant woman
legally binding 3. Abortion
● >1/2 American women receiving 4. Surrogate mother
abortions are in their 20s, aged 20–24. It 5. Failure of sterilization
is the highest rate of any age group. 17% techniques (family planning)
U.S. abortions are by teenagers. 6. Lack of cure for psychiatric mother
○ 60% women obtaining an abortion
already have a child Antenatal: Fetus
○ >37% have 2+ children. 1. Regarding the fetus in the antenatal
○ Women with family incomes below the period:
federal poverty level account for >40% 2. Feticide
of all abortions. 3. Abortion
● The reasons given for having an abortion 4. Loss of fetus by infertility techniques
are various and complex, ranging from 5. Malnutrition
concern for the health of the mother or 6. Vaccination
fetus. 7. Sexually transmitted diseases affecting
○ Younger women often reported that fetus
they were unprepared for the transition 8. Neglect of fetal care by mother
to motherhood, while older women 9. Ethical and legal issues in mentally
regularly cited their responsibility to affected pregnant woman
dependents.
○ For some women, the abortion came as Intranatal: Mother
a deep relief. Pro-choice advocates 1. Faced by the mother in the intranatal
favor intact dilation and evacuation, and period:
pro-life advocates use the term partial 2. Delivery: Unfavorable circumstances in
birth abortion. the hospital or home that disturb the lives
of the fetus and the mother
IMPORTANT AREAS IN OBSTETRICS: 3. Negligence or malpractice during labor
● antenatal, intranatal and postnatal periods 4. Mishandling third stage of labor leading
to primary pulmonary hypertension (PPH)
GYNAECOLOGY 5. Forced lower segment caesarean section
● problems in adolescent and reproductive (LSCS)
ages and during menopause periods.

26
 NCM 108: Health Care Ethics

Postnatal: Mother and Newborn dependent on the mother, it follows that

1. Faced by the mother and the newborn in the mother has the last word on whether it
the postnatal period: comes to viability.
2. Postpartum blues; neglect in mother and ● Once viability is achieved, however, the
newborn mother no longer has exclusive say over
3. Status of surrogate mother in postpartum the fetus.
period ● The objection to using viability as a
4. Sale of newborn for money by mother criterion for personhood is that it varies
5. Neglect of mother to feed the newborn over time and place. What this means is
with breast milk that as medical technology develops, what
6. Physical and sexual abuse in newborn counts as a person will change.

NURSING ETHICAL PRINCIPLES ETHICAL ISSUES IN ASSISTED

INVOLVING ABORTION CARE (IF IT IS REPRODUCTIVE TECHNOLOGIES
LEGALLY ACCEPTABLE)
● Autonomy: Respect the rights of the
ASSISTED REPRODUCTIVE
patient and give freedom of choice
TECHNOLOGIES (ART)
regarding treatment.
● Informed Consent: Get the informed ● All treatments or procedures that include
consent signed after providing full the in vitro handling of human oocytes
explanation; the consent should not be and human sperm or embryos for the
obtained by force. purpose of establishing pregnancy
● Respect for Person: Provide respect with ● First successful IVF: Louise Brown; 1978
dignity and do not tease the patients.
● Beneficence: Do only good to the patient ISSUES/CONCERNS
and provide a good choice of treatment. ● Rapid development in the field of ART
● Non-maleficence: Do not knowingly or ● “Moral panic” about the changes that ICF
unknowingly harm the patient. brought about
● Confidentiality: Keep all details regarding ● Continuous ethical dilemmas
the patient safe and confidential. ● Legislation
● Veracity: Always say the truth, report
accurately, and do not indulge in fraud. RAPID DEVELOPMENTS
● Fidelity: This refers to maintaining a ● Better protocols for ovulation induction
trustful and faithful therapeutic ● Success rates
relationship with the patient, not revealing ● PGD
the patient’s details and keeping all the ○ Preimplantation genetic diagnosis
details in confidence. (PGD)
● Accountability: Be answerable and ○ Screening of embryos for specific
responsible to each and every act during genetic traits before it is implanted
the abortion procedure. ○ “Embryo biopsy”
● Justice: Act in a fair manner to all patients ○ Enables couples at risk for certain
and treat them equally. genetic diseases to determine which of
their embryos are affected and which
THE VIABILITY ARGUMENT are not
● Viability focuses on the characteristic of ○ before the embryos are used to establish
biological independence. a pregnancy.
● The idea is that personhood requires some
sort of independence from other people,
particularly the mother.
● Since the fetus has standing only as a
27
 NCM 108: Health Care Ethics

MORAL PANIC ● Right of the child to know his/her origins

● No society has been neutral about
reproduction
● Social values PREIMPLANTATION GENETIC
● Morals DIAGNOSIS (PGD)
● Fears
● Screening of cells from preimplantation
● Separation of sex from reproduction
embryos for the detection of genetic
● Reproduction with the involvement of a
and/or chromosomal disorders before
third party
embryo transfer
● Gender issue
● Status of the embryo
● Ethical Issue
○ Discrimination
● Ideology or religion
○ “Designer” babies
○ Status of the embryo
○ Sex selection
○ Sanctity of the family’s genetic lineage
○ Destruction of unwanted embryos
● Utilitarian principles
○ Best for society
○ Best interest of the child ETHICAL ISSUES/RISK-BENEFITS
● Welfare of the child
○ Medical risks
ETHICAL CONCERNS ○ Family environment
○ Social environment
Autonomy
● Who is making the decisions for the
● Patient’s autonomy (respect for
welfare of the child?
autonomy)
○ Parents
● Reproductive freedom
○ Medical personnel
● Decision based on accurate information
○ Society and the law
● Issue of success rates
● Is it one’s best interest to be born?
● Eligibility
○ All infertile couples
SURROGACY
○ Only married couples
○ Single women without partners ● When a woman agrees to carry a baby to
○ Gay couples term and give it up to another set of
○ Lesbian couples parents to raise.
○ Menopausal women ● The contracting couple may be unable to
○ HIV-positive women or couples contribute genetic material for some
Gamete donor reason or the female may be unable to
● Sperm carry the baby to term.
● Oocyte ● Done for money or favor.
Commercialization
● Ethical concerns AGAINST: ETHICAL ISSUES IN SURROGACY
○ Exploitation ● It is the practice of surrogacy for money
○ Potentiality that causes the most concern
○ Dignity ○ Some people believe that it is unethical
○ Risk for distinctions in genetic pedigree for a woman to be used, even with her
● Ethical arguments for: consent, as an incubator for others.
○ Justice ○ Others believe that this is just another
○ Pay for a service economic opportunity for women who
○ Reward often have few other economic options.
○ Reproductive tourism ● What If the birth mother changes her
Donor anonymity mind? This is a very difficult
● Right of autonomy of privacy of the circumstance.
parents ● If the genetic material is that of the birth
● Right of privacy of the donor mother and a partner besides the
28
 NCM 108: Health Care Ethics

contracting parents, and if the woman LIVING WILL

agrees to return any money paid to her,
● Frequently to describe any number of
then one might be willing to let the baby
documents that give instructions about
remain with the birth mother.
future medical care and treatments or the
wish to be allowed to die w/o heroic or
NURSE’S ROLE IN HANDLING
extraordinary measures should the patient
SURROGATE MOTHER
be unable to communicate for self
1. A nurse should neither support nor go ● No uniformity in laws on living wills and
against the surrogate mother, if the nurse surrogate decision makers (FINAL
is still in a dilemma regarding whether to DECISION)
support or go against for it, he/ she should ● In some states, the advanced directives go
do the following: into effect only if a patient is terminally ill
2. Get the informed consent signed from and death is imminent
both the surrogate mother and the couple. ● Due to inconsistencies and limitation,
3. Ensure that the surrogate mother has many authorities recommend the use of
agreed by self and not by force and durable power of attorney over a living
support the mother at any cost. will
4. Check for any conflict between the two ● What to and what not to do
parties.
5. Never reveal the details regarding the
DURABLE POWER OF ATTORNEY
surrogate mother or the couple to any
third party. ● A power of attorney is a legal document
6. Never neglect or degrade the surrogate that gives someone you choose the power
mother or gossip about her or the couple. to act in your place, in case you become,
mentally incapacitated, you’ll need what
are known as “durable” powers of
ETHICAL ISSUES IN ORGAN DEATH
attorney for medical care and finances
& DYING
● Appointing someone in behalf of the
● The outcomes related to their care should patient
be their own wishes. ● This allows you to name someone as
● The decisions may involve the choice for: proxy, with the authority to make medical
Organ and decisions on your behalf should you
tissue donations become incompetent and unable to make
○ Advance directives decisions for yourself
○ Resuscitation

ADVANCED DIRECTIVES
DO NOT RESUSCITATE (DNR)
● a general term used to describe the
● A written physician’s order instructing
documents that give instructions about
health care providers not attempt CPR
future medical care and treatments
● Often requested by the family
● A legal, written document included in the
● Must be signed by the physician to be
px chart
valid must have a witness
●
● Several types of CPR decisions can be
○ Living will
made including:
○ Do not resuscitate order
○ Full code
○ Withholding or withdrawing treatments
○ Chemical code
○ Should have proper
○ DNR or “no code”- avoid use of CPR
documentation and
○ Slow codes- slows process
consent/waiver

29
 NCM 108: Health Care Ethics

FULL CODE give privacy to the family

● A call for CPR efforts
WITHHOLDING OR WITHDRAWING
● Contains all elements of ACLS (advanced
TREATMENTS
cardiac life support; oxygenation,
ventilation, cardiac massage, electroshock ● What is to be done and what is not to be
as necessary, emergency drugs) done must be included in clear terms
● Code blue (cardiac arrest situations) ● Honoring the refusal of treatments that a
patient does not desire, are
NO CODE disproportionately burdensome to the
patient, or will not benefit the patient can
● DNR
be ethically and legally permissible
● Written order placed in medical chart to
avoid the use of CPR efforts
○ DON’T ATTEMPT TO CHEST
COMPRESSION, VENTILATION, ETHICAL ISSUES IN ORGAN
CPR (can be charged for battery) DONATIONS
● When it is permissible to remove organs?
SLOW CODE
● Who should receive them?
● Health care teams slows the process of ● How is it to be financed?
emergency resuscitation so as to appear to
be providing the care but in actual fact is ETHICAL ISSUES
only providing illusion
● Document the gift that an individual
● Intent is more for family comfort than
executes before death
patient benefit; unethical for veracity
● Commercialization (exploitation, pay for a
because we are deceiving the family but is
service)
beneficial as we help them to accept the
● The need to obtain family consent in a
grieving, as px can’t be resuscitated
time of grief and stress has been a major
anymore
barrier to organ procurement
CHEMICAL CODE
LEGAL & SOCIAL STANDING OF
● Provides the drugs needed for EUTHANASIA
resuscitation but does not provide the
Euthanasia
other services
● Emergency drugs only ● Euthanasia means good death.
● act of killing a life and is known as mercy
killing or providing peaceful death.
DNR GUIDELINES
● done to chronic or terminally ill patients
● Should be documented for whom no more treatment methods are
● Should specify the exact nature of the available for their survival.
treatments to be withheld ● intentional killing by act or omission of a
● Patients, when they are able, should dependent human being for his/her alleged
participate in DNR decisions benefit.
● Decisions to withhold CPR should be ● The act of putting to death painlessly or
discussed with the health care team allowing to die, as by withholding
● DNR status should be reviewed on a extreme medical measures, a person
regular basis (q24h) suffering from an incurable, especially a
painful, disease or condition.
ETHICAL ISSUES ● The act or practice of killing or permitting
the death of hopelessly sick or injured
● Do DNR patients belong in intensive care individuals in a relatively painless way for
units (ICU)? reasons of mercy.
○ No, to give way for other patients and to
30
 NCM 108: Health Care Ethics

● Euthanasia - currently conceptualized as WITHHOLD TREATMENT

an action that aims to end the life of a ● This is not carrying out any extra heroic
human being taking into account measures or additional treatment to
humanistic considerations in relation to sustain the life of the patient.
the person or society ○ Eg. DNR
○ Quickening of death ● Active euthanasia- requires action that
○ Passive euthanasia- the allowance of speeds the process of dying
deadly process to proceed without ○ active acceleration of a ‘good’ death by
intervention use of drugs, etc. whether by oneself or
○ withdrawing of medical treatment with with the aid of a doctor. Active
the deliberate intention of causing a euthanasia uses lethal substances or
patient’s death, forces, such as administering a lethal
○ withdrawing any active treatment that injection, to kill a person
the patient receives for survival, for ○ Eg. Administration of KCl bolus, lethal
example, dialysis. The order ‘do not injection
resuscitate’ is also an example of
passive euthanasia.
○ Unethical if involuntary
● VOLUNTARY PASSIVE EUTHANASIA
IS ACCEPTABLE AND LEGAL IF
WELL-DOCUMENTED AND WITH
CONSENT/WAIVER
● CAN BE REVIEWED, RENEWED,
REVISED

PHYSICIAN-ASSISTED SUICIDE
● Person who is going to die needs help to
kill himself/herself and asks for it. The
suicide is facilitated by means of a drug
prescription or by information provided
by the physician. It may even be as simple
as putting the necessary drugs within the
reach of the patient.

EUTHANASIA BY OMISSION
● This is intentionally causing death by not
giving necessary and ordinary needed care
of food and water.
WITHDRAW TREATMENT
● This refers to the act of disconnecting any VOLUNTARY EUTHANASIA
treatment or any machine (such as oxygen ● This is carried out at the request of the
support) connected to the patient. person to whom it is to be applied.
○ Eg. Mech vent, hemodialysis for ESRD
(CKD px), chemotherapy, medications NON-VOLUNTARY EUTHANASIA
○ DO NOT REMOVE TUBINGS/MECH ● This happens when the patient is
VENT IF PX IS UNCONSCIOUS unconscious or otherwise unable to make
AND IF RELATIVES ASKED YOU. a meaningful choice between living and
● Px should be sent home, and family will dying, and an appropriate person takes the
be the one to remove decision on the patient’s behalf.
31
 NCM 108: Health Care Ethics

INVOLUNTARY EUTHANASIA BELGIUM

● In this case, the patient’s life is terminated Legalized physician-assisted suicide
for his/her own sake against his/her ● If an inpatient expresses a desire for
wishes or views. euthanasia, prior to becoming comatose,
○ Involuntary euthanasia- ignores the physician may comply with the request
individual’s autonomous rights and ● Include children who with the expressed
could potentially bring about the death permission of their parents may receive
of an unwilling victim lethal injection
● Orthotanasia refers to the art of promoting ● The child must be terminally ill and be
a humane and correct death conscious of their decision
○ Usual death/normal death
● Dysthanasia is the term for futile or USA
useless treatment, which does not benefit ● Doctors are allowed to prescribe lethal
a terminal patient. It is a process through doses of drugs to terminally ill patients to
which one merely extends the dying “aid in dying”
process and not life per se ● Only 5 states
○ Eg. Mechanical vent - it does not cure allow physician-assisted suicide
the disease but just help px merely ○ Oregon (1st state to legalize),
survive; using life support Washington, Vermont, Montana, and
● Talk to the family and don’t give false New Mexico
hope ● Active euthanasia is illegal
● Oregon act: allows a terminally ill patient
EUTHANASIA VS. SUICIDE to obtain a physician’s prescription for a
● A person has committed suicide when: fatal drug
○ Person brings about his/her own death
○ Others do not coerce him/her to do the
action
○ Death is caused by condition arranged
by the person for the purpose of
bringing about his/her death
● Physician-assisted suicide - allowed in the
Netherlands in 2002
○ Patient must request the assistance
freely and frequently after careful
consideration
○ Physician may act on request only if the
patient is terminally ill, with no hope of
improvement and in severe pain
○ May be actively-assisted
○ Physician must consult with another
physician and file a coroner (an official
who examines a person’s cause of
death)
GERMANY
● Does not allow active-assisted
suicide—where the physician prescribes
and administers the lethal dose
○ Does not allow
direct participation of the physician
● Allow assisted suicide, so long as the drug
is taken without any help
32