1.

Introduction to
ethics

1
Introduction .
At one time, health care ethics was the
domain of health care professionals
Doctors, nurses, and the other care givers
in the allied health care professions made
most of the decisions that pertained to the
ethics of their occupations
While patients were often consulted about
some of the medical decisions which
affected them, they were usually passive
insofar as ethical decisions were
concerned
2
Introduction .
Today, however, the situation has changed
considerably
Because of the technical revolution in both
information and in the provision of health
care, patients are now an integral part of
the medical decision-making process
Moreover, and perhaps more significantly,
the ethical questions to which science,
medicine, and health care give rise, affect
the present and future well-being of
people, whether they are sick or not
3
Introduction .
For example, the manner in which health
care is financed and provided now
concerns everyone
The escalation of health care costs is
fundamentally an ethical issue, as is the
need to provide health care based upon
human need rather than upon consumer
ability to pay
Many situations arise in the practice of
medicine and in medical research that
present problems requiring moral
decisions
4

Introduction .
Should a parent have a right to refuse
immunization for his or her child?
Is basic health care a right or a privilege?
Does public safety supersede an
individuals right?
Who dictates client care the client, the
physician, the attorney, or the medical
insurance carrier?
Should children with serious birth defects
be kept alive?
Should a woman be allowed an abortion
5
for
Introduction .
Should everyone receive equal treatment
in medical care?
Should people suffering from a genetic
disease be allowed to have children?
Should individuals be allowed to die
without measures being taken to prolong
life?
None of these questions has an easy
answer, and one hopes never to have to
deal with them
The decision for these issues is subjective,
hence need to refer legal and ethical
6
Introduction
ethics is a very personal concept and personal decision
Blanchard and Peale developed three questions to
serve as an ethics check that is a useful tool for
persons facing an ethical dilemma
1. is it legal or in accordance with institutional or
company policy?
2. does it promote a winwin situation with as many
individuals (client/employee/employer) as possible?
3. how would I feel about myself were I to read about my
decision or action in the daily newspaper? how would
my family feel? can I look myself in the mirror?
. If the answer to any one of the three questions is no,
the action is unethical
. If the answer to all three questions is yes, the action is
ethical
7
Introduction
Coach Thee suggests that leaders, managers,
health services providers and students ask and
answer the following eight questions to test the
rightness or wrongness of their actions
1. is it legal?

2. does it comply with my/our rules and guidelines?

3. is it in sync with my personal and organizational

values?
4. will I be comfortable and guilt free if I do it?

5. does it match my commitments and promised

guarantees?
6. would I do it to my family or friends?

7. would I be perfectly okay with someone doing it

for me? 8
Ethics and Morality

No matter what our social, cultural, economic or

professional backgrounds are, we are all in the
business of practicing ethics on a daily basis.
We have certain values (things we think are
important for their own sake) and beliefs (views
about the nature of existence and the way we
understand the world to be)
For example, we hold values such as charity and
generosity
Ethics is about carefully studying the values that
actually do guide our attitudes and behaviors in
given contexts, and it is about exploring what
values ought to guide our attitudes and behaviors
9
Ethics and Morality
ethics refers to standards of behavior that tell
us how human beings ought to act in the
many situations in which they find
themselves as friends, parents,
businesspeople, professionals
Ethics is:
A moral Principle
What is good and bad
What is right and wrong
Based on value system
10
Ethics and Morality

Ethical norms are not universal

depends on the sub culture of the society
Ethics is not following the law
Ethics is not following culturally accepted
norms
Ethics is not science

11
Ethics and Morality
Morality: is conformity to ideals of right
human conduct
Morality is the quality of being in accord with
standards of right or good conduct
Morality is looking at how good or bad our
conduct is, and our standards about conduct
Ethics is used to refer to the formal study of
those standards or conduct
Morals are the concepts of what is good and
what is bad and how one should behave
Ethics is primarily a matter of knowing
whereas morality is a matter of doing
12
What is Health Ethics?
Health ethics is the branch of ethics that
deals with ethical issues in health, health
care, medicine and science
It involves discussions about treatment
choices and care options that individuals,
families, and health care providers must
face
It requires a critical reflection upon the
relationships between health care
professionals and those they serve, as well
as the programs, systems, and structures
developed to improve the health of a
13
population
What is Health Ethics?...

few specific examples of health ethics

issues include:
Making decisions about end-of-life care
Determining whether to allocate funds to
the treatment of disease or the
promotion of health
Critically examining the discrepancies in
health status between populations and
our ethical obligations to ensure
equitable access to health services
Ensuring ethical conduct in health
14
health ethics and the law

Laws are societal rules or regulations that are

advisable or obligatory to observe
Ethics is a set of moral standards and a code for
behavior that govern an individuals interactions
with other individuals and within society
Laws are mandatory rules to which all citizens
must adhere or risk criminal liability
Ethics often relate to morals and set forth
universal goals that we try to meet,
However, there is no temporal penalty for failing
to meet the goals as there is apt to be in law

15
health ethics and the law

Both ethics and law are normative frameworks,

i.e. they define how people ought to act
Ethics and law are often complementary; for
example, a legal decree might require a person
to do what is ethically required (such as refrain
from harming others)
However, something can be legal and yet
conflict with ethical standards and vis-versa
For instance, there are no laws prohibiting
countries from investing vast public resources
in the development of medical interventions of
minor public health significance, such as a
cure for male pattern baldness 16
health ethics and the law

It is not ethical to devote their resources to minor

public health significance rather than reducing
the burden of life threatening disease
disrespectfully to ones parents may be
considered unethical, even though it is not
against the law
It is also possible that individual laws may
themselves violate important ethical principles
Ethical analysis of the law can stimulate
important reform efforts or acts of civil
disobedience
while ethics and law are different, ethics remains
a foundation for law, and often provides17 a
 Rationale of Health Ethics
Nowadays, conflicts of interests between
the government and medical institutions,
between medical institutions and medical
personnel, between physicians and patients
are getting more and more serious and
complex
High technologies not only brought us
hopes of cure but have also created a heavy
economic burden
The ethical dilemmas of high technology
medicine-brain death, organ
transplantation, and concerns about
18
quality
Rational
The attainment of highest possible level of
health is highly dependent, among other
things, on the regulation of health service
delivery and the application of suitable
ethical principles
Ethics is and always has been an essential
component of medical practice
Ethical principles such as respect for
persons, informed consent and
confidentiality are basic to the physician-
patient relationship
19
Rational
The study of ethics prepares public health
professionals, health and medical
practitioners and students to recognize
difficult situations and to deal with them in
a rational and principled manner
Ethics is also important in professionals
interaction with society and their
colleagues and for the conduct of medical
research
It provides standards of behavior for
health workers 20
Fundamental ethical
principles
Four fundamental principles of
ethics have usually been
recognized and widely discussed
in moral literature:
1. Autonomy,
2. Beneficence,
3. Non-maleficence,
4. Justice

21
Autonomy
Two Greek words: autos (self), and nomos
(rule), giving it the literal meaning of self-
rule or self-governance.
Implies an individual who is master of
himself or herself and can act, make free
choices and take decisions without the
constraint of another
Respect for Persons:
autonomous agents,

persons with diminished autonomy are

entitled to protection
Respect for autonomy is the basis for
informed consent 22
Autonomy
The application starts with the respect for a
persons right by providing them with adequate
and relevant information
The process of informed consent is begun when
initial contact is made with a prospective
subject and continues throughout the course
of the study in research
Pre-conditions of autonomy are
Competence (the capacity to be a moral agent)
Liberty or freedom
Individual autonomy may be diminished or
completely absent, as in the case of minor
children, mentally handicapped or incapacitated
23
Informed consent
The application of autonomy is seen in the
informed consent process
Informed consent in ethics usually refers to the
idea that a person must be fully informed about
and understand the potential benefits and risks of
their choice of treatment
Uninformed person is at risk of mistakenly making
a choice not reflective of his or her values or
wishes
Patients can elect to make their own medical
decisions, or can delegate decision-making
authority to another party
The value of informed consent is closely related
to the values of autonomy and truth telling
24
Beneficence
The term beneficence refers to actions that
promote the well being of others
Beneficence, or doing good, involves
promoting anothers welfare,
In the medical context, this means acting in
an individual's best interest and in a manner
which benefits others
doctors must take positive steps to help
people and not merely refrain from harm
However, uncertainty surrounds the precise
definition of which practices do in fact help
patients 25
Non-maleficence
the concept of non-maleficence is embodied
by the phrase, "first, do no harm," or the
Latin, primum non nocere
Many consider that should be the main or
primary consideration (hence primum): that it
is more important not to harm your patient,
than to do them good
This is partly because enthusiastic
practitioners are prone to using treatments
that they believe will do good, without first
having evaluated them adequately to ensure
they do no (or only acceptable levels of) harm
26
Non-maleficence
Much harm has been done to patients as a result,
as in the saying, "The treatment was a success,
but the patient died
It is not only more important to do no harm than
to do good; it is also important to know how likely
it is that your treatment will harm a patient
In practice, however, many treatments carry
some risk of harm
In some circumstances, e.g. in desperate
situations the outcome without treatment will be
grave,
Hence, risky treatments that stand a high chance
of harming the patient will be justified,27as the risk
Non-maleficence
So the principle of non-maleficence is not absolute,
and balances against the principle of beneficence
(doing good), as the effects of the two principles
together often give rise to a double effect
Double effect refers to two types of consequences
that may be produced by a single action, and in
medical ethics it is the combined effect of
beneficence and non-maleficence
Depending on the cultural consensus conditioning
(expressed by its religious, political and legal social
system) the legal definition of non-maleficence
differs
Violation of non-maleficence is the subject of
medical malpractice litigation
28

Justice
Justice is fairness or entitlement
we have an obligation to treat all people equally,
fairly, and impartially
Justice requires that equals be treated equally
and un-equals unequally
Implies that human beings as moral equals should
be treated equally unless there is a reasonable
justification for treating them differently
The general moral idea underlying the principle of
justice is that which states:
Do unto others as you would have them do unto
you if you were in their place and they in yours

29
Justice
The principle of justice demands
fairness in the treatment of individuals and
communities
the equitable distribution of the burdens and
benefits of research
Has important implications for such
issues as
choice of study population,
recruitment into study,
study and post-study benefits, etc.
30
 Conflicts between autonomy and
beneficence or non-maleficence
Autonomy can come into conflict with beneficence
when patients disagree with recommendations
that healthcare professionals believe are in the
patient's best interest
When the patient's interests conflict with the
patient's welfare, different societies settle the
conflict in a wide range of manners
In general, Western medicine defers to the wishes
of a mentally competent patient to make their
own decisions, even in cases where the medical
team believes that they are not acting in their own
best interests
31
Conflicts between autonomy
and.
However, many other societies prioritize
beneficence over autonomy
Examples include when a patient does not want a
treatment because of, for example, religious or
cultural views
in the case of euthanasia, the patient, or relatives of
a patient, may want to end the life of the patient
Also, the patient may want an unnecessary
treatment, as can be the case with
cosmetic surgery; here, the practitioner may be
required to balance the desires of the patient for
medically unnecessary potential risks against the
patient's informed autonomy in the issue32
Conflicts between autonomy
and.
A doctor may want to prefer autonomy
because refusal to the patient's self-
determination would harm the
doctor-patient relationship.
individuals' capacity for informed decision-
making may come into question during
resolution of conflicts between autonomy and
beneficence
The role of surrogate medical decision makers
is an extension of the principle of autonomy

33
Fundamental ethical
The four fundamental principles of ethics are
equally relevant and important within all
possible contexts and perspectives

They are cross-culturally valid, although the

emphasis given to each and the way they are
operationalised may differ slightly from
culture to culture, from place to place, from
context to context, and even from time to
time within the same context

34
4 ethical rules
Veracity truth telling, informed consent,
respect for autonomy
Fidelity loyalty, maintaining the duty to
care for all no matter who they are or what
they may have done
Privacy a persons right to remain private or
one is not observed or disturbed by others
during service delivery
Confidentiality only sharing private
information on a need to know basis
_disclose patient information based on need
35
Ethical Theories
Ethical theories provide a system of rules or
principles as a guide in making decisions about
what is right/wrong and good/bad in a specific
situation
Applied consistently to determine whether an
action is right or wrong
Allow a person to present a persuasive, logical
argument as to why certain actions should or
should not be allowed
Allow an executive branch to enforce conduct, i.e.
to penalize persons for actions that are not
allowed
36
Ethical theories

There are many ethical theories

Consequentialism
Deontology
Virtue Ethics
Natural Law
Relativism
Divine Command Ethics
Principilism

37
Ethical theories
There are three main approaches to
ethics:
Consequence-based approaches
Rule-based approaches
Character-based approaches
The first two approaches address the
question of how we should act (CONDUCT)
The third approach responds to the
question of what kind of person we should
be (CHARACTER)
Ethical theories

on the basis of
How should consequences
people act?
Fundament by following
al rules and thus
Question doing our duty
What kind of
person we
should be? develop
character and
virtues

39
Ethical theories

There are two basic ways of answer the

question, How should people act?

Consequentialism:
Act-oriented Look at the consequences
and choose the action that
approaches has the best consequences
Deontology:
Look at the rules and follow
the rules (ten
commandments, duty,
human rights, justice).
40
Consequentialism theory
The rightness or wrongness of an action is
determined by its consequences
Consequentialists maintain that whether
an action is morally right or wrong
depends on the action's consequences
In any situation, the morally right thing to
do is whatever will have the best
consequences
Consequentialist theories are sometimes
called teleological theories
41
Consequentialism
What Kind of Consequences?
Pleasure/pain
Happiness
Preferences/satisfaction
For whom the consequence is?
For the individual/me
For my group
For all human being
Consequentialism
Based on the consequence to whom,
consequentialism can be classified as:
a. Utilitarianism
The right action is the one that promotes
the greatest happiness of the greatest
number (maximizes social utility)
the choice that yields the greatest
benefit to the most people is the one
that is ethically correct
Bentham (1748-1832) and Mill (1806-
1873)
43
Consequentialism
There are two types of utilitarianism,
Act utilitarianism
An action is right or wrong to the extent that it
increases or decreases the total happiness of
affected members of society
Rule utilitarianism
Adopt moral rules which, if followed by
everyone, will lead to the greatest total
happiness of society
Principle of utility applied to moral rules, not
individual actions

44
Consequentialism
b. Ethical egoism - the ethics of self- interest
The right action is the one that promotes the
greatest happiness of the agent (maximizes the
agents utility)
everyone ought always to do those acts that
will best serve his or her own best self-interest
morally right actions are those that maximize
the best interest of oneself, even when it
conflicts with the interests of others
Two Ethical Egoists - Benjamin Tucker (1854-
1939) and Ayn Rand (1905-1982)

45
Consequentialism

c. Altruism - show concern for best

interests of others
Altruistic acts involve putting other
peoples interests ahead of our own
The ethics of altruism prescribes that we
sacrifice our interests and lives for the
good of others
Ethical egoist theorists are strongly
against to the ethics of altruism

46
Deontology
Deontology theories are rule oriented
The duty ethics theory, proposed by
Immanuel Kant (1724-1804)
The rightness/wrongness of an action is
determined by inherent features of the action
itself, or by an inherently valid rule
If an action is of the wrong kind, it is forbidden,
no matter how good its consequences are
Rejects both Utilitarianism and Ethical Egoism
The end doesnt justify the means
47
Deontology
The ethical action is one taken from duty, that
is, it is done precisely because it is our
obligation to perform the action
Behaving ethically by meeting our duties
Ethical obligations are the same for all rational
creatures (they are universal)
For Kant, choosing to obey the universal moral
law is the very nature of acting ethically
Duties such as, being honest, not cause
suffering of others, being fair to others,
keeping promises etc. are ethical and right
actions must be universalizable
48
Virtue Ethics
The rightness or wrongness of an action is
determined by the character traits it expresses
Emphasize what kind of person you should be
The qualities that one should develop in oneself
are called virtues (ex. honesty, fairness, kindness,
prudence, faithfulness, generosity, integrity,
bravery, etc.)
ethics should be concerned with the whole of a
persons life, not with the individual discrete
actions a person may perform in any given
situation
Aristotle (384-322 BCE) Confucius (551-479 BCE)
49
Ethical Relativism
This theory holds that morality is relative to
the norms of one's culture
states that before decisions are made, the
context of the decision must be examined
there are no absolute truths in ethics and that
what is morally right or wrong varies from
person to person or from society to society
variances in culture and society influence
whether an act is moral
Unlike deontology, this theory believes that
what is right for one group may not be right
for another; this theory believes there is no
universal truth
50
Divine Command Ethics

What makes an action right is the fact that

God commands it
They are religious oriented approach
10 Commandments
Islamic Sharia
Principilism theory
Principilism attempts to have both ways of
deontological and consequentialist
Now the dominant theory in medical ethics
It is a base for the development of the four
fundamental Principles of ethics
1. Autonomy
2. Beneficence
3. Non-maleficence
4. Justice
1 & 4 are deontological
2 & 3 are consequentialist
Early records on ethics
The Hippocratic Oath (400 BC)
is probably the earliest document that alludes
to morals and code of medical conduct for
physicians.
It appears to be designed for the swearing in of
a person at the beginning of a medical practice
It is the origin of ethics in health care
Thomas Parcival (1803)
His writing is probably the earliest statement
directing to peer-review: Before proceeding
with therapeutic innovation, a physician ought
to consult with peers
53
 Early records

Parcival went further to identify the

concept of vulnerable groups in the
statement:
for the poor-who being the most
numerous class of society, are the
greatest beneficiaries of the healing art
But in the accomplishment of the salutary
purpose, the gentlemen of the faculty
should be governed by sound reason, just
analogy, or well authenticated facts
and No such trials should be instituted,
without a previous consultation of the
54
physicians or surgeons, according to the
Early records
In between the Hippocrates and Parcival times:
much unethical research seems to have taken
place with very poor documentation of the details.
Uncontrolled, unscientific human experiments
which were purely empirical were done
vivisection was common without consent;
experiments on condemned criminals and
underprivileged;
prisoners could be offered pardons on participation
in inoculations
the famous inoculation of cowpox to an 8 Yrs. old
boy by Jenner happened during this period (1796)
55
 Early records
William Beaumont (1833)
records what some consider to be the oldest
American document dealing with research ethics
Beaumont identified key issues which may be
summarized as follows:
Experimentation is needed;
Investigator must be conscientious and
responsible;
Investigations must have good methodological
approach
Voluntary consent is necessary;
Discontinuation of experiment when it causes
distress to the subject or the subject56objects or
 Early records
1900 - Prussian Directive
Is response to public debate on human
subject experimentation.
Prohibited experiments in minors and
those not fully competent
Unequivocal consent required after
explanation of the experiment and
possible adverse consequences
Only certain people were allowed to do the
research and must keep written records

57
Early records
Prussian Directive
For the first time in history, informed
consent, the research process, and explicit
clarification of personal responsibility for
the experiment were required to be
included in the medical record
In addition, issues of written research plans
with a risk-benefit assessment, and the
need for previous animal experimentation
were raised
Ethical issues are required to be assessed
by peers on institutional review boards
58
Research History and Tragedies
Much of what we have as ethical codes
and guideline have been influenced by
tragic events which cause public concerns.
During the 1900, accounts of many
atrocities in the name of biomedical
research are documented
Experiments were liberally done on
underprivileged children, the poor and
prisoners.
Cases of vivisection have been reported
Genetic, racial hygiene experiments were
conducted, and in all cases, there59 is little
doubt that the subjects were not
The Nazi Experiments (WW-II 1939-1944)

Prisoners in Nazi concentration camps

were forced to undergo experiments that
included exposing them to extreme
temperatures, mutilating surgery, and
lethal pathogens

The gruesome experiments that maimed

and killed helpless prisoners outraged the
world and resulted in criminal indictments
against senior Nazi doctors, as well as
calls for international regulation of
medical experiments
60
The Nazi Experiments
Public outcry culminated in the 1946:
Nuremberg Doctors Trial
They were found guilty of murder,
torture, and other atrocities
During the trial at Nuremberg, the judges
codified fundamental ethical principles for
the conduct of research
In 1947, the Nuremberg Code thus
resulted with a set forth 10 conditions to
be met before research could be deemed
ethically permissible
61
The Nazi Experiments
Nuremberg Code became the first
international standard for the conduct of
research and introduced the modern era of
protection for human research participants
In 1948, The Universal Declaration of
Human Rights was adopted by the United
Nations
The Universal Declaration asserted the
principle that each human being was
entitled to certain rights and freedoms

62
 Human Radiation Experiments
The US government sponsored many radiation
experiments involving humans during the period
19441974
In the majority of cases, the experiments were
conducted to advance biomedical science;
however, some experiments were conducted
purely to advance national interests in defence or
space exploration
Most of these studies involved radioactive tracers
administered in amounts not likely to cause
physical harm
Attention was not given to issues of fairness in the
selection of participants
Further, research was conducted on participants
63
without their awareness or consent and on
The Jewish Chronic Disease
Hospital
Study
In 1963, studies were undertaken at New Yorks
Jewish Chronic Disease Hospital to understand
whether the bodys inability to reject cancer cells
was due to cancer or debilitation
These studies involved the injection of foreign, live
cancer cells into patients who were hospitalized
with various chronic debilitating diseases
Consent had been given orally, but did not include
a discussion on the injection of cancer cells, and
consent was not documented
The researchers felt that documentation was
unnecessary because it was customary to
undertake much more dangerous medical
procedures without the use of consent forms.
64
 The Jewish Chronic
Disease
Further, patients were not told that they
would receive cancer cells, because the
researchers felt it would unnecessarily
frighten them
Researchers defended this view with the
assertion that they had good cause to
predict that the cancer cells were going to
be rejected
Board of Regents of the State University of
New York found that the study had not been
presented to the hospitals research
committee and that the physicians
responsible for the patients care had
65
not
The Willowbrook Study
In a series of studies conducted from 1963
through 1966 at the Willowbrook State
School, a New York institution for mentally
defective children

In order to gain an understanding of the

natural history of infectious hepatitis under
controlled circumstances, newly admitted
children were deliberately infected with the
hepatitis virus

66
The Willowbrook Study
Researchers defended the deliberate
injection
the vast majority of them would acquire the
infection anyway while at Willowbrook, given
the crowded and unsanitary conditions, and
only children whose parents had given
consent were included
Parents found they were unable to admit
their children to Willowbrook unless they
agreed to their participation in the studies
67
The Tuskegee Syphilis Study (1932-
1972)
Study of the natural evolution of syphilis
infection in the long-term
Conducted at Tuskegee by the United States
Public Health Service
More than 400 black men with syphilis
participated, and about 200 men without
syphilis served as controls
The men were recruited without informed
consent and, in fact, were misinformed that
some of the procedures done in the interest of
research (e.g., spinal taps) were actually
special free treatment
68
The Tuskegee Syphilis

As early as 1936, it was clear that many

more infected men than controls had
developed complications,

and 10 years later, a report of the study

indicated that the death rate among those
with syphilis was about twice as high as it
was among the controls

In the 1940s, penicillin was found to be

effective in the treatment of syphilis

69
The Tuskegee Syphilis
This study continued, nonetheless, and the men
were neither informed nor treated with the
antibiotic
The first accounts of this study appeared in the
national press in 1972 following the revelation of
one of the participating nurse called Rivers
It was only in 1997 that a public acknowledgement
of Government responsibility was made by
President Bill Clinton, and the compensation of
surviving participants and the families of deceased
participants continues

70