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Nursing Ethics

  2. Why do we study ethics?  Providing guidelines in knowing What is GOOD or what is BAD? What is RIGHT and what is WRONG?
  3. Why do we study ethics? Ethics enables us to make correct judgement of different types of situations. In order to choose the right course of action that will help us towards the attainment of our goals which is to attain a happy and fruitful life.
  4. Ethics  Refers to well based standards of right or wrong that prescribes what human ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. – Example, ethics refers to those standards that impose the reasonable obligations to refrain from rape, stealing, murder, assault, slander, and fraud. – Ethical standards also include those that enjoin virtues of honesty, compassion and loyalty. – And, ethical standards include standards relating to rights, such as the right to life, the right to freedom from injury, and the right to privacy.
  5.  Refers to the study and development of one’s ethical standards.  Came from the Greek word “ethos” which means “moral duty”  Provide the standards that govern human conduct  Study of “good life”  Studies how people make judgement in right to right or wrong  Is about making choices that are best for the individual or society at certain times and in particular situations and then evaluating such choices and outcomes
  6.  Refers to the study and development of one’s ethical standards.  Came from the Greek word “ethos” which means “moral duty”  Provide the standards that govern human conduct  Study of “good life”  Studies how people make judgement in right to right or wrong  Is about making choices that are best for the individual or society at certain times and in particular situations and then evaluating such choices and outcomes
  7.  When singular: – is also known as “moral philosophy” – a field of philosophy that deals with the study of the moral value of human conduct and the rules and principles that ought to govern it.
  8. Ethical Theory and Moral Philosophy  Refer to philosophical reflection or when we speak of morality’s nature and function.  Purpose of theory: – To enhance clarity, systematic order and precision of argument in our thinking about morality.
  9.  When plural: – pertain to social, religious or civil code of behavior that is considered correct, for that of a particular group, profession, or individual. – It also refers to the moral fitness of a decision or course of action.
  10.  Foundation of a caring, ethical person: – The experience of a solid bonding between child and parents.  Foundation of bioethics is the very nature of our human being.  Each individual is born in love, with love and by love.
  11.  Basically, we tend to do good and right things from birth until such time that other influences drive us to do evil and wrong acts.  The experience of the pasts predicts the events of the future – As human beings, we are molded by everything we have experienced in our life.
  12. Morals  Are specific ways of behavior or accomplishing ethical practices  Fundamental standards of right and wrong, learned and internalized in early childhood, often based on religious beliefs  Moral Virtues: – Justice – Temperance – Fortitude – Prudence
  13. Morality  Derived from the Greek word “moralis” which refers to social consensus about moral conduct for human beings and society.  Refers to social conventions about right and wrong human conduct that are so widely shared that they form a stable, communal consensus, in a certain population or in a certain specific society.
  14.  Refers to behavior in accordance with custom and tradition and usually reflects personal and religious beliefs.  Addresses the questions of what is RIGHT and WHAT is WRONG.  Human tendency, right or wrong, good or evil, proper or improper, cruel or benevolent acts are explained in terms of morality.
  15. Elements determining Morality 1. Object: the act itself – Example: • To end the life of the fetus is object of abortion, • To end the life of a terminally ill patient is the object of euthanasia 2. End: Purpose, intension, motive, or reason – With out end, the act will not be carried out at all 3. Circumstances – Accidental aspects surrounding the act – Include time, place, means to the act
  16.  HUMAN ACT – Actions that are deliberate and involve the use of human intellect and reason.  ACTS OF MAN – Actions that does not involve the use of intellect and freewill, these actions are done unconsciously and without reason – Example: An insane person who attacks a nurse cannot be held liable for his actions
  17. Morals Ethics Principles and rules of right conduct Formal reasoning process used to determine right conduct Private and personal Professionally and publicly stated Commitment to principles and values are usually defended in daily life Inquiry or study of principles; Process of questioning and perhaps changing one’s morals
  18. CONSCIENCE  “Consciousness of an interior court of justice of man.”  :Inner voice  An innate faculty that tends to acts towards something that is good, proper and useful to self and others.  Suppression of libido – Freud
  19.  Conscience formation starts from the moment the child is conceived in the womb of the mother. PRE-FORMA FACTOR
  20. What constitutes the pre-forma factor? 1. The parent’s relationship with each other. – The quality of the conjugal relationship is very important in the shaping of the child’s innate positive traits. 2. The quality of sensory stimulation received in infancy and childhood. – The process of conscience formation is shaped by events and people, and by an individual’s response to them.
  21.  Birth to 6 years of age – Time of remote preparation for moral action, during which the child consciously develops an attitude toward authority, law and life.  The reaction of the parent to a child’s behavior serves as a conscience for the child revealing, the acceptability of “naughtiness” of certain acts.
  22.  6-7 years old – Age of reason – Child exhibits concern for knowing the rightness or wrongness of things. – Generally given programmed instruction in a particular system of values in daily life.
  23.  9-10 years – Child’s unconscious and instinctive behavior patterns among his playmates and peer group contradict those learned at home, forcing the child to think, and raising conformity to values from automatic reflex to conscious obedience.
  24.  12 years old – Capable of some discrimination between right or wrong. – Capable of making some autonomous decision – Child-morality is only partially conscious and is a participation in the morality of others
  25.  Adolescent – Chiefly preoccupied with personal and subjective moral values. – Greatly concerned about social justice and rights of the individual, and will devote great energy to a cause that captures his idealism and imagination. – Need to grow toward autonomy in order to establish a unique and independent person before parents and peers.  rebellion
  26.  Adulthood – Has assume responsibility not only for actions but for the self. – Has understanding of morality – Has subjective norm of his actions – Can read the exigencies of a situation accurately – Responds consistently with love and generosity.
  27.  The speed with which the development of conscience is accomplished depends upon the child’s: 1. Autonomy 2. Native intelligence 3. Emotional control 4. Self-image and moral instruction 5. Quality and variety of experiences
  28.  Some specific experiences that can aid in the gradual rationalization of behavior are: 1. The opportunities for choice 2. The experience of different levels of law 3. The experience of deception 4. The discovery of failure and weakness in this whom one depends
  29. Conscience Situations  Children are very observant and imitative.  They build their own character, language, and reactions to situations depending on what they see, feel and experience with adults close to them.  HOME has a big role to play in the formation and education of the child’s conscience and values.
  30. Theories  Jean Piaget – 2-stage process – Cognitive development  Lawrence Kohlberg – 6 stages with 3 levels – moral development is a continual process that occurs throughout the lifespan.  Carol Gilligan – Stages of the Ethic of Care
  31. Piaget’s Two-Stage Theory of Moral Judgment Younger than 10 or 11 Older children Rules as fixed and absolute Relativistic view of rules: He or she understands that it is permissible to change rules if everyone agrees Base moral judgments more on consequence Base judgments on intentions
  32. Heinz Steals the Drug "In Europe, a woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to make. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $ 1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: "No, I discovered the drug and I'm going to make money from it." So Heinz got desperate and broke into the man's store to steal the drug-for his wife. Should the husband have done that?" (Kohlberg, 1963).
  33. Levels Stages Level 1. Preconventional Morality Stage 1 - Obedience and Punishment Stage 2 - Individualism and Exchange Level 2. Conventional Morality Stage 3 - Interpersonal Relationships Stage 4 - Maintaining Social Order Level 3. Postconventional Morality Stage 5 - Social Contract and Individual Rights Stage 6 - Universal Principles
  34. Stage 1 - Obedience and Punishment  Earliest stage of moral development  Children see rules as fixed and absolute.  Obeying the rules is important because it is a means to avoid punishment
  35. Stage 2 - Individualism and Exchange  Children recognize that there is not just one right view that is handed down by the authorities.  Children account for individual points of view and judge actions based on how they serve individual needs.  Reciprocity is possible at this point in moral development, but only if it serves one's own interests.
  36. Stage 3 - Interpersonal Relationships  Often referred to as the "good boy-good girl" orientation  Focused on living up to social expectations and roles.  There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships.
  37. Stage 4 - Maintaining Social Order  People begin to consider society as a whole when making judgments.  Focus is on maintaining law and order by following the rules, doing one’s duty and respecting authority.
  38. Stage 5 - Social Contract and Individual Rights  People begin to account for the differing values, opinions and beliefs of other people.  Rules of law are important for maintaining a society, but members of the society should agree upon these standards.
  39. Stage 6 - Universal Principles  Based upon universal ethical principles and abstract reasoning.  People follow these internalized principles of JUSTICE, even if they conflict with laws and rules.
  40. Carol Gilligan and the Morality of Care  "In a Different Voice: Psychological Theory and Women's Development" (1982).  She suggested that Kohlberg's theories were biased against women, as only males were used in his studies.
  41.  Morality of caring and responsibility is premised in nonviolence,  Morality of justice and rights is based on equality.
  42. Approximate Age Range Stage Goal not listed Preconventional Goal is individual survival Transition is from selfishness -- to -- responsibility to others not listed Conventional Self sacrifice is goodness Transition is from goodness -- to -- truth that she is a person too maybe never Postconventional Principle of nonviolence: do not hurt others or self
  43. Development of Bioethics (Kuan, 1993) Wave No. Significant figures Bioethical principle I Creation of Hammurabi Moses Justice II Hippocrates Paternalism III New Testament; Jesus Christ Autonomy IV Media, Research, Economics, Pluralism Compassion and Veracity V Poverty, Super-rich, Migrants Sharing and allocation of resources
  44. Metaethics  Involves analysis of: 1. Language 2. Concepts 3. Methods of reasoning
  45. Values  “valere” = to be strong.  Strongly held beliefs or convictions about what one hold’s to be important and worthy in life.  Freely chosen, enduring beliefs, or attitudes about the worth of a person, object, idea, or action.  Person’s real values  shown by consistent patterns of behavior.
  46.  Value system – the organization of a person’s values along a continuum of relative importance.  Purposive behavior – actions that are performed “on purpose with the intention to reach some goal Purposive behavior  based on decisions or choices  based on values
  47. Value Transmission  The origin of a person’s values can be traced to: – Culture – Society – Institutions – Personality  Greatly influenced by SOCIOCULTURAL ENVIRONMENT  learned through observation and experience.
  48. Types of Values 1. Intrinsic value – Relates to maintenance of life 2. Extrinsic value – Originates outside the individual – Not necessary for the maintenance of life
  49. 1. Positive value – A view of what is desirable – How something should be 2. Negative value – Undesirable – How something not should be
  50. VALUE MEANING Religious Obtains strength from religious beliefs Theoretical Holds truth, rationality, and empiricism in high esteem Political Values power Economic Values usefulness and practicality Aesthetic Values beauty, harmony and form Social Values human interactions, is kind, sympathetic, and unselfish
  51. 1. Personal values – Used to individualized themselves 2. Societal values – Used to feel accepted 3. Professional values – Reflection and expansion of personal values – Acquired during socialization into nursing: • Codes of ethics • Nursing experiences • Teachers • Peers  Nursing values: COMPETENCE AND COMPASSION
  52. Important Values in Nursing (Watson) 1. Strong commitment to service. 2. Belief in the dignity and worth of each person. 3. Commitment to education. 4. Autonomy.  Nurses should be VALUE-NEUTRAL.
  53. Values Clarification  Is a process by which people identify, examine, and develop their own individual values.  Principle: no one set of values is right for everyone.  Promotes personal growth by fostering awareness, empathy and insight.
  54. Values Clarification Process (Raths, Harmon and Simon 1966) CHOOSING Beliefs are chosen •Freely, without outside pressure •From among alternatives •After reflecting and considering consequences PRIZING Chosen belief are prized and cherished. ACTING Chosen belief are •Affirmed to others. •Incorporated into one’s behavior •Repeated consistently in one’s life
  55. Obligations  Refers to the demands made on an individual, a society, a profession or government to fulfill and honor the rights of others
  56. Types of Obligation 1. Legal obligations – required by the law – such as the obligation of a nurse to pay professional tax when practicing his or her profession 2. Moral obligations – based on moral and ethical principles but are not enforceable under law – such as the moral obligation of the nurse to go on duty when the hospital is under staffed to ensure patient’s welfare
  57. Professional Ethics  A branch of moral science concerned with the obligations that a member of the profession owes to the public, to his profession, to his brethren, and to his clients  Norms of behavior or Code of Ethics of professionals to help members of the discipline to coordinate their actions or activities and to establish the public’s trust on the discipline
  58. Health Care Ethics  Is the division of ethics that relates to human health  Deals with the conduct and moral issues that arise in the practice of health care professionals  It resides in the realm of human values, morals, customs, personal beliefs, and faith
  59.  It strives to resolve ethical issues that often confront health care professionals such as: a. Choosing what is best for the mother and what is best for the unborn child b. What is best for the individual or her relatives c. What medical records can be disclosed and what must be held in strict confidentiality
  60. Bioethics  Is a living study of the conduct of HUMAN LIFE.  It is a systematic study of human behavior in the field of life science and health care in the light or moral values and principles
  61. Bioethics  Is a specific domain of ethics that focuses on moral issues in the field of health care.  It evolved into a discipline all on its own as a result of life and death dilemmas faced by health care practitioners.  Caring for people’s lives entails a continuous process of decision-making because we want to save lives and enhance quality of life at all times.
  62. Nursing ethics  In limited sense, is known as, nursing etiquette  In general sense, it is concerned with moral principles governing the right conduct of nurses in her relationship with patients, physician’s colleagues, the nursing profession and the public.  Examination of all ethical and bio-ethical issues from the perspective of nursing theory and nursing ethics (Johnston).
  63. Ethical Dilemma  Occurs when the decisions available in making an ethical decision are equally justifiable alternatives.  When there is only one course of action, or when conflict does not co-exist, there is no ethical dilemma.  Sometimes, it requires an individual to make a choice between two equally unfavourable alternatives.
  64.  It occurs because people have different ethical philosophy, follows different philosophy in life and see life situations at different perspectives.  In many instances, decisions must be made quickly because patient’s medical condition is rapidly deteriorating.
  65. Types of Ethical Problems (Wilkinson, 1993) 1. Decision-focused problems 2. Action-focused problems
  66. 1. Decision-focused problems  Difficulty lies in deciding what to do.  “What should I do?”  Moral Dilemma – Being between a rock and a hard plate – Difficulty is internal and personal – Addressed by: learning to make better decisions • Reviewing personal value system • Attending staff development offerings and ethics rounds.
  67. 2. Action-focused problems  Difficulty lies not in making the decision but in implementing it.  “What can I do?”  “What risk am I willing to take to do what is right?”  Moral distress – Nurse knows the right course of action but cannot carry it out because of institutional policies or other constraints.
  68. Ethics Committees in Hospitals  Composed of interdisciplinary group of health care providers (doctors and nurses), community representatives (government officials, NGOs, clergy), and non medical representatives (social workers, ethicist)
  69.  They discuss sensitive issues such as: – when to withdraw or withhold treatment for an adult and the treatment of a severely handicapped newborn – Some may include topics such as the right to die – informal consent – right to choose or refuse treatment – right to know who is treating the patient.
  70.  Ethics committee serves as a forum in which nurse and other health care professionals can challenge a treatment decision.  Increase communication between health care providers, patients, and their families in order to clarify issues, conflicts, and expectations. With increased understanding between them, lawsuits can be avoided.  Formulate organizational code of ethics.
  71.  Functions: 1. Give advice about policies and cases regarding ethical issues. 2. Consultation and case review by providing a forum for exchanging ideas in order to show the involved people the different courses of action available to them. 3. Formulating policies to help guide ethical decision making and thus ensure that each patient is treated fairly, that their decisions are honoured and the choices made for those who have no decision making capacity (children, unconscious, mentally incompetent) are for their best interest.
  72. Why be Moral? Perhaps sometimes you were told by your classmates while doing you surgical hand washing during your duty in the O.R. “Why do we have to follow all these sterile techniques when our CI won’t know anyway because she’s out there on the ward most of the time?” So why be moral if there is no one to see and judge you anyway?
  73. 1. The Answer of Divine Command. – We strive to become moral because God is good and He commands it to us to be also good. 2. The Answer that Morality pays. – This means that we should act from self interest. This emphasizes that good deeds are rewarded. Whenever a person does the right thing, his action is always to his advantage.
  74. 3. The Fair Play or Common Interest Argument. – This answer proposes that life is a game with rules and it is our mutual advantage or common interest to play by the rules. 4. “Because It is Right” Argument. – This view holds that a person should act morally simply because of his ethics or because it is right, not whether the act will pay or be rewarded
  75. A hallmark of a true professional is their willingness to accept a set of professional and ethical principles and follow these principles in the conduct of their daily affairs.
  76. Ethical Codes  Are systematic guides for developing ethical behavior.  They answer the normative question of what beliefs and values should be morally accepted.  Reflects the professions values and established standard of conduct or a written list of acceptable behavior that every member is expected to observe
  77. Functions of Ethical Codes (Kozier et al) 1. To inform the public about the minimum standards of the profession and to help them understand professional nursing conduct. 2. To provide a sign of the profession’s commitment to the public it serves. 3. To outline the major ethical considerations of the profession.
  78. 4. To provide general guidelines for professional behavior. 5. To guide the profession in self-regulation. 6. To remind nurses of the special responsibility they assume when caring for the sick.
  79. Functions of Professional Code of Ethics (Caffery and Sugarman) 1. Set forth basic principles and regulations to serve as guidelines 2. Serve as resource for the orientation of new practitioners for their duties, rights and privileges 3. Serves as guide to identify and evaluate qualities synonymous with professional conduct
  80. 5. Provide guideline for the establishment and operation of education programs to prepare future members for service in the profession 6. Identify common practices to be followed and those to be shunned 7. Provide a guide for considering the relationships of individuals to the employers, co-workers, society in general and to their won profession
  81. 8. Serve as a basis for identifying standards of quality practice 9. Provide, by implication, for legal actions against incompetents and violators of the code and for liability for the consequences of their actions 10.Provide for due process under the law for practitioners unjustly accused of misconduct in the performance of their duties
  82. Code of Good Governance  Promulgated by the PRC and adopted by Professional Regulatory boards  Set of professional and ethical principles which should be followed in the conduct of daily lives  Adopted to cover an environment of good governance in which all Filipino Professionals shall perform their duties
  83. General Principles of the Code of Governance 1. Service to Others – This implies a commitment to life of sacrifice and genuine selflessness in carrying out their duties even at the expense of personal gain.
  84. 2. Integrity and Objectivity – Professional should perform their responsibilities with the highest sense of integrity and imbued with nationalism and spiritual values, maintain objectivity, be free of conflicts, refrain from engaging in any activity that would prejudice their abilities to ethically carry out their abilities nor make any representatives that would likely cause a reasonable person to misunderstand and be deceived.
  85. 3. Professional Competence – It is their express obligation to keep up with the new knowledge and techniques in their field and upgrade their level of competence, taking part in a lifelong continuing education program. 4. Solidarity and Teamwork – Each professional shall maintain and support one professional organization for all its members promoting a deep spirit of solidarity and teamwork.
  86. 5. Social and Civic Responsibility – Professionals shall always carry out their professional duties with due consideration of the broader interest of the public, serve them with professional concern consistent with their responsibilities to society and as Filipinos, contribute to the attainment of the country’s national objectives 6. Global Competitiveness – Professional shall remain open to challenges of a more dynamic and interconnected world, rise up to global standards and maintain levels of professional practices fully aligned with global practices.
  87. Code of Ethics of Filipino Nurses  1982 – the PNA Special Committee under chairmanship of Dean Emeritus Julita V. Sotejo developed the Code of Ethics of Filipino nurses, was approved but not implemented
  88.  1984 – BON adopted the Code of Ethics of the International Council of Nurses (ICN) and added the fifth commitment which is “promotion of spiritual environment” through Board Resolution No. 633 and was enforced in 1989  1989 – Code of Ethics promulgated by the PNA was approved by the PRC through Board Resolution No. 1955
  89.  A new amended Code of Ethics for RNs has been promulgated by the BON in coordination and consultation with the PNA.  The Code of Good Governance was principal basis and was adopted and integrated as they apply to the Nursing Profession.  Adopted under RA 9173 and promulgated by the BON under Resolution No. 220 Series of 2004 last July 14, 2004
  90.  Preamble Health is a fundamental right of every individual. The Filipino registered nurse believing in the worth and dignity of each human being recognizes the primary responsibility to preserve health at all cost.  Emphasizes the responsibility of the nurse to: 1. People they serve 2. Practice 3. Co-workers 4. Society and environment 5. Profession
  92. Approaches to Ethics (Beauchamp and Childress, 1994) 1. Normative – Actions are based on standards of society and acts are judge by standards of what is accepted as right or good action. 2. Descriptive – What people believe and how they are phenomenologically described. 3. Analytic – People analyze concepts and methods of ethics in the light of what they observe, believe and practice.
  93. Normative Ethics/Prescriptive Ethics Theories or Approaches  It is the study of moral problems which seek to discover how one ought to act, how one does act or how one thinks one should act.  Types: 1. Teleological Approach 2. Deontological Approach 3. Virtue Ethics Approach
  94. Teleological Approach  Consequencialist Theory/Situation Ethics  Teleology comes from the Greek word “telos” or goal or end  Expressed in the maxim: “the right thing to do is the good things to do”  Based on the consequences of human action; action is morally right if the consequences of such action are favorable.
  95.  ACT UTILITARIANISM – we judge morality of each action by first determining the good or bad consequences of a particular act  HEDONISTIC UTILITARIANISM – good resides in the promotion of happiness or the greatest net increase of pleasure over pain  Holds that good is agape, the general goodwill or love for humanity  If the acts helps people, then it is a good act, and if hurts people, then it is a bad one  Often are made through risk benefit analysis
  96.  Example – The City Health Department is planning for their annual budget. To which program should they allot a bigger budget? The modernization of the city hospital or the Nutrition and Immunization Programs of the poverty- stricken families in the city? Will promotion of health and prevention of illness have priority over treatment of illness and rehabilitation? – Before any treatment is instituted to the patient, we discuss all treatment options to enable the patient to choose which treatment will produce the greatest amount of relief and largest amount of danger
  97. Deontological Approach  Duty-Oriented Theory/Nonconsequentialist Theories  Deontology came from the Greek word “deon” which means duty  Ethicist feels that basic rightness and wrongness of an act depends on the intrinsic nature rather upon the situation or its consequences.
  98.  A person is morally good and admirable if his actions are done from a sense of duty or reason.  Even when individuals do not want to fulfil their duty, Kant believes that they are required to do so.  Based on principles of obligation that must be followed by all irregardless of the consequences
  99.  Example – Suppose a nurse is assigned to care for a patient with AIDS. Could she reasonably refuse to care for the patient on the ground that the patient’s condition may threaten her health? As practitioners of the healing art, nurses are to take care of the sick even if patients have conditions that threaten their personal health. Nurses, however, must observe the necessary precautions to protect their health.
  100. Ross list the duties which believes reflects our moral convictions:  Fidelity: duty to keep promises  Reparation: duty to compensate others when we harm them  Gratitude: duty to thank those who help us  Justice: duty to recognize merit  Beneficence: duty to improve the conditions of others  Self-improvement: duty to improve our virtue and intelligence  Nonmaleficence: duty not to harm others
  101. Virtue Ethics Approach/Virtue Theories  Known as aretaic ethic from the Greek word “arête’ is focused on primarily on the heart of the person performing the act  Virtues: good habits that are used to regulate emotion, good character traits that are natural right and useful for getting what one wants
  102.  Cardinal virtues: wisdom, courage temperance and justice  Christian or theological virtues: faith, hope and charity  Example – a person who has developed the virtue of courage will stand firm in response to feelings of fear when he or she is face of danger
  103. Divine Command Ethics  Based on the theory that there is a Supreme or Divine being that sets down the rules to provide guidance to moral decisions.  For Christians, these rules are found in the Ten Commandments  Example – A nurse is approached by her friend who request for an abortion. The nurse refuses but refers the friend to a doctor who can perform it. This is a violation of the divine command, “Thou shall not kill.”
  104. Universal Principles of Biomedical Ethics  Ethical Principles Used in Health Care 1. Respect for Individuals 2. Autonomy 3. Veracity 4. Beneficence 5. Nonmaleficence 6. Justice 7. Fidelity 8. Confidentiality
  105. Respect for Individuals  Overarching maxim of morality that influences all other ethical principles
  106. Autonomy  Comes from the Greek word – “autos” meaning self and – “nomos” meaning governance, rule, law  Personal liberty to determine one’s action  Self- governance  Individual choice  Freedom of will  Causing one’s behavior (Beauchamp and Childress, 1994)
  107.  It involves self-determination and freedom to choose and implement one’s decision, free from deceit, duress, constraint and coercion
  108.  To govern one’s self, one must have the capacities to: 1. Understand the issue and what the situation is all about 2. Reason out and give one’s own opinion 3. Deliberate by weighing the pros and cons of the issue 4. Make an independent choice
  109.  Examples: allowing the patient to refuse treatment if he so decides, disclosure of his ailments, prognosis, mode of treatment and maintaining confidentiality, have the right to determine what should be done to his body.
  110. Application of Autonomy • Informed consent – Nurses do not give advice to what course of action but their primary task is to provide all information
  111. Paternalism  The principle and practice of paternal administration: government as by a father, the claim or attempt to supply the needs or to regulate the life of a nation or community in the same way a father does of the children.” - (Immanuel Kant and Stuart Mill, 1880s)
  112.  Principle of Paternalism/Parentalism – Means acting in a fatherly manner which involves engaging in behaviors associated which those of the traditional father of the family such as leadership, decision-making, discipline and protection. – Should assist others in pursuing their best interest when they cannot do themselves – In health care, the concept of paternalism is applied when health care givers, especially physicians, assume the authority to make decisions for the patients.
  113. – Thought of as a violation of the patient’s right for autonomy or freedom to choice – Applied in instances where patient’s have diminished decision making capacity such as mentally incompetent, delirious, unconscious or under the influence of drug – Nurses can make the decision for the patient to promote patient’s well being or to be protected from harm or injury (Justified only to prevent harm to the patient) – The role of nurses as patients advocate is related to this concept
  114.  Example: – The nurse capacity to restrain a violent patient (without need of asking for the patient’s consent) who may harm himself or other persons around him – An unconscious patient brought to the emergency room who receives medical treatment without him being made to sign consent for medical treatment first
  115. Standard of Best Interest  Pertains to health care providers making decisions about the a client’s health care when they are unable to make decisions about their own care  The health care provider must decide what the best course of action for the patient is and carry it out
  116.  Restrictions on autonomy may occur when there is potential harm to others such as communicable diseases or acts of violence. – For example: a person in the acute stage of contagious disease must be isolated, even against his will, in order to prevent the spread of disease and protect the greater public.  Therapeutic privilege is the legal exception of the rule of informed consent, – which allows the caregiver to proceed with care in case of emergency, incompetence, waiver, or implied consent
  117. Liberty-limiting Principle (Justification for overriding autonomy)  Harm principle – A person’s liberty is justifiably restricted to prevent that person from harming others  Offense principle – A person’s liberty is justifiably restricted to prevent that person from offending others  Principle of paternalism – A person’s liberty is justifiably restricted to prevent that person from harming himself or herself
  118.  Principle of extreme paternalism – A person’s liberty is justifiably restricted to benefit that person  Principle of legal moralism – A person’s liberty is justifiably restricted to prevent harm to that person from acting immorally  Social welfare – A person’s liberty is justifiably restricted to benefit others
  119. Veracity  Telling the truth  The physician tells the patient and his family his diagnosis, plan of care, treatment and possible risks involved, length of treatment, possible expenses and other options they may take if there be any  Applied in the nurse’s responsibility never to mislead or deceive a patient
  120. 3 Elements for Communication to be Credible 1. Logia – Substantial views of world truth. 2. Pathos – Element of empathy – Ability to put one’s self in a true situation 3. Ethos – Morally correct and true to the event.
  121. Veracity is necessary in Professional- Patient Relationships for three reasons:  1. The obligation of veracity is based on respect owed to others. – In asking patients their consent, for any deemed necessary intervention, the validity of the consent depends on the thorough information, full disclosure, and enlightenment given to the patient regarding the procedures to be done.
  122.  2. Veracity has a close connection to obligations of fidelity and promise- keeping. – When we communicate with others, we implicitly promise that we well speak thrutfully and that we will not deceive out listeners. – Example, relationship is entered into a contract, thereby gaining a right to the truth regarding diagnosis, prognosis and all other pertinent information.
  123.  3. Relationship of trust between persons are necessary for fruitful intervention and cooperation. – At the core of these relationships is confidence in and reliance on others to be truthful. – Truth telling is necessary to foster trust. – Lying and inadequate disclosure show disrespect for persons, violate implicit contracts and threaten relationships.
  124. In Filipino culture, the two traits that affect truth telling are: 1. Family orientation to illness – Means members are often informed of serious diagnosis before the patient is told. 2. Nonconfrontational attitude – Prevents us from disclosing unpleasant views – Most physicians still subscribe to death denial culture. – Fear of hurting otherz
  125.  How we say the information oftentimes makes them acceptable or not  Example: – The physician or health practitioner is requested not to tell the relative the exact nature of the patient’s illness: A young married male who was diagnosed to have AIDS request the doctor not to tell his diagnosis to his wife. • Telling the wife would be far more advantageous so that she can be examined, protected or treated as the case may be. She would be able to use proper precautionary measures for herself, understand the husband’s illness, and participate in his case
  126. – Relative request the physician not to tell the patient his condition or diagnosis: The children of an aged mother suffering from metastatic cancer request the doctor not to tell their mother her diagnosis and instead to proceed with the chemotherapy. • Gently telling her the truth would help convince her to participate in the treatment plan and including spiritual preparation towards peaceful death. – Physician intentionally withholds information according to his sound judgement when such revelation would do more harm to an emotionally unstable or depressed person. • This is called benevolent deception.
  127. Beneficence  Latin words “Bene” = good  “fiche” = to act or do  All forms of action done for the benefit of others.  To do good and what is best for the patient.  Promoting acts of kindness and mercy that directly benefit the patient.  Charity, altruism, love, humanity
  128.  Includes: – Nonmaleficence – Attentiveness – Prevenance (anticipating one’s needs) – Positive reinforcement – Helpfulness – Positive paternalism – Sharing – Truth-telling
  129.  BENEVOLENCE – Refers to the character trait or virtue of being disposed to act for the benefit of others  PRINCIPLE OF BENEFICENCE – Refers to the moral obligation to act for the benefit of others. – Asserts obligation to help others
  130. Principle of Benevolence  Should help those in need
  131.  Ideal Beneficence – is a benevolent act that involves going out of one’s way to do good to others.  Obligatory Beneficence – Is a mandatory act to do good, to give aid to those who are in need.
  132. Five Rules of Beneficence from Principles of Biomedical Ethics 1. Protect and defend the rights of others. 2. Prevent harm from occurring to others. 3. Remove conditions that will cause harm to others. 4. Help persons with disabilities. 5. Rescue persons in danger.
  133. Patient’s Rights A. Right to Medical Care and Human Treatment B. Right to Informed Consent C. Right to Privacy D. Right to Information E. Right to Privilege Communication F. Right to Choose Physician G. Right to Self-determination
  134. A. Right to Religious Belief B. Right to Medical Records C. Right to Leave D. Right to Refuse Participation in Medical Research E. Right to Correspondence and Receive Visitor F. Right to Express Grievances G. Right to be Informed of His Rights and Obligations as a Patients
  135. Nonmaleficence  An admonition in the negative form to remind health practitioners to do no harm  Obligation to avoid injuring another individual  The legal requirements of duty of care and accountability clearly arise from this principle  “Prinum non nocere” = above all do no harm to anyone
  136.  The principle affirms the need for professional competence.  Expressed in the Hippocratic oath: – “I will use treatment to help the sick according to my ability and judgment, but will never use it to injure or harm them.”  An extension of this is the obligation of health care providers to protect from harm those who cannot protect themselves such as children, mentally incompetent, and unconscious client
  137.  In 1988, Gert, a bioethicist working in moral-oriented disciplines, gave the following typical examples of nonmaleficence: 1. “Do not kill.” 2. “Do not cause pain or suffering to others.” 3. “Do not cause offense to others.” 4. “Do not incapacitate others.” 5. “Do not deprive others of the goods of life.”
  138.  Example: – Not assisting in performing abortion – Not assisting to commit suicide – Not performing euthanasia or mercy killing – Not wilfully subjecting patients to experimental drugs whose potential harm may be greater than the benefit – Not harming a person’s reputation by revealing confidential information – Not participating in treatments or procedures that will harm the patient – Not able to perform skin test prior to administration of allergic medications
  139.  The principle may justly be violated in some medical situations. – When a pregnant women with advanced cardiac disease must have abortion – When you insert intubate a patient – Violated in short term to produce greater good for the patient in the long term such when painful and disfiguring surgery is performed like radical neck dissection for the purpose of prolonging life in a patient with advanced laryngeal cancer – When a gangrenous limb of a diabetic patient must be amputated in order to prevent the spread of infection to the other parts of the body
  140. Justice We give what is due and we get what we merit for our conduct in life. FAIRNESS EQUITABLE DESERVED APPROPRIATE
  141.  If an individual need care, he/she has the right to be cared for because care is his/her due.  No one therefore has the right to refuse health care to someone who is in need.  Emergency: regardless of the individual’s capacity to pay, health care must be given to the person needing care because as health care professionals, out first duty is save lives.
  142. Justice  The right to demand to be treated justly, fairly and equally  Fair opportunity rule is based on the EGALITARIAN PRINCIPLE that emphasizes equal access to goods and services  Underlies the nurse commitment to provide services with respect for human dignity and render nursing care to the best of her ability to every patient irregardless of religion, sex, race, economic status, and
  143.  Basis of the law that provides for equal access to health care for all.  Example: The hospital put up triage schemes to determine who should be served first
  144. Injustice  Involves a wrongful act or omission that denies people benefits to which they have a right  Sharing of responsibility is not equal among responsible people.  Exploitation of nurses to unpaid overtime  Overcharging of government for patient services which are not done.
  145. Types of Justice (Beauchamp and Childress (1994) 1. Distributive justice – Fair, equitable, and appropriate distribution of responsibilities, or share of rights and roles. 2. Criminal justice – Just infliction of punishment or penalty proportionate to the crime committed. 3. Rectificatory justice – Just compensation for transactional problems such as breaches of contract and practice based on civil law
  146.  When the supply is limited, distributive justice requires that more should be given to the one who needs most and the one who will most benefited to attain quality life.  When the available supply is too limited, and there are just too many who desire to avail of the limited supply, sometimes it is resolve by lottery, giving each one a fair probability of being selected.
  147.  Engelhardt, Keusch, Wildes (1995) and others have suggested the following principles as valid material principles of distributive justice: 1. To each person an equal share. 2. To each person according to need. 3. To each person according to effort. 4. To each person according to contribution. 5. To each person according to merit. 6. To each person according to free-market exchanges.
  148. Some influential theories that go with the principles of justice: 1. Utilitarian – Emphasizes a mixture of criteria for the purpose of maximizing public utility. 2. Libertarian – Emphasizes rights to social and economic liberty, invoking fair procedures rather than substantive outcome.
  149. 3. Communitarian – Stresses the principles and practices of justice that evolve through traditions in a community. 4. Egalitarian – Emphasizes equal access to goods in life that every rational person values.
  150. Allocation of Scarce Resources  To allocate = to distribute by allotment.  Macroallocation decisions – Determine funds to be expended and the goods to be made available, as well as the methods of distribution.  Microallocation decisions – Determine who will receive particular scarce resources.
  151.  Justice in health care implies that every individual should: 1. Receive benefits due him or her by right; 2. Receive benefits he or she deserves after balancing competing claims of other persons against his/hers 3. Share in the burden of paying for the cost of health care and health research.
  152. Southeast Asia Center of Bioethics (1995) recognizes: 1. Every human being has a fundamental right to health. 2. Individuals have the primary responsibility to promote their own health. 3. As independent social beings, people have a right to seek the help of others in fulfilling this responsibility. Reciprocally, people have the duty to give the same help to others
  153. Fidelity  Obligation of a person to be faithful to agreements, responsibilities and commitments that he has made to himself and to others..  It is the main principle that supports the concept of accountability of nurses and other professionals
  154.  Fiduciary responsibility – Refers to the contract of relationship we enter into with the patient. – Bank in trust and confidence  Model of fidelity is: – Keeping one’s word of honor – Loyalty to commitments and oaths – Reliability
  155.  ABANDONMENT is a breach of fidelity and infidelity amounting to disloyalty. – Council of Ethical and Judicial Affairs on Health Care (1992)
  156. Confidentiality  Confidential communication is termed as privilege communication or professional secrecy because it is given based on trust.  Both legal and moral obligation of health care providers  The patient and his/her family are entitled to known information or facts within the limits determined by the physician.
  157.  Nurse may only repeat what the doctor wishes to disclose  Any information gathered by the nurse during the course of caring for the patient should always be treated confidential until the patient’s death  Nurses reassures the patient that information gained in the interview will be treated confidential
  158.  Persons required to observe confidentiality: a. Physicians who deal with the patient even for a briefest times at various phases of the patient’s illness or treatment b. Pharmacist who prepares and dispenses the medication prescribed to the patient c. All other health care professionals involved in the care of the patient such as nurses, medical technologist, hospital chaplain, student nurses and social workers d. All other personnel who attend to the care of the patient such as janitors, hospital receptionists, secretaries, accountant, treasurer, etc.
  159.  Confidential information may be revealed when: a. The patient himself/herself permits b. The case is medico-legal c. The patient is ill of communicable or highly contagious disease and public safety may be jeopardized d. Given to the members of the health team if information is relevant to his care e. Upon order of the court or when public safety and order require otherwise ( Article IV, Section 4(1) of the New Constitution
  160. Privacy  Defined as the individual’s control over access to himself or herself extending to physical or informational inaccessibility.  Person has the right to control access.  Libel – written defamation  Slander – oral defamation
  161. What counts as a loss of privacy and what affects an individual’s sense of loss of privacy = to what one values as strictly personal or very private.
  162.  Hospital settings – Territorial inaccessibility and non-exposure to others  Privacy is a necessary condition, the necessary atmosphere for maintaining intimate relationships of respect, love, friendship and trust.” – Charles Fried (1990)
  163.  Privacy certainly has such instrumental values.  We grant access to ourselves in order to have and maintain such relationships.  Whether we grant someone else access to some aspects of our lives will depend on the kind of relationship we want in pursuit of our goals. – Example: we allow physicians access to our bodies in order to protect our health.
  164.  “I need breathing space.”  In relationships, this means a need to with one’s elf, to be private in order to decongest the self from the other’s shadowing.  In any relationship, we have to provide time for being alone, for being private, and to be just ourselves and be inaccessible to others.  In health care, each person is unique and private. Let us respect out patients’ needs for privacy, for moments of silence.
  165.  Distinction between infringement of privacy and infringement of confidentiality, – Only a person or institution to whom information is given in a confidential relationship can be charged with violating rights of confidentiality.
  166. Filipino Primary Principles of Bioethics 1.Goodness 2.Beneficence 3.Family
  167. Goodness  Demonstrated through the practice of justice, respect for autonomy, compassion, veracity, fidelity, and confidentially.  Filipinos: delicate and generous HOSPITALITY  Sharing of goods – Lending money, materials, equipment, and even human resources
  168.  “Utang na loob” (indebtedness or gratitude) – Belief that good favors done to one member should be perpetuated in acts of gratefulness forever.  Extends to keeping secrets even it would have been more charitable to reveal the secret.  Confrontative dialogues are avoided because of the guise of being good and not hurting the feelings of others.
  169. Family  Solid bank one can rely on where withdrawal of help and support is endless and the resources is never exhausted.  All principles of human conduct of life begin and end in the family.  Visayan: “Ginikanan” = source of everything  Source of all right conduct.
  170. The Beginning of Life  Life begins at the moment human sperm fertilizes a mature human ovum.  Respect to an unborn human being starts at the moment fertilization takes place.  WRONG AND BAD any means or procedures that arrest the right to life and care due to this growing, living, human being.
  171.  It is unjust because the innocent, helpless, developing human being is deprived of the human right to be cared for, to be borne and to live.  ABORTION = always regarded as bioethically a violation of the unborn child’s right to live and grow with dignity.  “WHAT IS LEGAL IS NOT ALWAYS MORALLY CORRECT.”
  172. 2 Significant things to remember in caring for the unborn 1. Physical environment – Receive all the necessary nutrition – Clean surroundings and sufficient sleep 2. Psycho-emotional-spiritual ecology – Refers to love and spirituality of the mother and father of the child – Child must be loved, wanted and prayed over
  173. Virtues of Professional Life TRADITIONAL MODEL CONTEMPORARY MODEL Obedience Autonomy Submission Justice Persistence Courage
  174. 1. Compassion  Is a trait that combines a attitude of active regard for another’s welfare with an imaginative awareness and an emotional response for deep sympathy, tenderness and discomfort at the other’s misfortune or suffering.  Resembles CARE.
  175. 2. Discernment  Rests on sensitive insight involving acute judgment and understanding and it results in decisive action.  Includes the ability to make judgments and reach decisions without being unduly influenced by extraneous considerations, fears and personal attachments.  Pairs in action with courage and fidelity to one’s duty and prudence.
  176. 3. Trustworthiness  Shown when someone you believe to be solidly true, loyal, and good will stand by you through thick and thin.  Trust entails confidence that another will act with the right motives in accord with moral norms.
  177. 4. Integrity  Soundness, reliability, wholeness, and integration of moral character,  Coherence of the person’s words, actuations, and his or her way of life.
  178.  Describes two aspects of a person’s character: 1. coherent integration of aspects of the self – emotions, aspirations and knowledge so the each complements and does not frustrate others 2. Character trait of being faithful to moral values and standing up in their defense when they are threatened or under attack.
  179. Guidelines, Moral Principles or Theories for the Nurses  to use to be able to respond to a given situation with sound moral judgement  Moral principles – Are statements about broad
  180. 1. God is the author of life; therefore, no one has the right to take it except Him 2. Health is wealth. 3. The golden rule: Do unto others what you want would like others do unto you.
  181. 4. Theory of double or two-fold effect – A situation which may both have good and bad effects – Choose the lesser evil, which may produce greater good effects – The basis of action may be the following: 1. That action must be morally good 2. That the good effect must be willed and that the bad effect merely allowed 3. That the good must not come from evil action but from the initial action itself directly 4. That the good effect must be greater than the bad effect
  182.  Example: – It is not morally good if a boy steals in order to alleviate his hunger because the action itself is already bad. – On the other hand, if the patient who has cancer of the uterus submits to hysterectomy, she will not be able to bear a child. If she does not have the operation, she will die. It is the gynaecologist’s intention to help the mother and not harm her. The surgeon’s action is morally good since saving the mother’s life is the primary importance. Also the doctor himself did not will that the patient lose her child-bearing.
  183. 5. The principle of totality – The whole is greater than the sum of its parts. – Example: a man who has a gangrenous foot must be amputated so as to save his life and he can still walk through aid of crutches or artificial limbs 6. The greatest good for the greatest number – The result should be one that benefits the most number of people – During epidemic, immunization against communicable diseases is administered to people. Although some may have some slight reactions to the vaccine, the greater majority of the population shall be considered rather than the isolated few
  184. 7. One who acts as through an agent may be himself responsible. – Example: a nurse recommends a doctor to an unwed pregnant adolescent for abortion 8. The end does not justify the means – If the action taken is bad, the result, no matter how good, is not enough for his bad action. – Giving a sedative to a chronically ill person so he/she can die in peace is morally wrong. A physician assisted a woman diagnosed as having Alzheimer’s disease in committing suicide is both legally and morally wrong
  185. 9. Epikia – Exception to the general rule – Example: if a mental patient went out of control and the doctor could not be contacted, the patient may be restrained by the virtue of epikia. Another is allowing a relative to see a seriously ill patient who expresses the desire to see the former although it is not yet visiting hours 10.No one is obliged to betray himself or herself – In testifying in court, no one can force any person to answer a question if such will incriminate him/her
  186. 11.Defects of nature can be corrected. – Patients with cleft palate may have their defects corrected by plastic surgery. 12.If one is willing to cooperate in the act, no injustice is done to him/her. – Example: suppose a patient subjects himself/herself willingly to an experimental drug and he/she has been told of the possible effects, is of right age and is sane, there is no violation to human rights
  187. 13.A little or less does not change the substance of an act – If a nurse gets medicine from a hospital stock without permission or without prescription, he or she is guilty of theft even if she got only one tablet 14.No one is held to the impossible – To promise that a patient with heart transplant will live may be impossibility. Yet such procedures are done in the hope of saving or prolonging a patient’s life. The doctor or the nurse cannot be held if they have done their best to take care of the patient and the latter dies
  188. 15.The morality of cooperation – Man is morally responsible not only for his own actions but also to the effect of his actions to other people as well as his reaction to others men’s action – Formal cooperation in an evil act is never allowed  Types of Cooperation with Evil:
  189. 1. Positive Cooperation: – Voluntarily doing an act which contributes to the evil act of another – Example: A nurse who assist in abortion (Immoral operations such as abortion shall not be participated upon by a nurse even if the doctor commands it) 2. Negative Cooperation: – Cooperation by omission in which the person did not do anything to prevent another person from committing the evil act – Example: A nurse who saw another nurse stealing medical supplies and does not stop the said nurse or report the incident to her supervisor
  190. 3. Direct/Immediate Cooperation: – happens when a person’s cooperation occur while the act is being performed – Example: A nurse who acts as a “watch” while the doctor injects a fatal dose of sedative to un unconscious patient 4. Indirect/Mediate Cooperation: – committed before and after the evil act; however, cooperation is not necessarily to the evil act itself – Example: A nurse destroys all evidence of an abortion although he did not assist while the surgical procedure was being performed
  191.  Medical situations in which a nurse may commit immoral act by cooperation – IUD insertion – Abortion – Sterilization – Infertility studies in which a male patient may be require to collect semen specimen by masturbation – IVF – End of life issues: “DNR order” – Euthanasia
  192. 15.Principle relating to the origin and destruction of life. – One of God’s Commandments: Thou shall not kill – Example: euthanasia
  193. INFORMED CONSENT  Is the client’s approval (or that of the client’s legal representative) to have his or her body touched by a specific individual.  It indicate the client’s participation in the decision making regarding health care
  194. Informed Consent  Originates from the legal and ethical right of the patient to direct what happens to her body  Based on principle of autonomy.  The nurse’s responsibility is to WITNESS the giving of informed consent.
  195. Witnessing involves the FF: 1. Witnessing the exchange between the client and the physician 2. Establishing that the client really did understand, and was really informed 3. Witnessing the client’s signature  “Witnessing only signature”: if a nurse witnesses only the client’s signature and not the exchange between client and physician
  196. Requisites of Informed consent 1. Informed 2. Voluntary 3. Competent
  197. Elements of Informed Consent 1. Threshold elements a. Competence (to understand and decide b. Voluntariness (in deciding) 2. Information elements a. Disclosure (of material information) b. Recommendation (of a plan) c. Understanding (of the information and plan) 3. Consent elements a. Decision (in favor of the plan) b. Authorization (of the chosen plan) c. Signature (execution of the consent through signature)
  198. 3 major elements of informed consent 1. The client must be given enough information to be the ultimate decision maker 2. The consent must be given voluntarily 3. The consent must be given by an individual with the capacity and competence to understand – COMPETENT AND AN ADULT – Over 18 years old, conscious and oriented
  199.  INFORMED consent requires that patient has the right to: a. clear explanation, in lay person’s terms, all proposed procedures, including identity of the person who will perform the said procedure b. possibilities of any risk or side effects c. problems related to recuperation, and d. the probability of the risk involved and e. how he will be subjected to any procedure without his informed consent.”
  200.  VOLUNTARY – That the decision is of his own free will and he is not coerced or put under duress to do so. He must be allowed to make decisions even if the choices may have harmful consequences as long as he does not cause harm to others. • Example: Patient is allowed to refuse the more effective chemotherapy and chooses alternative treatments such as herbal medication – Nurses must make certain precautions and assess the patient’s ability to understand his situation, understand the risk associated and at hand to communicate a decision based on that understanding – If possible, it would be better if the patient can verbalize full understanding of the procedure before he is asked to sign a consent form.
  201.  COMPETENT – He must have the intellectual capacity to make a rational decision – Mentally and emotionally – Must be of legal age
  202. 2 Functions of Informed Consent 1. Protective – To safeguard against tension of integrity 2. Participative – To be involved in the health care decision making
  203. Persons who cannot provide consent 1. Minors 2. Unconscious or severely injured 3. Mentally ill/chronic dementia other mental deficiency 4. Under the influence of drugs and alcohol
  204.  Informed consent of Minors – Parents or guardians have the authority to give consent on the behalf of minors and children under 18 years old – Parents are ethically and legally responsible because they are considered to be one who care most of their children and as well treatment and diagnosis will have impact of the family – The right to make decisions on behalf of their children includes 1. Right to give consent 2. Right to refuse and discontinue treatment even those life sustaining
  205.  Minors and children can make their own informed consent if they are: Emancipated minor – Has established independence from parents through/by: • Self-supporting and not living at home • Marriage • A parent • Service in the armed forces • By a court order
  206.  Informed consent of a. Mentally Incapacitated b. Declared incompetent c. Unconscious d. Chronic dementia or other mental deficiency e. Under the influence of alcohol or dugs – If a client is declared mentally or emotionally incompetent, the next of kin, legal gaurdain (appointed by the court), or the durable power of attorney has the legal authority to give consent.
  207. REFUSAL TO CONSENT  A patient who is mentally and legally competent (sane mind and of legal age) has the right to refuse the touching of his body or to submit to a medical and surgical procedure no matter how necessary, nor how imminent the danger to his life or health if he fails to submit to treatment.
  208. CONSENT FOR STERILIZATION  Sterilization is the termination of the ability to produce offsprings.  HUSBAND and WIFE must consent to the procedure if the operation is primarily to accomplish sterilization.  Medically necessary and an incidental result = PATIENT’s CONSENT ALONE is sufficient.
  209. Implied consent  Presumed consent and need not to be obtained during emergency situations when the patient is unconscious or incompetent and no surrogate decision maker is available.  Based on the principle of beneficence when health care providers are obliged to act on the patient’s behalf when the life of the latter is at stake.

Notas do Editor

  1. from the ordinary to familiar chain of events that make up our day to day existence to the most difficult conflicts and changing crisis that face us,
  2. Ethos = custom or character It is the study of morality
  3. Generic terms for various ways of understanding and examining the moral life of a person.
  4. The practices or beliefs of a certain group (eg, nursing ethics) Expected standards of behavior if a particular group (these standards are described in the group’s code of professional conduct).
  5. Common morality: comprises socially approved norms of human conduct. Personal standards of right or wrong.
  6. Code of values that guides man’s choices and actions. Concerned with knowing and doing what is right, with the goodness and badness of man’s actions as they conform to some set of standards imposed by society.
  7. Elements of Human Act: Advertens: To be considered a human act, a person must know what he is doing, whether it is good or bad. 2.Violation: person must deliberately will the act or exercise his freewill in wanting the act. Passion such as fear or anger are possible impediments to human acts as they could cloud a person’s judgment and freewill. This is one of the reason why nurses and doctors are not advised to get involved in the treatment of their loved one in critical condition as their passion may impair their free will and professional judgment. Execution
  8. Comparison of Morals and Ethics
  9. Self-consciousness, Super consciousness, to see what is good or bad both for ourselves and others. Role in making moral judgments Innate light that tells us to do good and avoid evil. Feeling and will play a significant role in the application of human action, more affirmative than consciousness and abstract knowledge
  10. If the father and mother are not very open and honest  child being conceived will likely have a tendency not to tell the whole truth. A child grows up in an atmosphere of fine visual, auditory and tactile stimuli is bound to learn language easily and be appreciative of things of beauty. The quality of touch received makes an individual sensitive to the needs of others and will render that person helpful to others.
  11. Usually motivated by fear of punishment and of losing the security of parental love. The guilt one feels when disobeying or displeasing one’s parent is irrational and automatic.
  12. 6-7: Child begins to reevaluate and seeks reasons behind the norms been followed. 9-10’
  13. Conscience is not yet, strictly speaking, independent and personal Norms which the child judges the situations are those accepted uncritically from parents, peers, and teachers
  14. Expects everyone including himself to love up to an absolute ideal  failure of the adult world to live up to professed ideals, confuse him. Conflict between his own standards, those of his peers and those of adults significant in his life. Struggles to emotional upheaval and social insecurity.
  15. Street language, boisterous laughter, rough or bully actions, aggressive reactions, are all picked up by the child. If good breeding, refined manners, polite language and good taste, children are propelled to be good, and will develop values, character and delicate conscience. Parents should involve themselves in choosing television programs, or selecting games and reading materials for their children. When child goes to school, a congruence and consistency of values and opinions over issues should exist between parental and school teaching. INCONSISTENCE  CONFUSION. Situation – Conflict among parental teachings Situation – Conflict between parents and teacher
  16. Kohlberg - reasoning
  17. < 11: They believe that rules are handed down by adults or by God and that one cannot change them. Thinks about moral dilemmas in one way. The child primarily considers the amount of damage--the consequences--whereas the older child is more likely to judge wrongness in terms of the motives underlying the act (Piaget, 1932, p. 137).
  18. Avoid punishment Gain Reward Gain Approval & Avoid Disapproval – Good boy or good girl Duty & Guilt/ Law and Order Agreed upon rights Personal moral standards – Principled conscience
  19. is especially common in young children, but adults are also capable of expressing this type of reasoning. To the Heinz dilemma, the child typically says that Heinz was wrong to steal the drug because "It's against the law," or "It's bad to steal," as if this were all there were to it. When asked to elaborate, the child usually responds in terms of the consequences involved, explaining that stealing is bad "because you'll get punished" (Kohlberg, 1958b). Kohlberg calls stage 1 thinking "preconventional" because children do not yet speak as members of society. Instead, they see morality as something external to themselves, as that which the big people say they must do. Example: A nurse follows a physician’s order so as not to be fired.
  20. Different individuals have different viewpoints.  In the Heinz dilemma, children argued that the best course of action was the choice that best-served Heinz’s needs. "Heinz," they might point out, "might think it's right to take the drug, the druggist would not." Since everything is relative, each person is free to pursue his or her individual interests. One boy said that Heinz might steal the drug if he wanted his wife to live, but that he doesn't have to if he wants to marry someone younger and better-looking (Kohlberg, 1963, p. 24). Another boy said Heinz might steal it because maybe they had children and he might need someone at home to look after them. But maybe he shouldn't steal it because they might put him in prison for more years than he could stand. (Colby and Kauffman. 1983, p. 300) The philosophy is one of returning favors--"If you scratch my back, I'll scratch yours." To the Heinz story, subjects often say that Heinz was right to steal the drug because the druggist was unwilling to make a fair deal; he was "trying to rip Heinz off," Or they might say that he should steal for his wife "because she might return the favor some day" (Gibbs et al., 1983, p. 19) Example: A client in the hospital agrees to stay in bed if the nurse will buy the client newspaper.
  21. Two-person relationships with family members or close friends They believe that people should live up to the expectations of the family and community and behave in "good" ways. Good behavior means having good motives and interpersonal feelings such as love, empathy, trust, and concern for others. Heinz, they typically argue, was right to steal the drug because "He was a good man for wanting to save her," and "His intentions were good, that of saving the life of someone he loves." Even if Heinz doesn't love his wife, these subjects often say, he should steal the drug because "I don't think any husband should sit back and watch his wife die" (Gibbs et al., 1983, pp. 36-42; Kohlberg, 1958b). If Heinz’s motives were good, the druggist's were bad. The druggist, stage 3 subjects emphasize, was "selfish," "greedy," and "only interested in himself, not another life." Sometimes the respondents become so angry with the druggist that they say that he ought to be put in jail (Gibbs et al., 1983, pp. 26-29, 40-42). A typical stage 3 response is that of Don, age 13: It was really the druggist's fault, he was unfair, trying to overcharge and letting someone die. Heinz loved his wife and wanted to save her. I think anyone would. I don't think they would put him in jail. The judge would look at all sides, and see that the druggist was charging too much. (Kohlberg, 1963, p. 25) Example: A nurse gives elderly clients in hospital sedatives at bedtime because the night nurse wants all clients to sleep at night.
  22. Becomes more broadly concerned with society as a whole Now the emphasis is on obeying laws, respecting authority, and performing one's duties so that the social order is maintained. In response to the Heinz story, many subjects say they understand that Heinz's motives were good, but they cannot condone the theft. What would happen if we all started breaking the laws whenever we felt we had a good reason? The result would be chaos; society couldn't function. As one subject explained, I don't want to sound like Spiro Agnew, law and order and wave the flag, but if everybody did as he wanted to do, set up his own beliefs as to right and wrong, then I think you would have chaos. The only thing I think we have in civilization nowadays is some sort of legal structure which people are sort of bound to follow. [Society needs] a centralizing framework. (Gibbs et al., 1983, pp. 140-41) Example: A nurse does not permit a worried client to phone home because hospital rules stipulate no phone calls after 9:00 PM.
  23. In response to the Heinz dilemma, stage 5 respondents make it clear that they do not generally favor breaking laws; laws are social contracts that we agree to uphold until we can change them by democratic means. Nevertheless, the wife’s right to live is a moral right that must be protected. Thus, stage 5 respondent sometimes defend Heinz’s theft in strong language: It is the husband's duty to save his wife. The fact that her life is in danger transcends every other standard you might use to judge his action. Life is more important than property. Example: A nurse arranges for an East Indian cleint to have privacy for prayer each evening.
  24. In response to the Heinz dilemma, stage 5 respondents make it clear that they do not generally favor breaking laws; laws are social contracts that we agree to uphold until we can change them by democratic means. Nevertheless, the wife’s right to live is a moral right that must be protected. Thus, stage 5 respondent sometimes defend Heinz’s theft in strong language: It is the husband's duty to save his wife. The fact that her life is in danger transcends every other standard you might use to judge his action. Life is more important than property. Example: A nurse becomes an advocate for a hospitalize client by reporting to the nursing supervisor a conversation in which a physician threatened to withhold assistance unless the client agreed to surgery.
  25. Ethics of Care
  26. Another way to look at these differences is to view these two moralities as providing two distinct injunctions - the injunction not to treat others unfairly (justice) and the injunction not to turn away from someone in need (care). She presents these moralities as distinct, although potentially connected. In her initial work, Gilligan emphasized the gender differences thought to be associated with these two orientations. The morality of care emphasizes interconnectedness and presumably emerges to a greater degree in girls owing to their early connection in identity formation with their mothers. The morality of justice, on the other hand, is said to emerge within the context of coordinating the interactions of autonomous individuals. A moral orientation based on justice was proposed as more prevalent among boys because their attachment relations with the mother, and subsequent masculine identity formation entailed that boys separate from that relationship and individuate from the mother. For boys, this separation also heightens their awareness of the difference in power relations between themselves and the adult, and hence engenders an intense set of concerns over inequalities. Girls, however, because of their continued attachment to their mothers, are not as keenly aware of such inequalities, and are, hence, less concerned with fairness as an issue. Further research has suggested, however, that moral reasoning does not follow the distinct gender lines which Gilligan originally reported. The preponderance of evidence is that both males and females reason based on justice and care. While this gender debate is unsettled, Gilligan's work has contributed to an increased awareness that care is an integral component of moral reasoning.
  27. Individualis and autonomy Transition period is a time period when the individual recognizes a conflict or discomfort with some present behavior and considers new approaches. 1. Caring for oneself 2. Caring for others 3. Caring for onself and others
  28. Code of Hammurabi – Babylonia, provided laws that covered every facet of Babylonian life including medical practice.
  29. Comes from the latin word Big determinants of his decisions and actions Shaped out of society’s norms, religion and family orientation Not permanent characteristics People have many and different set of values Form a basis of behavior --- freedom, courage, family, dignity Once you are aware of your values, they become internal control of behavior.
  30. Or bringing about a certain result. Value set – the group of values a person holds.
  31. People learn moral reasoning during their SOCIALIZATION – the process by which individuals learn the knowledge, skills, and dispositions of their social group and society. Acquiring values is a gradual process, usually occurring at an UNCONSCIOUS LEVEL.
  32. Intrinsic – food and water Extrinsic – health, holism, humanism
  33. Positive: some nurse value the holistic approach to nursing Negative: talking unkindly about clients is considered by many nurses to be undesirable
  34. Types of Values and Selected Meanings
  35. Personal: family unity, self-worth, worth of others, independence, religion, honesty, fairness, love, sense of humor, safety, peace, financial security, material things, money, property of self, property of others, leisure time, work, travel, plants, animals, physical activity, intellectual activity, artistic activity, neatness Societal values: Human life, individual rights, individual autonomy, liberty, democracy, equal opportunity, power, health, wealth, youth, vigor, intelligence, imagination, education, technology, conformity, friendship, courage, compassion, family
  36. Nursing is a helping, humanistic service. This values means that the nurse acts in the best interest of the client regardless of nationality, race, creed, color, age, sex, politics, social class, or health status. This reflects societal value of lifelong learning. Continuing education is needed to maintain and expand the nurse’s level of competence and to increase the body of professional knowledge. Assume independent functions. Value neutral – should be aware of the client’s values and not assume that their own are superior.
  37. Valuing Process Choosing (cognitive) Prizing (affective) Acting (behavioral)
  38. Ethics applied to life (life and death decision making)
  39. Results to anger, guilt, and loss of integrity
  40. Formal statement of a group’s ideals and values.
  41. It focuses on the traits and virtues of a good person It states that it is not only doing the right thing that is all needed but one must have the right motivation, disposition, and traits for being good and doing good
  42. Jesus Christ teachings the primacy of man’s freedom to make choices and decisions. Never forced his disciples: “ If you wish to become one of my disciples, then come and follow me.” Individual if free from threats or any type of force or coercion. This means the individual is in full control of self, totally aware of what is the issue, and in a capacity to make appropriate moves and decisions for the best outcome.
  43. An autonomous person who signs a consent form without reading or understanding the form has failed to act autonomously because of failure to read and understand what the consent demanded.
  44. Health care: the professional has superior training, knowledge and insight and is in an authoritative position to determine the patient’s best interest.
  45. Hippocrates – family physicians seen as the supreme health authority of the family’s health. The physician’s orders are often obeyed at all cost Authority figure such as the state or one’s father, knows best and that each individual is obligated to comply with the authority. BENEVOLENT INTERVENTION – one that likens the state to a protective parent caring for one incompetent minor.
  46. Principle of truthfulness. Deal with honesty
  47. Doctors hesitate to tell a patient that he or she is dying. Example: Myra knows that her friend lisa’s husband is having an affair with his secretary. Myra cannot confront lisa to tell her what she knows because this might do harm to the relationship. In reality, grave conflicts between husband and wife are bound to arise by not confronting Lisa with the truth while the affiar is at its early stage. Another example is hearsay.
  48. To override a patient’s right to truth needs a very string justification. The most common situation is when truth telling will harm the patient or others because coping mechanisms needed to accept facts are weak.
  49. Utilitarianism is based on beneficence  goodness and kind deeds form the backbone of the utilitarian theory Utilitarianism – defines as the moral and political rightness of an action and is determined by its contribution to the greatest good of the greatest number. Parable of the Good Samaritan Altruism – to do acts of kindness and goodness towards self and others because all by nature are good and all deserve goodness.
  50. Benevolence – goodness in each personhood Provenance – attentiveness dictated by kindness to anticipate what one needs. Organ donation under beneficient act of giving one’s organ to another, we also touch the principle of stewardship PRINCIPLE OF STEWARDSHIP – reminds us that we are care takers or stewards of our body and that we cannot just give any part of our body without due cause or the utmost benefit of another person in need.
  51. Ideal: a nurse was riding on a bus. Suddenly one of the passengers fainted probably because of hypoglycemia and fatigue. The nurse brings her to the nearest hospital, stays with her until she regained full control of herself. In addition, she brought her back to her home and gave her good. This act is virtuous and ideal; not everyone would do such a good act for a stranger. The nurse felt she had to do it because it was her inner extreme moral obligation that prodded her to do so. Obligatory: in emergency cases, no one should be denied urgent care. To offer a glass of clean water when someone is thirsty,to shelter the homeless, to feed the hungry, to give love to abondoned children , are some examples of obligatory beneficence.
  52. (1994) Explaining to the patient who will undergo surgery. Putting side rails up, double gloves when doing intervention for aids. tutoring a failing student will help him or her pass the course. Caring for mentally ill patients, remove hazardous materials sharp objects; avoiding talking about topics that will depress or provoke patients to violence Guiding or holding the hands of blind or deaf while crossing the street, reading a newspaper with defective eyesight Throwing a lifesaver to some who is drowning, cheering up someone who is depressed
  53. The Patient’s Bill of Rights helps health practitioners provide more effective patient care.
  54. Not to inflict harm intentionally. Maxim of medical ethics Example: not creating false rumors to destroy another’s reputation
  55. In healthcare
  56. Nurses should make their stand known and should withdraw from the team if what is to be done is against their conscience
  57. When Adam and Eve succumbed to pride by disobeying God’s command. If you disobey, you deserve a corresponding action. Coode of Hummarabi: during fights for land and resources, whoever won the battle will get all the oxen, women, children and belongings of losing party. If you win, you get all: if you lose, you have nothing. Moses came down from the Mountain of Yahweh: Those lived by the Ten Commandments enjoyed prosperity and peaceful, those you did not suffered all sorts of malediction Contemporary: court trials, those who are guilty of crime are punished; those who have not are set free.
  58. The client has the right to receive care. The health professional has the obligation to give that person the needed care.
  59. Human needs and efficient service must be equitable.
  60. Problems if distributive justice arise under conditions of scarcity and competition.
  61. Macro – deals with how much of the society’s resources will be used for various needs, including health-related expenditures. Government decides how much of the national budget goes to healthcare and what proportion of available health funds goes to which program. Micro – deal with how much scarce resource is distributed among individuals with competing claims to it. Health care providers select with patient will receive the scarce resource.
  62. such as life, minimum health care, information for decision-making and confidentiality of private information such as equal opportunity to get an ICU, a pacemaker or an organ transplant
  63. Obligation to act in good faith and to keep vows and promises, maintain relationships and fiduciary responsibility. Spanish = palabra de honor
  64. A. such revelation as in the case of claim for hospitalization, insurance benefits, and among others B. such as attempted suicide, gunshot wounds which have to be reported to the local police or NBI or constabulary C. Ra 3573: Law on reporting of communicable diseases
  65. Intrusion of one’s private life. Eavesdropping - is the act of secretly listening to the private conversation of others without their consent. Target unknowingly loses some measure of privacy.
  66. Screening the patient’s territorial area when giving health care Discussing the patient’s case publicly TRESPASSING WITHOUT PRIVACY , Fried argues “these relationships are inconceivable.”
  67. Aling Saling knows that her neighbor, Aling Minda has a terrific armpit odor. But because she wants to be good to Aling Minda, she will keep this in confidence even if she knows she could have been more charitable to others by frankly telling Aling Minda that she needs to ise a deodorant for other’s people’s sake.
  68. Very important in Filipino culture. Parents are looked up to as mature, respectable, responsible adults.
  70. Abortion, although legal in some countries. Even extreme poverty cannot right such a wrong act. Values, views on life and manner by which you conduct yourself is very much influenced by how much you were conceived, reared, nurtured and educated as a child.
  71. Children born under ecology of fear, unwantedness, anger anxiety, and hatred, they turn out to be problematic in behavior and personality
  72. People all over the world feel reassured and cared for when they sense that you are a person of compassion.
  73. Most important ingredient in our choice of one physician rather than another. (Baier, 1986). Friends part ways and married couples separate – basic cause of the break-up is usually a loss of trust. Trust seals the bond of openness and confidentiality If physician trusts his or her nurse – propels effective teamwork
  74. “Enlightened consent”
  75. Informed (threshold elements) - preconditions
  76. Letty Kuan
  77. Information elements Disclosure (of material information) – full information of the mat Recommendation (of a plan) Understanding (of the information and the plan)
  78. Not under decision distress Not under the influence of intoxicating chemicals Not pathologically impaired Not threatened by any form of coercion
  79. MINORS Under legal age as defined by state statute Parents or guardians must give consent EMANCIPATED MINORS: has established independence from parents through marriage, pregnancy, service in the armed forces or court order UNCONSCIOUS or SEVERELY INJURED Consent obtained from closest relative In life-threatening emergency = consent is IMPLIED or ASSUMED MENTALLY ILL/CHRONIC DEMENTIA OTHER MENTAL DEFICIENCY Persons judged or declared by the court to be incompetent UNDER THE INFLUENCE OF DRUGS AND ALCOHOL
  80. However, every parental decision should be for the welfare of the child. If it is unclear to be for the child’s best interest, their decisions can or should be challenged. Nurses and doctors have ethical and legal duty to advocate for the child’s best interest Initially, ethics consultation and discussion should be made between the parents and the other persons involved In the initial effort is unable to resolve the conflict, elevating the problem to the court of law to determine the appropriate care for the child might be necessary.
  81. Applicable also to children and mentally incapacitated persons when their parents or guardians are not around to make decisions on their behalf