HEALTH ETHICS
MODULE 1: Theories and Principles of Health Ethics
ETHICO-MORAL ASPECT OF NURSING
• Guiding principles of conduct of an individual
• Uniform compared to morals
• Influenced by profession or organization
• Proper and improper acts
• Influenced by society, culture or religion
• Not related to professional work
• Vary according to culture and religion
BIOETHICS
• Principles that govern rights and proper conduct of a person regarding life, biology,
& with health professionals
NURSING ETHICS
• related to all the principles of right conduct as they apply to the profession
• Johnstone (1999) examination of all kinds of ethical and bioethical issues from the
perspective of nursing theory and practice
WHY DO WE NEED TO STUDY ETHICS?
• Makes clear why one act is better than another
• Keeps an orderly social life by having agreement, understanding, principles or
rules of procedure
• Moral conduct and ethical systems must be appraised seeks to point out to men
the true values of life as it attempts to stimulate the moral sense.
ETHICAL DILEMMA
• Problem in decision making because there is no correct or wrong choice. This may
result in having to choose an action that violates one’s principle or value in order
to promote another.
ETHICAL THEORIES
DEONTOLOGICAL
• Greek word deon (duty)
• The basic rightness or wrongness of an act depends on the intrinsic nature rather
than upon the situation or its consequences
DEONTOLOGICAL
Duty-based (Immanuel Kant)
• Absolutism
• We can control our motives and intentions, but we are unable to control the
consequences of our actions
• Respect for moral law
DEONTOLOGICAL
Natural Law (Thomas Aquinas)
• Good is to be done and pursued; while evil is to be avoided
• Rightness is self-evident and determined by nature not by customs or preferences
GELEOTOLOGY
• Stems from the word “telos” meaning end orpurpose
• An action is “good” if it will hace a good end or purpose
• Used in philosophy as an argument for the existence of God to suggest that there
is order and a purpose in the world
• Is an APOSTERIORI argument
UTILITARIAN
• If the act helps people, then it is a good one, and if it harms people, then it is a bad
one (Joseph Fletcher)
Utilitarianism in 3 Stages
1. Principle of utility
The greatest balance of good over evil
2. Principle of pleasure
The greatest happiness over pain
3. Principle of maximation
The greatest happiness for the greatest number
VIRTUE ETHICS
• Aristotle
• Aim for a virtuous life
• Actions must be:
• To the right person
• To the right extent
• At the right time
• For the right reason
• In the right way
• Integrate virtue with duty
• Based on the excellence of one’s character
• Originated from Plato and Aristotle, Buddhism and Florence Nightingale
Valuing obedience (Florence Nightingale) — Obedience to practical wisdom
MORAL GROUND MODEL VIRTUES
INTELLECTUAL VIRTUES
Insight
• Awareness and knowledge of the moral nature of nurses’ day-to- day work
and that moral suffering can be transformed
Practical wisdom
• Using deliberate reason to direct actions
MORAL VIRTUES
Truthfulness
• Refrain from deception through false communication
• Refrain from self deception
Gentleness
• Mildness in verbal and non-verbal communication
Compassion
• Desire to separate others from suffering
Lovingkindness
• Desire to bring happiness to oneself and others
Just generosity
• Giving and receiving based on need
Courage
• Putting fear aside in difficult circumstances to act for a purpose that is more
important than one’s fear
Sympathetic joy
• Rejoicing in other’s happiness
Equanimity
• An evenness and calmness of being
ETHICS OF CARE
• Moral experiences of women
• Emphasis on personal relationships and relationship responsibilitie
• The situation must be evaluated with:
• Caring
• Consideration
• Understanding
• Generosity
• Helpfulness
• Willingness to take responsibility
GILLIGAN’S THEORY
• Focuses on a care perspectives
• Organized around the notions of responsibility, compassion (care), relationships
• No one should be harmed or abandoned
• Everyone should receive the same treatment
• Process of developing an “ethics of care”
– Stage I: caring for oneself
– Stage II: caring for others
– Stage III: caring for oneself and others
• Each stage ends with a transitional period (a time when the individual recognizes
a conflict or discomfort with some present behavior and considers new
approaches)
The Standard of Best Interest
• When a person cannot make informed decision,
the health care providers or family make the decision based on what they believe to be
in his/her best interest.
VALUES
• Values: are freely chosen, enduring beliefs or attitudes about the worth of a person,
object, idea, or action (e.g. freedom, family, honesty, hard work)
ETHICAL PRINCIPLES
AUTONOMY
• Patient Self-determination Act
• a person has unconditional worth and has the capacity to determine his own
destiny. It involves self determination and freedom to choose and implement one's
decision, free from deceit, duress, constraint or coercion.
• Involves the right of self-determination, independence, and freedom.
• Respect for autonomy means that nurses recognize the individual’s uniqueness,
the right to be what that person is, and the right to choose personal goals
• Nurses respect a client's right to make decisions even when those choices seem
not to be in the client’s best interest
• Respectforpeoplealsomeanstreatingotherswith consideration
• In the clinical setting, this principle is violated when a nurse disregards client's
subjective accounts of their symptoms (e.g. pain)
RIGHTS
• Rights form the basis of most professional codes and legal judgments
• Self-determination rights
• Rights and cultural relativism
• Rights of the unborn
• Rights of privacy and confidentiality
PATIENT’S BILL OF RIGHTS
• Right to considerate and respectful care
• Right to obtain from the physician complete information of his health and care
• Right to receive information necessary to give informed consent prior to procedure
• Right to refuse treatment and be informed of medical consequences
• Right to every consideration of his privacy concerning his medical care program
• Right to confidentiality of record pertaining to his care
• Right to expect reasonable response from hospital to request of service
• Right to obtain information as to any relationship of his care
• Right to be advised if the hospital proposes to engage in human experimentation
• Right to expect reasonable continuity of care
• Right to examine and receive an explanation of his bill regardless of the source of
payment
• Right to know what hospital rules and regulations apply to his conduct as patient
AUTONOMY
INFORMED CONSENT
• Patients should be given informed consent before
tests and procedures are carried out
• Ex: informed consent; allowing the patient to refuse treatment if he decides so
Death and dying
– Right to informed refusal
– Care of the body
– Organ donation (RA 7170)
– Autopsy
– Assisted suicide
– Unauthorized patient’s discharge
Paternalism – giving care like a good father/mother of a family
• Do not resuscitate/DNR (No Code order) an order by the patient’s physician instructing the
w/holding of CPR if the patient goes into cardiac or respiratory arrest.
Duties of the nurse:
• Assure that everyone in the process understands the meaning of DNR
• In case of conflict nurse will often act as mediator & help participants reach some shared
understanding.
• Ensure that the following information are documented:
▪ Patient’s condition
▪ Prognosis
▪ Summary of decision making
▪ Parties involved in the decision making
▪ Future date to review the DNR order
BENEVOLENT DECEPTION
• Young, married man diagnosed with AIDS, requests the doctor not to tell his diagnosis to his
wife
• The children of an aged grandmother suffering from metastatic cancer request the doctor not to
tell their mother her diagnosis and instead to proceed with the chemotherapy
PATERNALISM
• Intentional limitation of the autonomy of one person by another, where the person who limits
autonomy appeals exclusively to grounds of benefits to the other person
FIDUCIARY – relationship with patient based on the confidence placed in them and the inequality
of their position in regard to information
PROXY CONSENT/LEGALLY ACCEPTABLE
REPRESENTATIVE
▪ the process by which people with the legal right to consent to medical treatment for
themselves or for a minor or a ward delegate that right to another person.
PROXY CONSENT/LEGALLY ACCEPTABLE
REPRESENTATIVE
There are three fundamental constraints on this delegation:
1. The person making the delegation must have the right to consent.
2. The person must be legally and medically competent to delegate the right to consent.
3. The right to consent must be delegated to a legally and medically competent adult.
2 types of proxy consent:
1. power of attorney to consent to medical care - used by patients who want medical care but
are concerned about who will consent if they are rendered temporarily incompetent by the
medical care
2. living will
PROXY CONSENT/LEGALLY ACCEPTABLE
REPRESENTATIVE
• Persons under 18 years old do not have the right to consent to their own medical care
• The parents of a minor have the sole authority to consent to medical care for the minor
• This does not give the physician the legal right to force care on a mature minor, nor may the
physician render medically questionable care, such as a sterilization, at the parents' request.
CONFIDENTIALITY
• Nurses are also obligated to preserve the principle of confidentiality in the practice of nursing.
The principle of confidentiality is founded in the patient's right to privacy and the preservation
of the nurse-patient relationship.
PRIVACY
• Individual’s constitutional right to be left alone, to be free from unwarranted publicity, and to
conduct his or her life, without its being made public
• Individual’s right to limit access to his/her healthcare information
Privacy:
• A right or expectation to not be interfered with
• Be free from surveillance
• A moral right to be left alone.
• RESPECTS PATIENT'S BODY
Confidentiality :
• Is the right of an individual to have personal, identifiable medical information kept out
of reach of others.
• RESPECTS PATIENT'S INFORMATION
VERACITY
Telling the truth
• As a nurse should I tell the truth when it is known that doing so will cause harm?
• Should I lie when it is known that the lie will relieve anxiety and fear?
• Should I lie to dying people?
Fraud – deliberate deception intended to
produce unlawful gain
• Defamation – character assassination verbal or written
• Libel – written
• Slander – verbal/oral
• Medical record
FIDELITY
• Loyalty/faithfulness and keep promises
• Nurses have the responsibility to clients, employers, government, society, the profession,
and themselves
• Circumstances often affect which responsibilities take precedence at a particular time
• keeping a commitment and is based upon the virtue of caring.
JUSTICE & FAIRNESS
• allocation of goods & services & how or to whom they are distributed
• Principle in healthcare ethics
• Basis of a duty-based ethical theory
• Treated justly, fairly and equally
3 CATEGORIES:
1. Compensatory Justice : concerns the just way in compensating someone for a past
injustice or what he/she lost when wronged by others.
2. Retributive Justice: consists in the just imposition of punishment and penalties on those
who do wrong. This is related to procedural justice, referring to fair decision procedures,
practices, agreements.
3. Distributive Justice: involves the fair distribution of benefits and burdens.
BENEFICENCE
• Taking action to promote the welfare of other people
• Promote the wellbeing of patients
• Mercy
• Kindness
• charity
NONMALEFICENCE
• do not harm
• remove harm
• Prevent harm
What is Ethical Decision Making?
• When faced with an ethical dilemma the objective is to make a judgment based on well-
reasoned, defensible ethical principles.
• The risk is poor judgment
• A low-quality decision can have a wide range of negative consequences
Two Types of Ethical Choices
• Right vs wrong: choosing right from wrong is the easiest
• Right vs right
– Situation contains shades of gray i.e. all alternative
have desirable and undesirable results
– Choosing “the lesser of two evils”
– Objective: make a Defensible Decision
Factors that influence EDM
1. Codes for Nurses
2. The patient’s rights
3. Social and cultural attitudes
4. Science and technology
1. Legislation
2. Judicial decisions
3. Funding
4. Personal religious and philosophic viewpoint
Factors in the work environment that affect EDM
1. Status as an employment
2. Collective bargaining contracts
3. Collegial relationships
4. Authoritarian and paternalistic background
5. Ethics committees in health care
6. Consumer involvement in health care
Some Guidelines for Making Ethical Decisions
1. Choose correct moral language.(Often, the way in which you initially conceptualize a situation
will affect what moral conclusions you will make)
2. Be as clear as you can about the facts, both empirical and philosophical
3. Consider the relevant moral principles and rules, and make your best judgment.
ETHICAL PRINCIPLES IN DECISION MAKING
1. Identifyandsettinguptheethical problem
2. State the relevant facts
3. Identify the stakeholders
4. Identify the relevant options
5. Determine the most appropriate action
