because the end never justifies the means.

NCM 108: HEALTH CARE ETHICS We may not do evil so that the good may
come of it.
Other Relevant Ethical and Bioethical Principles
CASE 2
1. Principle of Double Effect A married woman complains of pain, and upon
 A good action has two effects – an examination, the doctor discovers an abnormal
intended and otherwise not reasonably pregnancy. The implantation occurs in the fallopian
attainable good effect and an unintended tube instead of the uterus (ectopic pregnancy). If he
yet foreseen evil effect – is licit. does nothing, the tube will swell further and finally
 It goes with the most famous term “Go with rupture, probably killing the woman. The only cure
the Lesser Evil”. It simply says to select is to remove the tube promptly, which will save the
the least evil consequence when you are mother and result in the death of the fetus. Is it
faced with two or more problems. moral for the doctor to operate?
 In certain difficult situations, it may be
permissible to produce a bad effect to Analysis: Yes, it is. The tube being in a pathologic
achieve a good one, provided that the condition, it is moral to remove it under the principle
action undertaken is not itself evil, that the of double effect. The purpose of the procedure is to
evil is not intended, that it is not a means to remove a pathologic organ that threatens the
the good result, and that there is at least as mother’s life. The death of the fetus is unintended
much good produced as evil. and merely tolerated.

Doctrine of double effect 2. Principle of Cooperation

 Performing a good action may be  Cooperation comes from the Latin word
permissible even if it has bad effects, but cum meaning “with” and operari, which
performing a bad action to achieve good means “to work”. Cooperation is working
effects is never permissible. with another in the performance of an
 The principle contemplates two effects or action.
outcomes arising from the performance of  Implies that one works with others in the
an action. The 1st or primary effect results performance of an act to accomplish a
from the agent’s intent, desire, or wish. goal.

There are 4 conditions or criteria Various Degrees of Cooperation

a) The act itself must be morally good or at not a) Formal cooperation consists of an
itself evil. explicit intention and willingness for the
b) The bad effect is sometimes said to be evil act. The one formally cooperating
indirectly voluntary. That the evil is not categorically wills and intends the evil
intended. action.
c) The good effect must be produced directly Ex. The medical doctor agrees to perform a
by the action, not by the bad effect. hysterectomy (remove the uterus) when the
Otherwise, the agent would be using a bad patient demand. – not a necessary or valid
means to a good end, which is never reason, but the doctor still accepted it.
allowed.
d) The good effect must be sufficiently b) Material cooperation consists of an act
desirable to compensate for the allowing of other than the evil act itself but
the bad effect facilitates and contributes to its
achievement. The one materially
Case 1 cooperating may provide means apart
HYPEREMESIS GRAVIDARUM (severe nausea from the evil act itself, which is used to
and vomiting during pregnancy) is easily solved by perform an evil act.
the termination of pregnancy. However, this is not Ex. Scrub Nurse assisting in the surgery –
morally permissible. It violates the rule of the accomplice in formal cooperation.
double effect in the following ways:
a) That action is not morally good. c) Direct cooperation consists of direct
b) Termination of pregnancy in hyperemesis participation in the performance of an
gravidarum is not morally permissible evil act. The one directly cooperating
 gets involved by openly and group at a higher level assume
straightforwardly participating in the responsibility. This idea is summed up in the
practice of evil action. principle of subsidiarity.
Ex. The patient demanded a hysterectomy. For example, if a family is
experiencing problems, the state can
d) Indirect cooperation consists of an act intervene only if the family or the
that is not intimately connected with the parents are overburdened and
performance of an evil act as in formal cannot resolve them. Being able to
and direct cooperation, but whose effect help oneself is an important
may have an indirect bearing upon it. component of the dignity of the
Ex. Janitor – may saw the illegal procedure human person
done.
4. Confidentiality and Privacy
e) Proximate cooperation consists of an
act intimately linked with an evil action’s Confidentiality
performance due to its close bearing.  Confidentiality in health care refers to the
obligation of professionals who have access
f) Remote cooperation consists of an act to patient records or communication to hold
with a distant bearing upon or that information in confidence.
connection with the execution of an evil  Surbhi (2018), defines confidentiality as a
act. state when it is intended or expected from
someone to keep the information secret.
3. Principle of Common Good and Subsidiarity The term confidentiality is extracted from
 The principle of Common Good means the word 'confidence' which means 'trust.'
working for the good of all. This means The information which is told in confidence
respecting the rights and responsibilities of to someone, will be kept secret from the
all people. reach of unauthorized people until the
 Examples of particular common goods or parties agree to uncover the information.
parts of the common good include an  In Medical, legal, and other professions, it is
accessible and affordable public health care common that the information shared
system, an effective system of public safety between the patient and the nurse or the
and security, peace among the nations of doctor and the patient, will not be told to the
the world, a just legal and political system, third party. It prevents the access of
an unpolluted natural environment, and a sensitive information from being public.
flourishing economic system ...
Confidentiality implies that:
Common Good  Information about a patient be kept private.
 Common Good is "the sum total of social  Information in the patient's record is
conditions which allows people, either as accessible only to those providing care to
groups or as individuals, to reach their the patient.
fulfilment more fully and more easily." It is  No one else is entitled to that information
about the progress of persons (Vatican II). unless the patient has signed a “Consent for
Release of Information" that identifies with
Subsidiarity whom information may be shared and for
 Often considered a consequence of the what purpose.
principle of the common good  Discussing patients outside the clinical
 Subsidiarity requires those in positions of setting, telling friends or family about
authority to recognize that individuals have patients, or even discussing patients in the
a right to participate in decisions that elevator, cafeteria or any area outside the
directly affect them, in accord with their nursing unit with other workers violates
dignity and with their responsibility to the patient confidentiality.
common good.  The patient has the right to review the
 Every task of society should be assigned to records pertaining to his/her medical care
the smallest possible group that can and to have the information explained or
perform it. Only if the smaller group is interpreted as necessary, except when
unable to resolve the problem itself should a restricted by law.
 from public interference.
Maintaining confidentiality may be observed by:  Confidentiality is a situation when
 Not discussing patient issues with other information is kept secret from the reach of
patients or uninvolved staff in the patient's any other person.
care.  Privacy talks about a person, but
 Not sharing health care information with confidentiality is about information.
others (including family members, friends or  Privacy restricts the public from accessing
neighbors of the patient, member of the the personal details about a person,
press) without the patient's permission. whereas confidentiality protects the
 Not publishing information, embarrassing information from the range of unauthorized
facts about the patient. persons.
 Not accessing medical records when  In privacy, everyone is disallowed from
unauthorized to do so. interfering in the personal matters of a
 Sharing patient information only in private person. Conversely, in confidentiality some
and scheduled areas. specified and trustworthy people are
 Protecting the medical record (including allowed to have access to the information.
electronic health records) from all  Privacy is voluntary; it is the choice of a
unauthorized recorders. person. In contrast to confidentiality, it is
compulsory if the relationship between
Privacy parties is a fiduciary (involving trust).
 Privacy is the state when an individual is  Privacy is a right. However, confidentiality is
free from public interruption and intrusion. an agreement.
 The word privacy is derived from the word
'private' which means the role of the public 5. Veracity
is limited, so the term privacy refers to a Truth Telling and Right to Information
condition where a person is apart from Zolkefli (2018) and Amer (2019) share the following
public attention and observation. He can views on veracity:
draw a boundary on the access of his  Veracity pertains to the ethics of telling the
information from the use of others. truth. To respect veracity in relationships is
 Privacy, certainly has a vital role in patient- to deal honestly with patients and
health care provider relationship. For colleagues as they are.
example, the patient grants the nurse or  The ordinary ethics of truthfulness is
physician access to his/ her body and mind generally summed up in two commands.
in order to protect his/her health. First, do not lie. Second, you must
 Medical privacy is vitally important. communicate with those who have a right to
the truth.
Examples of violations and invasion of the patient's  The first command leaves you free to not
privacy are as follows: communicate, to remain silent or to evade
 Taking photographs of the patient. the question or even to tell a falsehood,
 Use of the patient's name or picture for the which, as we shall see, is not the same
sole advantage of the health care agency. thing as a lie.
 Leaving the curtains or room door open  The second command opens up the
while a treatment or procedure is being question of who has a right to
performed. communication of the truth.
 Allowing individuals to observe a treatment
or procedure without the patient's consent. Veracity in the Health Care Setting
 Leaving a confused or agitated patient  It refers to comprehensive, accurate, and
sitting in the nursing unit hallway. objective transmission of information, as
 Interviewing a patient in a room with only a well as to the way the professional fosters
curtain between patients or where the patients' or subjects' understanding.
conversation can be overheard.  In this regard, veracity is closely connected
Surbhi (2018) states that the following are the to respect of autonomy.
major differences between privacy and
confidentiality): Veracity in nursing-where do we stand?
 Privacy is a situation when a person is free The underlying reasons why truth-telling is
important is because it shows respect for people
and allows them the right to autonomy-giving them informed of the result of the evaluation of the nature
all the information they need to make their own and extent of their disease. Any other additional or
choices. Veracity can be violated by either further contemplated medical treatment on surgical
deliberately lying or also by withholding all or part of procedure or procedures, including any other
the truth or communicating it in such a way that the additional medicines to be administered and their
other person is misled. Veracity is one of the basic generic counterpart including the possible
moral and ethical principles in society. It is complications and other pertinent facts, statistics or
entrenched in medical ethics and in nurses' ethical studies, regarding their illness, any change in the
codes. plan of care before the change is made, the
person's participation in the plan of care and
However, there is no denying that in certain necessary changes before its implementation, the
circumstances withholding the truth from a patient extent to which payment maybe expected from
is the compassionate and moral choice-to protect PhilHealth or any payor and any charges for which
them from mental and emotional distress. Veracity the patient may be liable, the disciplines of health
is necessary in professional-patient relationships care practitioners who will furnish the care and the
for three reasons, namely: frequency of services that are proposed to be
a) The obligation of veracity is based on furnished.
respect owed to others. Example: In asking
patients their consent for any deemed Violations of Veracity
necessary procedure or intervention, the Veracity can be violated in several ways:
validity of the consent depends on the a) Omission means that critical relevant facts
thorough information, full disclosure, and are intentionally left out when disclosing the
enlightenment given to the patient regarding patient's medical information.
the procedure or intervention to be done. b) Commission means that medical personnel
b) Veracity has a strong association with intentionally tell the patient, or her family, a
obligations of fidelity and promise-keeping. lie.
Example: When we communicate with c) A third, more subtle way to violate the
others (e.g., patients, families, significant principle of veracity is to cloak the truth in so
others, communities), we implicitly promise much medical jargon that the patient or her
that we will speak truthfully and that we will family will be unable to understand it.
not deceive our listeners.
c) Relationship of trust between persons are Truth Telling
necessary for successful intervention and Baillie, H.,et al. (2013) assert the following
cooperation. At the core of these statements on truth telling:
relationships, is confidence in and reliance  Every competent person has a right to
on others to be truthful. Example: information about himself or herself, and
Relationships between health care about what is planned for him or for her. All
professionals and their patients and information must be disclosed in order to
between researchers and their subjects make correct decisions both for the moment
ultimately depend on trust and adherence to and for the future.
the rules of veracity. These are all  Therefore, truth telling is the right of every
necessary to foster trust. The right to full individual to have insight into the situation.
disclosure requires that the researcher has To rescind a patient's right to the truth
fully described the nature of the study,the needs a very strong justification. The most
person's right to refuse participation, the common situation is when truth telling will
researchers responsibilities, and likely risks harm the patient or others due to
and benefits. Whereas, lying and unpreparedness to accept dreadful
inadequate disclosure is utter disrespect for diagnosis or situation.
persons, violate implicit contracts, and
constrain relationships. Cultural Considerations on Truth Telling:
 In the Filipino culture, traits of family
The ethical principle of veracity is explicitly orientation to illness and the non-
supported by the Patient's Bill of Rights of the confrontational attitude affect truth telling.
Philippines number (4) Right to Information. In the  Family orientation to illness depicts that
course of their treatment and hospital care, the family members are often informed before
patients or their legal guardians have a right to be the patient, on serious diagnosis, e.g.,
 cancer. Most often, the family may request required by organizational policy and the
the physician not to tell the truth to the law
patient because this may bring more harm,  Fidelity requires that nurses treat all
like hopelessness, depression, refusal to patients with respect. It's not always
undergo treatments. easy, especially if a patient manifests
 It has to be recognized by health care inappropriate behavior. Nurses need to
workers that the family is a very essential put aside any negative feelings about
component of Filipino culture and they have such patients and adhere to the
the right to know the truth. standards of care. Nurses should talk
 Whereas, the nonconfrontational attitude with their team members if they believe
prevents us from disclosing unpleasant their feelings toward a patient could
views. Physicians may hesitate to tell a compromise care.
patient that he/ she is dying. Many
physicians as well as nurses still subscribe For instance, a patient asks the nurse not to
to the death denial culture. At times, reveal that she is dying or give her diagnosis to her
physicians use euphemisms and oftentimes, family. The nurse asks why she does not want her
this leads to erroneous conclusions and family advised. The patient explains that her family
inappropriate decisions. is very emotional and has stated they would do
 Moreover, the nonconfrontational attitude of everything to keep her alive, even if it required
Filipinos prevents issues from being long-term mechanical ventilation. The patient has
addressed. Thus, issues that could have explained multiple times that she does not want
been resolved at their early stages are dealt mechanical ventilation. The nurse recognizes that
with when they are already advanced or keeping this information in confidence while
overwhelming. supporting the family is an example of exercising
Example: a person is experiencing signs fidelity.
and symptoms attributable to COVID-19
and Variants infection. The patient and the 7. Principle of Stewardship
family may not seek consult or report to  This principle is grounded in the
appropriate authority of the situation, until presupposition that God has absolute
the patient's condition worsens and the Dominion over creation, and that, insofar as
entire family is affected by the contagion. human beings are made in God's image
and likeness, we have been given a limited
6. Fidelity dominion over creation and are responsible
 Fidelity is the keeping of promises. for its care.
 For nurses, that means remaining faithful to  The principle requires that the gifts of
the professional promises made to provide human life and its natural environment be
quality, competent care to their patients. used with profound respect for their intrinsic
 Fidelity implies the obligation to act in good ends. Accordingly, simply because
faith and to keep vows and promises, fulfill something can be done does not
agreements, maintain relationships and necessarily mean that it should be done (the
fiduciary responsibilities. fallacy of the technological imperative).
 As applied to health care, the principle of
The Importance of Fidelity in Nursing Ethics stewardship includes but is not reducible to
 In health care, fidelity is the most concern for scarce resources; rather, it also
important of the ethical principles implies a responsibility to see that the
because it governs the other six. Nurses mission of health care is carried out with
promise to provide competent care to particular commitment to human dignity and
patients and to do so in a way that is the common good.
honest, responsible and fair.
 Fidelity is considered by many nurses to Stewardship in Nursing
be the most common source of ethical Stewardship in nursing involves valuing and
conflict. Health care professionals may respecting patients' priorities and self-
find themselves caught between what determination. Nurses become stewards or
they believe is right, what the patient teachers to patients who may not have the
wants, what other members of the expertise or experience in the disease process, but
health care team expect, and what is who understand the consequences of their illness.
 Future nurse leaders or stewards will be being decided, the patient ought to be taken
directly centered on working with nurse into consideration. This implies that
practitioners and nurse educators to transform the whenever therapeutic procedures tend to
practice environments in which they work. The cause harm to the patient or cause
intended outcome is to make practice environments disagreeable side-effects, the benefits must
more positive, healthy and engaging. Areas for justify the advantages of the medical
dialogue may be within: treatment proportionally.
a) patient-population centeredness
b) safety for patients and health care
personnel
c) the needs of an ageing workforce
d) increased autonomy for advanced nurse
practitioners
e) increased respect for the contributions
made by professional nurses
f) clarification of the caring work of the nurse,
and
g) enhancement of the collaborative practice of
the multidisciplinary health care team.

In health care ethics, stewardship refers to

the execution of responsibility of the health care
practitioners to look after, provide necessary health
care services, and promote the health and life of
those entrusted to their care.
a) Personal – taking care of self
b) Social – Zumba
c) Ecological – proper waste disposal
d) Biomedical – researches for the betterment

8. Principle of Totality
 Wholeness, Completeness, or Entirety.
 The principle of totality applies to any entity
that is made up of parts that together
constitute a whole
 The human body is an integral part of the
human person and is worthy of human
dignity. It must be kept whole. No body part
should be removed, mangled, or
debilitated unless doing so is necessary
for the health of an essential body part
or the body of a whole. An unessential or
redundant body part may be removed for
another person’s good.
 Surgeries that needlessly remove body
parts or organs are immoral
 Self-mutilation is self-hatred expressed in
the body
 Even if the pro-choice argument that an
embryo is part of the woman’s body rather
than an independent human person is true,
it should not be removed except when its
presence endangers the woman’s life.
 The person should be considered as a
single entity, that is, whenever medical
procedures, therapies, and medications are