BIOETHICS POWER POINT.docx

7/27/2019 BIOETHICS POWER POINT.docx

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BENEFICENCE

Beneficence refers to action done for the good of others.

Nonmalifecence refers to prevention of harm and the removal of harmful conditions.

In line with these principles, we shall discuss guidelines on the use of extraordinary means in

critically injured individuals and for those whose clinical conditions are irreversible.

The field of bioethics has evolved fast because of the continuously changing economics and

lifestyle of people all over the world.

We have now classified extraordinary measures as proportionate or disproportionate depending

on the pathologic conditions of the sick as well as on their socioeconomic capabilities.

Our morality dictates that not only do we respect a persons autonomy but also that we

contribute to their welfare.

Let us keep in mind that each person by nature is good.

Everyone possesses kindness in the depths of their hearts and beings.

Let us study together the significance of beneficence in our dealings with ourselves and with

others.

As you go through the text, you will see that beneficence goes hand in hand with benevolence

and provenance.Benevolence is goodness in each personhood.

Provenance is the attentiveness dictated by kindness to anticipate what one needs.

In each one of us, there is that inner goodness that pushes us to alleviate the pain and discom-

forts of other people.

THE CONCEPT of BENEficence

Bioethicists defined beneficence as an act of mercy, kindness and charity.

Humanity, altruism and love are also considered as forms of beneficence.

Many acts of beneficence are not obligatory but there are instances when one is obliged to do

emergency care to one who is hovering between life and death.

Benevolence refers to the character trait or virtue of being inclined to do good and act for thebenefit of others.

Some ethical theories like utilitarianism are based on the principle of beneficence.

This means goodness and kind deeds form the backbone of the utilitarian theory.

Utilitarianism is defined as the moral and political rightness of an action and is determined by

its contribution to the greatest good of the greatest number.

Later thoughts on beneficence touch on obligatory beneficence and ideal beneficence.

Different philosophers employed the term beneficence to identify positive obligations to others.

Many critics though are suspicious of the claim that we have these positive obligations.

Beneficence is purely a virtuous ideal or an act of charity, thus persons are not morally deficient

if they fail to act beneficiently.

These concerns rightly point to a need to clarify and specify beneficence, taking care to note

the limits of our obligations and the point at which beneficence is optional rather than

obligatory.

An example of beneficence is found in the New Testament in the Parable of the Good

Samaritan, which illustrates several problems in interpreting beneficence.

As the parable goes, a man travelling from Jerusalem to Jericho was beaten by robbers who

left him half dead.

After two other travellers passed by the injured man without rendering help, a Samaritan saw

him, had compassion, went to him and bound up his wounds, brought him to an inn and took


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care of him.

In having compassion and showing mercy, the Good Samaritan expressed and attitude of

caring for the injured man.

Both his motives and actions were beneficent.

The parable suggests that positive beneficence is more an ideal than an obligation because

the Samaritans act serves to exceed ordinary morality.

Furthermore, suppose that the injured man, when encountered by the Samaritan gives an

advance directive indicating that he wants to die.

The Samaritan then would face a dilemma: should he respect the injured mans wishes or

will he take care of him against his wishes?

Beneficence then, is sometimes an admirable ideal of action that exceeds obligations, and at

other times is appropriately linked to other moral obligations.

The following questions are ask:

Are we ever obligated to act beneficently?

Does our moral obligation stem from our feelings and duties to do good to our neigbor?

The question can be initially addressed by noting the acts of beneficence play a vital role in

moral life quite apart from the principle of obligatory beneficence.No one denies that many beneficent acts, such as the donation of kidney to a stranger are

morally praiseworthy and not obligatory.

In organ donation, we are cautious because under the beneficent act of giving ones organ

to another, we also touch the principle of stewardship.

This 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.

Everyone agrees that common morality does not contain a principle of beneficence that

requires severe sacrifice and extreme altruism.

Only ideal beneficence incorporate such extreme generosity.

We are likewise not morally required to give benefits to persons on all occasions, even if weare in a position to do so.

For example, we are not morally required to perform all possible acts of generosity or charity

that would benefit others.

We can readily grant then, that ideal beneficence means going out of ones way in order to

do good to others.

Beneficence is plain goodness to others without going out of ones ways.

Nonetheless, several rules on obligatory beneficence form an important part of morality.

Because of the wide range of types of benefits, the principle of beneficence supports an

array of more specific rules, including some that are already noted without referring to

them as rules.

What we have to keep in mind are the following beneficent rules taken from Principles of

biomedical Ethics:

1. Protect and defend the rights of others2. Prevent harm from occurring to others3. Remove conditions that will cause harm to others4. Help persons with disabilities5. Rescue persons in danger


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BENEFICENCE and NONMALEFICENCE and their IMPLICATIONS on CERTAIN SITUATIONS

The principle of nonmaleficence asserts an obligation not to inflict harm intentionally.

The maxim of medical ethics is Primum non nocere, which means, above all, do no harm to

anyone.

An obligation of nonmaleficence and an obligation of beneficence are both expressed in the

Hippocratic Oath: I will use treatment to help the sick according to my ability and judgment,

but I will never use it to injure or harm them.

Many controversies in biomedical ethics surround the terminally ill and the seriously ill and

injured.

It is of prime importance that you have a framework for decision-making about life-sustaining

procedures and assistance in dying.

At the center of the framework is an interpretation of the principle of nonmaleficence that

sanctions rather than suppresses quality of life judgment.

This framework allows patients, guardians and health care professionals under certain

conditions to accept or refuse treatment after weighing the benefits and burdens of those

treatment.

Bioethicists suggest the following scheme to distinguish the principle of nonmaleficence andBeneficence without proposing any normative ranking or hierarchical structure.

Nonmaleficence

One ought not to inflict evil or harmBeneficence

One ought to prevent evil or harm One ought to remove evil or harm One ought to do or promote goodEach of these three forms of beneficence requires taking action by preventing harm,

removing harm and promoting good, whereas non-maleficence only requires intentionally

refraining from actions that cause harm.Other philosophers and even some bioethicists may have other points by which they make a

distinction between nonmaleficence and beneficence.

Nonmaleficence is explained using the term harm.

Nonmaleficence is not doing harm or inflicting evil on someone especially physical harm.

Nonmaleficence is avoiding any intent or cause that will lead to death.

Because there are many types of harm, the principle of nonmaleficence supports many

specific moral rules.

Other principles such as autonomy and justice, are also occasionally called upon to help

justify these rules.

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.Obligations of nonmaleficence are obligations of not including harm and not imposing risks of


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harm.

A person can harm or place another person at risk without malicious or harmful intent and the

agent of harm may or may not really be morally or legally responsible.

To safeguard health care workers, hospitals and medical centers follow a standard of due care.

The standard of due care specifies that with emergency or urgent cases, attempting to save

lives after a major accident justifies the risks created by such emergency measures.

Negligence in caring someone in need is considered a departure from the standard of due care.

In the Philippines, hospitals and medical centers, both of the government and private types,

subscribe to this standard of due care.

When it comes to withholding versus withdrawing treatments, letting go for the dignity of

death versus committing assisted suicide could be very well be an issue.

This often places the health care professionals in a confusing situation.

Most of the time, the health care professional is guided by his or her values, family practices,

philosophies and beliefs.

It is in situations like these that guidelines are very much appreciated.

However, not all hospitals and medical centers have bioethics committees that can issue

bioethical guidelines.

Some guidelines for the following main issues:

Withholding versus Withdrawing Treatments

Many health care professionals and families feel guilty when treatment is withdrawn (stopped)

compared to when treatment is withheld (not started).

As health care professionals, how do you feel about this?

Since we do have different personalities, reactions to this issue are varied.

Both withholding and withdrawing treatment are bioethical issues which can be acted upon or

justified by the following conditions:1. When the case is irreversible and any form of treatment will not benefit the patient2. When death is imminent or when patient is already dead.When condition is such that any intervention will not benefit the patient, then treatment is not

obligatory.

We have to respect the patients call for dignity of death and caring should surround the

person until the time of death.

Ordinary versus Extraordinary Measures

Recent developments in Bioethics talk about use of extraordinary and ordinary measures;

whether these are proportionate or disproportionate to the case and to the families concerned.

Extraordinary measures entails the use of aggressive modalities vis-a-vis the financial

capabilities of the family.There are cases where families who can very well afford it, continue to give extraordinary

measures such as being hooked to respirators and giving third generation antibiotics

indefinitely.

These measures do not necessarily offer any benefit to the patient.

The act is usually done to ease the guilt feelings of the family and for them to feel that they

did everything they could.

However , these extraordinary measures are artificially prolonging the life of the patient.


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Obviously, these extraordinary measures means are loading the patient with more burden and

fatigue and are in fact a hindrance to letting the person go in peace and dignity.

Since families insist on these measures can afford them, the expenditures are expenditures

are proportionate to their demands.

What we can do as health care professionals is to enlighten these families on the futility of

The actions and that resources can be better used in other channels resulting in more

benefit to others.

Ordinary measures comprise the provision of necessities of life and usually pertain to food,

normal respiration and elimination process.

Hence, intravenous fluids, nasogastric tube feedings, indwelling catheters are considered

necessary measures and may be sustained even if the case is irreversible.

All measures considered to be ordinary may be sustained until the time of death.

Subjecting patients to chemotherapy and hemodialysis when they are on the verge of

Death may become disproportionately extraordinary because of the burden on the patients

already weak body vis-a-vis the intervention will offer no benefit to the patient, then be

forced on the patient.

Killing versus Letting Go

Nowadays , we are beset with the issue of assisted suicide.

Some first-world countries have legalized the persons choice to die at his or her own chosen

time.

Assisted suicide is knowingly administering some help to hasten death.

In a way, this is a form of killing because something is introduced in the body to end life earlier

than its natural schedule.

Letting go, on the other hand, is allowing a patient to die by not administering any hastening

element.

When treatments and extraordinary measures are withdrawn because these measures no

Longer offer any benefit to the patient, you are actually allowing that person to die withdignity at his or her time of final departure.

What we have to keep in mind is that we should always give the best care surround the

dying person with much love, respect, and prayers.

The Do Not Resuscitate (DNR) order is indicated when the case is far beyond reversibility

and death is very certain.

By not administering any cardiopulmonary resuscitation in the event of cardiac arrest, we are

actually letting the person go in peace and in dignity.

We should not feel guilty that we have not done our part in these situations as long as we have

rendered our best nursing care.

In all these instances, the principle of beneficence and nonmaleficence should be our guides

in the care of patients.

Summary

This chapter discussed the principle of beneficence and the accompanying principle of

nonmaleficence.

Both principles point to one direction: to attentively do good to others and to avoid inflicting

harm.

The field of Bioethics which is the study of the human conduct of life will always be confronted


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by many issues because of the advances in biomedicine, biotechnology , eco-engineering and

many other fields.

Consequently, our lifestyle also changes little by little because of the changes within the

ecology and society.

We also discussed the implications of the principles of beneficence and nonmaleficence in

several concerns:

killing versus letting go, ordinary versus extraordinary means as well as withholding versus

withdrawing treatments.

The Do Not Resuscitate Order for irreversible cases is along the line of letting patient go and

die in dignity.

Let us remember that treatment is not obligatory when this does not offer benefit to the

patient.

At all times, let us uphold that we are here to help patients live a quality life, giving them

utmost goodness and kindness at all times.

AUTONOMY

Autonomous choices of persons have to be respected.This is a principle that runs deep in common morality.

However , people do not agree totally regarding the nature of autonomy.

This sometimes results in endless debates.

There is indeed a need to analyze the principle of autonomy especially as this relates to specific

interventions in health care.

We cannot talk of autonomy without touching on the issue of informed or enlightened consent

especially in clinical research.

In this module, we shall discuss the meaning of autonomy and significance of informed

consent, taking into consideration the Filipino culture and traditional family practice.

We shall be citing some concrete clinical cases and learn together some guidelines on what we

should know about autonomy in the course of our professional life.We should learn what makes a consent informed or enlightened and we will examine our

role to help our co-professionals respect the autonomy of our clients.

Meaning and Extent of Autonomy

The word autonomy is derived from the Greek words autos meaning self and nomos

meaning rule, governance or law.

The original usage of this word was for the self-rule-rule or self-governance of the independent

Hellenic city states.

Since then, the term has been extended to individuals and has acquired diverse meanings

and interpretations.

In the University of the Philippines System, for instance, the term autonomous is employed

for the operation of the different campuses which are: UP Dilliman, UP Manila, UP Los Banos,

UP Visayas, UP Mindanao, UP Baguio and UP Open University.

This means each campus can govern and subsist on its own and can make decisions without

violating the policies and regulations of the whole system.

There is independence and autonomy in the sense that one is able to see, judge and decide

what is logical and best for the person to survive and enjoy living.

In autonomy, the individual is free from threats or any type of force or coercion.

This means that the individual is in full control of self, totally aware of what is the issue and in


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a capacity to make appropriate moves and decisions for the best outcome.

The problem that comes next is: Are there qualifications needed to exercise autonomy? Can

we say that people regardless of age, status, creed and race have autonomy? This question can

be answered affirmatively if we regard autonomy as a human feature.

However, autonomy can be studied in many aspects.

For instance, some theories on autonomy have featured the traits of an autonomous person.

An autonomous person must have the capacity for self-governance.

To govern ones self, one must have these capacities: to understand the issue and what the

Situation is all about; to reason outand give ones own opinion; to deliberate by weighing the

pros and cons of the issue and to make an independent choice.

Basic to making an independent choice is ones capacity to make decisions.

Beauchamp and Childress (1994:121) agree that even autonomous persons with self-governing

Capacities often fail to govern themselves in their choice because of temporary constraints

imposed by illness, depression, extreme fatigue or because of ignorance, coercion or conditions

that restrict options.

These authors continue to state that an autonomous person who signs a consent form without

reading or understanding the form has failed to act autonomously because of a failure to read

and understand what the consent demanded.On the other hand, some individuals who are not generally autonomous can at times make

autonomous choices.

As an example, some patients who are confined in a mental hospital or institutions may be

unable to care for themselves and are legally declared incompetent.

However, they can still make autonomous decisions such as stating preferences for meals,

refusing some medications and interventions, or making her choice to talk to certain relatives

and friends.

Some writers on ethical theory contend that autonomy is largely a matter of having the

capacity to reflectively control and identify with ones own basic or so-called first-order

desires or preferences through higher-level desires or preferences.

To make this clearer, let us take an example of an alcoholic who may have a desire to stopdrinking or a smoker who desires cigarettes but at the same time also wants to quit smoking.

An autonomous person in this situation is one who has the capacity to rationally identify

with, accept or repudiate a basic order desire or preference in a manner that is independent

of the manifestation of the desires.

Such acceptance or repudiation of the lower level in favour of the higher level, demonstrating

the individuals capacity to change his or her preference structure, constitute autonomy.

However, when we consider the Filipino people in general, there is a common tendency to

consider hierarchy and family authority in making decisions, even decisions for the self.

Many of our decisions and actions are influenced by people in authority such as the family.

In order to practice autonomy, there is a need to fully inform or educate the individual so he or

she can reach a decision that we can call appropriate self-governance.

For an action to be autonomous, requirements should touch mainly on a substantial degree of

understanding and freedom from constraints.

Autonomy of the client must be respected because this is a persons right to exercise freedom

of decision and choices.

As health care providers, there is a need for each of us to keep this in mind so that the client is

assured of his/her practice of autonomy.

Now let us pause and see how much we remember. Challenge yourself with the following


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questions. The answers can be found at the end of this chapter, but answer the questions first

to test yourself. Here we go!

Summing up the principle of autonomy brings us to the corollary principle of respect for

autonomy.

Respect for autonomy means we acknowledge the individuals right to hold views and

opinions, to make choices and to take action based on personal values, traditions and

beliefs.

Respect is concretized through action, reaction and attitude.

It means allowing the person to act to his or her own, in other words, autonomously; and

accepting the person positively for what he or she is to us.

Disrespect for autonomy involves attitudes and actions that ignore, insult, belittle, despise

or demean a person.

Why respect an individuals autonomy?

Because all persons have unconditional worth and each one has the capacity to determine

his or her own destiny.

Philosophers have strong contentions on their statement of personal destiny.

To violate a persons autonomy is to treat the person merely as a means, that is, in

accordance with anothers goals with no regard to that persons own goals.Such treatment is a fundamental moral violation because autonomous persons are ends in

themselves capable of determining their destinies.

We must also consider the individuality of a person in shaping their own lives because

each individual has the capacity to develop the self according to personal convictions.

This is as long as their development does not interfere with the freedom of others.

There should be an effort in each one of us to respect and recognize what the person is

worth without prejudice and prejudgments.

Informed or Enlightened Consent

Informed consent is also known as enlightened consent.

Prior to any substantial interventions or research participation, clients must have fullinformation of what the procedure is all about, the objectives, the need and advantages.

During the disclosure phase, alternatives measures as well as outcomes of the procedure

(the positive and negative sides) are also made clear to the client.

Consent forms are legal documents and they serve as prima facie (first hand) evidence

in court cases.

Hence, consent must be obtained in observance of the following evidence:

1. Threshold elements (preconditions)2. Competence (to understand and decide)3. Voluntariness (in deciding)Competence covers the domain of being mentally, emotionally and physiologically well

and sane.

This means that the individual is not under decision distress, not under the influence of

any intoxicating chemicals, not pathologically impaired, not threatened by any form of

coercion.

In brief, the person is sound and free to decide and to make choices because he or she

is competent and understands what is going on.

1. Information elements2. Disclosure (of material information)


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3. Recommendation (of a plan)4. Understanding (of the information and the plan)Disclosure is full information of the matter.

If the topic is about a procedure such as surgical intervention, disclosure includes

information about the part of the body involved, the procedure to be done, the effects

of the whole system, the cost of the procedure and the outcome of the intervention.

In some instances, visual aids are necessary to facilitate understanding of the procedure

or intervention.

Informed consent shall be obtained by the health professional who performs the

interventions or procedure.

The nurse is the witness to see to it that the elements of informed consent are executed

by the doctor.

Recommendations of a plan entails two-way discussion on the advantages and disad-

vantages of the proposedprocedure and making clients feel that the plan is for their

utmost benefit.

Alternative plans should be offered so that clients are really given the best opportunity

to choose what they believe to be the best for themselves.Informed consent carries two main functions:

1. Protective to safeguard against tension of integrity2. Participative to be involved in the health care decision makingIf the client asks question to validate what he or she thinks and if these questions are

satisfactorily answered, the understanding of the disclosure and the recommendation of

the plan is evident.

1. Consent elements2. Decision (in favour of the plan)3. Authorization (of the chosen plan)4.

Signature (execution of the consent through signature)

Consent obtained from the client starts when there is already a decision.

The chosen plan is clear and the client freely gives consent by voluntary signing the

consent form.

At this point, there is no more hesitation or vagueness of what the procedure or

intervention is all about.

All points have been discussed and clarified.

The signature of the person concerned is affixed.

This shows that the consent given is an informed and enlightened one.

This whole process of informed or enlightened consent hold true for participants in

research projects, especially if the research entails some invasive methodologies.

Consent must be obtained from all who participate as subjects in research.

In research projects, disclosure should generally be made as to the aims, methods,

anticipated benefits and risk of the research.

Additional disclosures and special precautions to ensure that the persons understand may

also be necessary, including disclosure of the criteria used for the selection of subjects.

It may also be important to indicate that the person has an opportunity to ask further

questions.


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Autonomy and the Health Care Professional

There are situations in clinical practice that sometimes bewilder a health care professional.

Let us take for example, the hospital routine procedure of giving a patient bath everyday.

More often than not, the patient submits to the routine activity even without our asking

whether the patient would have preferred not to have a bath that day.

Taking for granted, the patients autonomy or personal preference happens often in our

clinical practice.

It takes a finer sense of awareness of the other persons rights to be able to give due

respect to anothers autonomy.

Taking a persons likes or dislikes for granted is one demonstration of the violation of

autonomy.

What does a health professional do when the patient is not in his or her right sense when

obtaining the informed consent?

Who serves as the patients advocate when a patient is in coma?

What about minors, who makes decision for them?

These question often get vague answers considering the undefined stand of healthprofessionals.

The field of bioethics as promoted by the Institute of Ethics and Human Rights in Houston,

Texas (1993) specifies the following:

1. When the patient is in coma, unconscious or incapable of making a decision, thoseclosest to him or her such as the family or relatives may decide for the best benefit

of the patient.

2. In instances when there are no close relatives and decisions must be made, the healthProfessionals with honest desires and intentions to give the best strategy or

intervention to the patient may decide for the patient.

The health professionals are expected to execute their advocacy role to the best

outcome of the patient.3. In cases of minors, parents and family of the patient will assume the patients

autonomy and make the decision which should always be the best for the patient.

It is morally necessary then for each health professional to handle with care their advocacy

and counselor roles.

It is worthwhile to remind health professionals that each patient is an individual equipped

with his or her rights and therefore has autonomy.

It is our role to enhance this feeling of self worth in each one.

Hence , due respect should be carried in our very attitude and in our very nature of how

We respect ourselves as health professionals and how we regard each one of us a unique,

dignified person.

Summary:

This chapter taught you autonomy and respect for decision-making.

You have also seen what is informed or enlightened consent and the components that are

necessary in obtaining consent from patients.

I hope you have grasped the significance of informed consent as legal document and as an

assurance of safety for the patient and for health care professionals.

Invasive interventions must always have informed consent.

The process of securing consent is an excellent opportunity to teach and inform patients of


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what is best for them to attain quality living.

In the same manner, informed consent should be a part of the protocol of the research

process because most researchers involve patients lives.

Honesty is a trait that we health professionals should carry in our very selves when asking

patients to sign informed or enlightened consent forms.

Nurses must be aware that obtaining consent is not our main domain because disclosure

should be complete and this is the duty of health professional who will perform the

intervention or procedure.

In this case, the responsibility falls on the physician, surgeon or whoever does the

intervention or procedure.

In the field of research, some exigencies or informed consent are expected.

Purpose , methodology and outcome of the study should be fully explained so that

autonomy of the participant is expected.

In the domain of informed consent, the nurse as a witness must see to it that the

elements and thresholds of the consent are being observed and correctly executed by

the physician.

The best way to demonstrate autonomy is to practice it on ourselves.

We can transmit respect to others through the honest conduct of our lives.

JUSTICE

Is there justice in access to health care? to education? to job placement?

These questions revolve around the concept of some Filipinos that justice is often equated

With chance, lottery, strong connections, powerful influence.

The term justice evokes fairness, what is deserved, due, equitable, or appropriate in

society determined by norms that structure the terms of social cooperation.

There are some implications of justice as it touches on the micro and macro allocation ofresources, focusing on the Filipino family its values, traditions, customs and practices.

As we study about justice, take note of your own family practices, values, customs and

traditions and see how principle of justice applies.

The Concept of Justice

The terms fairness, deserts (what is deserved) and entitilement (that to which one is

entitiled) have been mentioned by various philosophers in an attempt to explainthe term

justice.

Justice is giving each one his or her due.

Lets take an example, someone who has been working hard on the job does not get the

needed promotion while another one who gets promoted without merit.

The one who worked hard is entitled to something; in this case, a promotion.

An injustice therefore involves a wrongful act or omission that denies people benefits to

which they have a right to.

There are many types of justice :

1. Distributive justice refers to fair, equitable and appropriate distribution of responsibilities, or share of rights and roles.

2. Criminal justice refers to the just infliction of punishment or penalty proportionateto the crime committed.


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3. Rectificatory justice refers to just compensation for transactional problems such asbreaches of contract and practice based on civil law.

Problems of distributive justice arise under conditions of scarcity and competition.

When the supply is limited, distributive justice requires that more should be given to the

one who needs most and to the one who will be most benefited to attain quality life.

When fairness is observed with honest justification in allotting shares of limited goods,

distributive justice flows without much problem.

When the available supply is too limited, and there are just too many who desire to avail

of the limited supply, sometimes it is resolved by lottery, giving each one a fair probability

of being selected.

The following are valid material principles of distributive justice:

1. To each person an equal share2. To each person according to need3. To each person according to effort4. To each person according to contribution5. To each person according to merit6. To each person according to free-market exchangesThere is no obvious barrier to the acceptance of more than one principle and some

theories of justice accept all six as valid.

A plausible moral theme is that each of these material principles identifies a prima facie

obligation whose weight cannot be assessed independently of particular circumstances

in which they are especially applicable.

Additional specification may also establish the relevance of these principles to a circums-

tance in which they formerly had not been judged applicably.

Theories of distributive justice have been developed to specify and unite our diverse

principles, rules and judgments.A theory attempts to connect the characteristics of persons with morally justifiable

distribution of benefits and burdens.

For example, a persons service, effort or misfortune might be the basis of distribution.

Several systematic theories have been proposed to determine how social burdens,

including health care goods and services should be distributed or redistributed.

Some influential theories that go with the principle of justice are the following:

1. Utilitarian emphasizes a mixture of criteria for the purpose of maximizing publicutility.

2. Libertarianemphasizes rights to social and economic liberty invoking fair proceduresrather than substantive outcome.

3. Communitarian stresses the principles and practices of justice that evolvethrough traditions in a community.

4. Egalitarian emphasizes equal access to goods in life that every rational personvalues.

The acceptability of any theory of justice is determined by the strength of its moral

argument.

But we must all seek to provide the best possible health care for all citizens and promote


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public interest through cost-containment programs.

Gender, race, or social status should not become impediments to having and getting

what is due.

Allocation of Scarce Resources

To allocate is to distribute by allotment.

Such distribution does not presuppose either a person or a system that rations services.

A criterion of ability to pay in a competitive market, for example, is a form of allocation.

Macroallocation decisions determine the funds to be expended and the goods to be

made available as well as the methods of distribution.

Macroallocation decisions in the Philippines deal with how much of the societys

resources will be used for various needs, including health-related expenditures.

Government decides how much of the national budget goes to health care and what

proportion of available health funds goes to which program.

Microallocation decisions, in contrast, determine who will receive particular scarce

resources.

This distinction between the macro and the micro levels of allocation is useful but the

line between them is not clear and oftentimes they intersect.In the Philippines, microallocation deals with how scarce resource is distributed among

Individuals with competing claims to it.

Health care providers select which patient will receive the scarce resource.

Our moral obligation often drives us into two conflicting directions: either to allocate

more to treatment, or allocate more to prevention and education.

Determining which should receive a priority ranking in the allocation of health care

resources is not easy because philosophies of people vary.

In these instances, we can only recourse to giving a person his or her due.

It also means treating each one equally.

We have to keep in mind that justice in health care implies that every individual should:

1.

Receive benefits due him or her by right such as life, minimum health care, informa-tion for decision-making and confidentiality on private information.

2. Receive benefits he or she deserves after balancing competing claims of otherpersons against his/hers: such as equal opportunity to get an ICU bed, a pacemaker

or an organ transplant;

3. Share in the burden of paying for the cost of health care and health research.The following statements are based on what the Southeast Asia Center for Bioethics

recognizes:

1. Every human being has a fundamental right to health.2. Individuals have the primary responsibility to promote their own health3. 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.

In all these, the principle of justice would at least require equal opportunity for all.

The Filipino Family and Its Principle of Justice

The Filipino family is included in the discussion of the principle of justice because this is

the beginning unit of society where seeds of justice are implanted.

It is the unit of the society that ingrains in the young mind what is just and what is fair as


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exemplified by family members.

The Filipino family is seen as the solid bank where withdrawal of resources is endless.

In all kinds of crises, calamities, setbacks, and emergencies, the family is an ever ready

source of help, strength and security.

This is an institution where each family member gets its allocation without having to

undergo prioritization or screening.

The family does not disregard anyone.

The principle of justice here becomes questionable when parents play favourites among

their children.

By nature, parenting is fair and just because each child is a product of the love and

sacrifice of both the father and the mother.

Each child in the family is unique and has his/her particular place in the hearts of

parents and siblings.

The principle of justice also explains why members of the family avoid giving a bad name

or bringing dishonour to the family.

Parents invest their time, talent and money on each child.

All members of the family then must endeavour to promote fair and honest rewards by

Bringing honor to the family equal to the commitment and investment of the parents.Now , in your own reflection, think about how the principle of justice applies to the

Filipino family.

Summary:

This chapter enlightened you on the principle of justice.

There are types of justice that emanate from this principle such as distributive, criminal

and rectificatory justice.

In line with these justice classifications, we discussed the meaning of utilitarian, commu-

nitarian, libertarian and egalitarian theories of justice.

We discussed allocation of resources in the macro and micro levels.

The Filipino family being the reliable source of resources and values, is like a solid bankfounded on the principle of justice.

The principle of justice is important especially in countries like the Philippines because

We face corruption, abuse kin relationships, and political pressure in the context of

scarce resources.

I hope that this topic helped you find ways and means to apply the principle of justice

in your professional practice and personal conduct of life.


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Professional Patient Relationship

This chapter on professional patient relationship discusses the relationship in terms of

virtue, character, principles and rules of bioethics.

Professional health care relationships are important because health care delivery is a

team effort.

Team work requires good relationships within the team as well as between the patient and

the family.

Problems of adequate communication, cooperation and mutual support arise when the

ethical standards of some differ from those of others.

In individual patient care, the attending physician is the leader.

He or she is the person in authority.

Fellows, residents, interns, clerks, nurses, therapists, dentists and pharmacists are his or

her co-workers.

Within the hospital, the administrators are the persons in authority.

Professionals such as physicians and nurses as well as the ancillary and maintenance staff

are their co-workers.The person in authority is always looked up to and there is danger that this position may

be abused or misused.

This module discusses privacy, veracity, fidelity, truth-telling and confidentiality in

relation to health professional-patient relationships.

Privacy

Privacy may be defined as the individuals control over access to himself or herself

extending to physical or informational inaccessibility.

In brief, the person has the right to control access.

This kind of definition may seem too limited.

In this module, we are going to study privacy in its limited sense focusing mainly on whatThe persons rights are when he or she is in a health care situation.

Filing of libel cases in court most often starts with intrusion into the persons private life.

Intruding into ones private life can stem from eavesdropping and the target unknowingly

loses some measure of privacy.

What counts as a loss of privacy and what affects an individuals sense of loss of privacy

is proportionate to what one values as strictly personal or very private.

In hospital settings, when we emphasize respect for the patients privacy, we oftentimes

allude to territorial inaccessibility and non-exposure to others as in screening the patients

territorial area when giving health care.

Discussing the patients case publicly, as in students medical rounds without asking the

patients permission is trespassing into the patients privacy.

Let us keep in mind that Privacy is a necessary condition, the necessary atmosphere for

maintaining intimate relationships of love, respect, friendship and trust.

Without privacy, these relationships are inconceivable.

Privacy certainly has such instrumental value.

We grant access to ourselves in order to have and maintain such relationships.

Whether we grant someone else access to some respect to our lives will depend on the


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kind of relationship we want in pursuit of our goals.

For example, we allow physicians to have access to our bodies in order to protect our

health.

We often hear the expression, I need breathing space.

In relationships, this means a need to be with ones self, to be private in order to

decongest the self from the others shadowing.

In any relationship, we have to provide time for being alone, for being private, to breathe

and to be just ourselves and be inaccessible to others.

In health care, person is unique.

Each is private.

Let us respect our patients needs for privacy, for moments of silence.

Veracity

Veracity in its basic meaning is truthfulness.

To be true is to accept ones self as one is.

To respect veracity in relationships is to deal honestly with patients and colleagues as they

are.

With veracity goes virtues of candor and truthfulness and these are the widely praisedcharacter traits of health professionals in contemporary biomedical ethics.

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 enlighten-

ment given to the patient regarding the procedures or intervention to be done.

The respect owned to other human beings includes respect for their liberty.

2. Veracity has a close connection to obligations of fidelity and promise-keeping.When we communicate with others, we implicitly promise that we will speak

truthfully and that we will not deceive our listeners.

Voluntary participation in these social conventions engenders an obligation of veracityand of truthfulness.

Example is when a relationship is entered into a contract, thereby gaining a right to

the truth regarding diagnosis, prognosis and all other pertinent information.

The professional gains a right to truthful disclosure of information from patients and

research subjects.

3. Relationship of trust between persons are necessary for fruitful intervention andcooperation.

At the core of these relationships is confidence in and reliance on others to be

truthful.

Relationships between health care professionals and their patients and between

Researchers and their subjects ultimately depend on trust and adherence to rules of

veracity.

These are all necessary to foster trust.

On the other hand, lying and inadequate disclosure show disrespect for persons,

violate implicit contracts and threaten relationships.

Fidelity

Fidelity means the obligation to act in good faith and to keep vows and promises, fulfil

agreements, maintain relationships and fiduciary responsibilities.


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Fiduciary responsibility refers to the contract of relationship we enter into with the patient.

The model of fidelity is: keeping ones word of honor, loyalty to commitments and oaths,

and reliability.

Why so? Because the model of fidelity learns on the values of loyalty and trust as well as

standing true to ones word.

In popular Spanish parlance, this is known as palabra de honor.

With fidelity goes the traits of maturity and commitment of the person.

Fiduciary relationship bank on trust and confidence.

This means that once a physician or nurse enters into a relationship with the patient, these

professionals become the trustees of the patients health and welfare.

Hence, both the physician and the nurse are obligated to maintain the contract of care.

They cannot withdraw their care without giving notice to the patient, the relatives or

responsible friends who need enough time to look for their replacement attendants.

The Council on Ethical and Judicial Affairs on Health Care specifies that abandonement

is a breach of fidelity and infidelity amounting to disloyalty.

Whether or not a promise was made, such infidelity undermines trustworthiness, honesty

and loyalty.

Traditionally , nurses have been discouraged from developing and acting on their ownethical judgments.

Although the institutions of nursing and medicine developed separately until the late

eighteenth century, the increasing importance of the hospital in health care brought

nursing under the dual command of physicians and hospital administrators.

Recent codes of nursing ethics define the moral responsibility of the nurse in sharply

different ways from the codes of two or three decades ago.

In America, for example, in 1950, American Nurses Association stressed the nurses

obligation to carry out the physicians orders but the 1976 revision stressed the nurses

obligation to protect the reputation of associates, the later code emphasized the

obligation to safeguard the client and the public from the incompetent, unethical or

illegal practices of any person.In the same manner, the Philippine Nursing Law, particularly RA 7164, passed,

Promulgated and executed in 1992, emphasizes the role of the nurse as the client

advocate or patient advocate who can do independent nursing measures.

In brief, the nursing profession acts on ethical guidelines, independent of the

command of physicians or hospital administrators.

This demands keen assessment, competence and fidelity to the patient and to the

profession for every nurse who cares for patient regardless of creed, race or age.

Fidelity is possible when one knows what is beneficent to others and when one respects

the autonomy of others because these lead to honesty and trust.

Truth Telling

Every competent person has a right to information about himself or herself and about

what is planned for her or him.

All informations must be disclosed so that correct decisions are arrived at both for the

moment and for the future.

Truth telling then is the right of every individual to know what the situation is all about.

to override a patients right to the truth needs a very strong justification.

The most common situation is when truth telling will harm the patient or others because


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coping mechanisms needed to accept facts are weak.

In the Filipino culture, the two traits offamily orientation to illness and the non- confron

tational attitude affect truth telling.

Family orientation to illness means family members are often informed of serious

diagnoses before the patient is inform.

Many times, the family may request the doctor not to tell the truth to the patient, as

in the case of cancer because telling the patient may bring more harm.

The non-confrontational attitude, on the other hand, prevents us from disclosing

unpleasant views.

Doctors may hesitate to tell a patient that he or she is dying.

Most physicians still subscribe to the death denial culture.

At times, doctors use euphemisms and oftentimes this results in wrong conclusions and

inappropriate decisions.

But these are realities we cannot ignore because the family is a very essential component

of Filipino culture and they have the right to know the truth.

The non-confrontational attitude of Filipinos prevents issues from being addressed.

The following situation is an example:

Myra knows that her friend Lisas 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, graver conflicts between husband and wife are bound to arise by not

confronting Lisa with the truth while the affair is at its early stage.

Another example is hearsay.

Rumors have no roots but they fly far and wide and they bring damage to the

persons concerned.

Non-validation and non-confrontation are aspects of some Filipino characteristics

traceable to shame or hiya.

Confidentiality

Keeping in confidence all that one has learned in the course of caring for the patient and

the family is a very strong basis for an effective and working professional-patient

relationship.

To confide in someone like a physician or nurse, one has to feel secure that secrets are

securely guarded and kept in confidence.

Confidentiality often does not apply to families because each member knows or will try

to know about each other.

The distinction between infringement on privacy and infringement on confidentiality.

An infringement of Xs right to confidentiality occurs only if the person to whom X

discloses the information in confidence fails to protect the information or deliberately

discloses it to someone without Xs consent.

In contrast, a person who without authorization enters a hospital records room or

computer data bank, violates the right to privacy rather than confidentiality.

In sum, only the person or institution to whom information is given in a confidential

relationship can be charged with violating rights of confidentiality.

Nurses, physicians and guidance counsellors are some of the professionals among

whom confidentiality must be observed, respected and guarded because many

confidences are revealed to them in the course of exercise of their profession.


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These professionals must have keep ears to listen, big hearts to understand and very

small mouths to talk.

Once secrets are confided, they should be sealed with much respect because with

confidentiality, there is trust.

In health care, truth-telling and confidentiality are essential components that must

always be respected.

Smooth professional-patient relationships happen when truth telling and confidentiality

along with the other components of relationship such as privacy, veracity and fidelity

are honestly kept and respected at all times.

Hence, we need constant discernment of our words and critiques so that we are

reminded of the magnitude of our responsibilities in all our relationships with others.

Virtues in Professional Life

Virtues of nurses reflect oftentimes the models of the nursing profession and its roles

and responsibilities.

In the model of yesteryears, the nurse was regarded as the handmaid of the physicians

thus she was expected to portray the passive virtues ofobedience and submission.

In contemporary models, the nurse is a co-manager, a partner in health care and has anactive role of advocacy for patients.

Hence, the prominent virtues to be portrayed include respect for autonomy, justice,

persistence and courage.

Obedience to rules is demanded in the traditional model but constant attention to

patients rights and preservation of the nurses integrity are emphasized in contempora-

ry autonomy models, especially those that call on the nurses to be the patients

advocate.

In the health care profession, we often say that a virtuous person has a virtuous character.

It is difficult to describe all the virtues in a person but some virtues are more focal and

proximate for health care professionals.

1. Compassion. This is a trait that combines an attitude of active regard for anothers welfare with an imaginative awareness and an emotional response of deep sympathy,

tenderness and discomfort at the others misfortune or suffering.

Compassion presupposes sympathy, has affinities with mercy and is expressed in acts

of beneficence that attempt to alleviate the misfortune and suffering of other person.

Unlike integrity, which is inwardly focused on the self, compassion is outwardly focused

on other selves.

The trait of compassion resembles closely the moral sentiment of care.

People all over the world feel reassured and cared for when they sense that you are a

person of compassion.

It is therapeutic to feel compassion in the health care professional because this is an

assuring assistance.

The health care professionals who express no emotion in their behaviour, only

professional skill , often fail to provide what patients most need.

Emotional engagement and communication are important parts of human relationships

in general and health care in particular.

2. Discernment. The virtue of discernment rests on sensitive insight involving acute


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judgment and understanding and results in decisive action.

Discernment includes the ability to make judgments and reach decisions without being

unduly influenced by extraneous considerations, fears or personal attachments.

Discernment often pairs in action with courage and fidelity to ones duty.

Practicality of mind and common sense have big roles in the exercise of discernment.

With discernment goes the virtue of prudence.

A person of practical wisdom knows which goals should be chosen and knows how

to realize them in particular circumstances while keeping emotions within proper

bounds and carefully selecting from among the range of possible actions.

the practically wise person understands how to act with the right intensity of feeling

in just the right way, at just the right time, with the right balance of reason and

desire.

In general, the person of discernment identifies what a circumstance calls for in the

way of human responsibilities.

For example, a discerning nurse will find ways and see when a patient in despair needs

empathic comfort more than privacy.

If comfort is the right choice, the discerning nurse will find appropriate type and level

of consolation in order to be helpful rather than intrusive.Discernment is a necessary condition in a good decision.

Discernment is an essential component of care.

It is a talent and an ability to understand what needs to be done for patients.

It is also an ability to understand how to do caring by giving sensitive responses.

Discernment is consistent and constant trait and is of great factor in providing quality

care.

3. Trustworthiness. To trust someone is to have a confident belief in and reliance uponthe ability and moral character of another person.

Trust entails confidence that another will act with the right motives in accord with

moral norms.Trust is often the most important ingredient in our choice of one physician rather than

another.

A perceived lack of trustworthiness in a physician may be the primary reason for a

patients decision to switch to another.

Trust binds friendship and intimate relationship.

If friends part ways and married couple separate, the basic cause of break-up is usually

a loss of trust.

Oftentimes, infidelity sets in when trust is no longer present in the relationship.

In the professional-patient relationship and even in ties among friends, trust seals the

bond of openness and confidentiality.

When a physician trusts his or her nurse, the professional relationship propels effective

teamwork.

At the same time, when a patient trusts her or his nurse, the interaction invites

compliance to treatment and other forms of therapy.

We have to cultivate trust in ourselves because trust is a very essential factor in

fostering congenial professional-patient relationships.

4. Integrity. By integrity, we mean soundness, reliability, wholeness and integration ofmoral character.


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Oftentimes, integrity is seen as moral integrity which refers to fidelity in adherence to

moral forms.

Integrity describes two aspects of a persons character:

1. Coherent integration of aspects of the self emotions, aspirations and knowledge,so that each complements and does not frustrate the others.

2. Character trait of being faithful to moral values and standing up in their defensewhen they are threatened or under attack.

An individual with integrity is endowed with values that are consistent and constant

in practice.

There is also congruence and genuineness in his or her words and actions.

in a professional-patient relationship, people with integrity easily win friends and

reliance from others.

Summary :

We have seen in this module the essence of the professional-patient relationship.

This relationship anchors its strength on effective teamwork which in turn counts on

certain traits, character and virtues that every professional health care giver must

possess.In the process, we learned the meanings and significance of privacy, veracity, fidelity,

truth telling and confidentiality.

Health care professionals must have such virtues as compassion, discernment, trust-

Worthiness and integrity make the health care professionals worthy to carry and main-

tain effective professional-patient relationships.

Caring is highly based on therapeutic interaction between the caregiver and the client.

This relationship is a contract enveloped in mutual trust and confidence.

Now that we have seen the importance of the components of an effective professional

patient relationship, let us strive to cultivate and develop the traits, virtues, and

character needed to help us become better professional caregivers.

Issues of Bioethical Concerns

Nursing faces currently several issues that oftentimes throw the nurse into confusion.

Some of these issues are:

1. When is organ harvesting done?2. How does one certify that the person is clinically dead?3. Who decides DNR4. What is the role of the nurse in maternal-fetal conflict cases?5. Who is responsible in getting informed consent?6. Who should remove the respirator when futility is evident?7. When is the service of the nurse exploited?8. How honest are clinical cases submitted for board examination requirement?9. How much is the price of nursing program?10.How true are the number of RLE hours reflected in the students record?11.How were the masters and doctoral degree of faculty earned?12.How qualified are deans and chief nurses in school and hospitals and in review

centers?

13.Why are so many schools even those without base hospitals running with somany students?

14.How are students supervised in the clinical areas? How are students taught in


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review centers?

15. Is there honesty in submitting clinical cases for graduation compliance?There are more questions boggling in the minds of those who are bioethically oriented.

Answers will never be found as long as nurses do not strive to learn Bioethics and live

in the line of Bioethics.

There are head principles that revolve around us today.

Nurses must be aware of these pervading principles and must know how to combat

them.

Perhaps it is worth mentioning these mundane principles because our reaction will

utilize the values we profess and the Bioethics we practice in our life.

Let us go over these mundane principles and let us see how we can combat them

especially in the practice of our nursing profession.

Hedonismthe principles of pleasure, of what is easy, of what is profitable for self.

Many times we succumb to Hedonism when we cut short anything to reach the end of

what we like.

When we pay courses without having to spend time in school, when we buy cases to

complete requirements or invent RLE hours, when we hire not qualified faculty, notquailified deans or chief nurses, when we short cut nursing procedures and many other

acts of similar tone, then we are subscribing to Hedonism.

Nurses should combat Hedonism by having an honest attitude and commitment to the

profession of nursing.

Be a self-disciplined nurse professional at all times and in all places.

We have to cultivate the culture of fidelity to do honest and loyal service to all patients

who cross our pathways.

A disciplined nurse will not be easily swayed to Hedonism.

Pluralism. The drawing, attractive principles to do what the majority of people are doing.

When we follow the impulse of what everybody does even though we know it is notadmirable, then we act and follow the flow of fashion like robots.

When we cheat others, when we do things because others are doing it, like for example

exposing our umbilicus, exposing our bodies without sense of decency, we act like robots

simply following the currents of time.

To combat pluralism, nurses should know what to prioritize and how to prioritize.

Hierarchy of values follow the priorities in life from what one has learned from childhood.

A principled nurse will know what values go with proper decorum not only in outward

ways of dressing up but mostly in words, attitudes and reactions to situations.

To be able to know how to prioritize moves stems from a value in life honest from the

family , from childhood and practiced in life with constancy and with congruence.

Consumerism.The madness sale principle of buying all that is advertised, offered or

displayed.

One is tempted to buy and buy whatever is on sale or what is offered.

Actually , we do not need to have two cars when we can drive only one at a time.

We do not have to own two cell phones when we use only one at a time.

The problem with us is that we go with the crowd to buy and buy and accumulate things

that we do not really need.

Then we are met with the problem of how to dispose of the things we bought because


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we realize later on that we do not need them.

When we are taken by the tide of buying during madness sale attraction, we succumb

to the consumerism fever.

To combat consumerism, nurses should lead simple lifestyle.

Great people are very simple and they live simply.

It is when we have to impress others that we live in superfluous living, and we impress

people with our complexity.

Simple lifestyle goes hand in hand with values, with priority of needs, with honesty and

integrity.

When nurses have this in their lives, then we can be assured of safe, satisfactory and

effective nursing care because virtues will shine in the therapeutic encounter of nurses

to patients.

Above all, the spirituality of the nurse will help the nurse to be a real healer because

every touch, every encounter and every word of the real good nurse will give solace to

the aches and ills of the patients.

Let us strive to shun away from pluralism, hedonism and consumerism because they

bring down to the dregs the profession of nursing.

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