Ethical Principle

7/23/2019 Ethical Principle

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ETHICAL

PRINCIPLE

GENERAL

RULE/DEFINITI

ON

EXEMPTIONS FOR DISCLOSURE

Autonomy

Autonomy is

the “personal rule

of the self that is

free from both

controlling

interferences by

others and from

personal limitations

that prevent

meaningful choice.”Autonomous

individuals act

intentionally, with

understanding, and

without controlling

inuences.

THE !"HT T# $#%&E%T

!nformed consent is re'uired for all medical investigations

and procedures and is considered a cornerstone of modern

medicine. However, there are several legal e(ceptions to the right

of consent concerning minors, incapacitated patients, with mental

illness and patients su)ering from communicable diseases.

The amount of information re'uired to ma*e consent

informed may vary depending on comple(ity and ris*s of

treatment as well as the patient+s wishes. urthermore, individual

patients will have di)erent intellectual capabilities andunderstanding of their illness. !t isa therefore mandatory to tailor

information provided to the individual patient and the current

situation. An emergency li*e acute myocardial infarction for

e(ample will allow less time to discuss diagnosis and treatment

than an elective endoscopy.

To -udge whether a patient has really understood the

information provided can be dicult and often little of the

information is retained. This leaves physician in doubt whether

their patient+s consent is truly informed. $onsent based on partial

information may be invalid but this may go unnoticed by patient

and treating physician.

The principal of an absolute right to consent could be easily

undermined by partial information. !t is highly dependent on the

willingness to provide full information and the patient+s capability

to understand and weigh up the options.



!n summary the patient+s right to autonomy should always be

respected and step shall be ta*en to ma*e consent truly

informed. #n the basis of philosophical, ethical, legal and

practical considerations, however, there is no absolute right to

consent.

Examples/a. !n a prima facie sense, we ought always to respect the

autonomy of the patient. &uch respect is not simply a

matter of attitude, but a way of acting so as to recogni0e

and even promote the autonomous actions of the patient.

The autonomous person may freely choose values,

loyalties or systems of religious belief that limit other

freedoms of that person. or e(ample, 1ehovah2s

3itnesses have a belief that it is wrong to accept a blood

transfusion. Therefore, in a life4threatening situation

where a blood transfusion is re'uired to save the life of

the patient, the patient must be so informed. The

conse'uences of refusing a blood transfusion must be

made clear to the patient at ris* of dying from blood loss.

A desiring to 5bene6t5 the patient, the physician may

strongly want to provide a blood transfusion, believing itto be a clear 5medical bene6t.5 3hen properly and

compassionately informed, the particular patient is then

free to choose whether to accept the blood transfusion in

*eeping with a strong desire to live, or whether to refuse

the blood transfusion in giving a greater priority to his or

her religious convictions about the wrongness of blood

transfusions, even to the point of accepting death as a



predictable outcome. This communication process must

be compassionate and respectful of the patient+s uni'ue

values, even if they di)er from the standard goals of

biomedicine.

!n analy0ing the above case, the physician had a prima

facie duty to respect the autonomous choice of the patient, aswell as a prima facie duty to avoid harm and to provide a medical

bene6t. !n this case, informed by community practice and the

provisions of the law for the free e(ercise of one2s religion, the

physician gave greater priority to the respect for patient

autonomy than to other duties.

b. #ne clear e(ample e(ists in health care where the

principle of bene6cence is given priority over the principle

of respect for patient autonomy. This e(ample comes from

Emergency 7edicine. 3hen the patient is incapacitated

by the grave nature of accident or illness, we presume

that the reasonable person would want to be treated

aggressively, and we rush to provide bene6cent

intervention by stemming the bleeding, mending the

bro*en or suturing the wounded. !n this culture, when the physician acts from a benevolent

spirit in providing bene6cent treatment that in the physician2s

opinion is in the best interests of the patient, without consulting

the patient, or by overriding the patient2s wishes, it is considered

to be 5paternalistic.5 The most clear cut case of -usti6ed

paternalism is seen in the treatment of suicidal patients who are

a clear and present danger to themselves. Here, the duty of

bene6cence re'uires that the physician intervene on behalf of



saving the patient2s life or placing the patient in a protective

environment, in the belief that the patient is compromised and

cannot act in his own best interest at the moment. As always, the

facts of the case are e(tremely important in order to ma*e a

-udgment that the autonomy of the patient is compromised.

Benefcence

!nscribed in the

natural law, the

p!nc!p"e o#

$enefcence

provides that good

must be done

either to oneself or

to others. This

fundamental

principle binds and

urges everyone to

do what is good

and perform for

good as moral

obligation. !tmandates the right

of every human

person to the

preservation of life,

promotion of

'uality life, physical

integrity and

health.

#ne instance of an e(emption would be a case of bone

marrow transplant, which has the possibility of ris*s of the donor

becoming a cripple or even dying, to be underta*en from a

societal member to bene6t a democratic president of a epublic

who is su)ering from an end4stage organ failure. This e(ample

ma*es it clear that an unconstrained principle of utility carries

danger 8especially to the minority, unpopular or disadvantaged9

with it since it implies that dangerous and sometimes immoral

researches on human sub-ects “ought” to be underta*en. This is

echoed by "allap &urvey who argues that the general principle of

bene6cence especially that with a version of the principle of

utility implies that premature or hastened death of individual

donors of cadaver organs done in order to bene6t patients is

-usti6ed. Thus for &urvey, the principle of utility shows that the

principle would -ustify hastening death of one patient in order tobene6t say 6ve others who would procure a heart, a *idney, a

liver, an eye and bone marrow each. This situation that

bene6cence implies is very problematic. !t shows that the

principle is prone to abuse. As a matter of conse'uence,

unconstrained principle of bene6cence generates a sense of

distrust and fear for abuse in donors of cadaver organs as they

would always worry that physicians might declare them dead

prematurely in order to bene6t other patients.



Non%

m&"efcence

Engraved in

the natural law, the

p!nc!p"e o# non%

m&"efcence

provides that evil or

harm should not beinicted either on

oneself or on

others. This

fundamental moral

principle binds and

urges everyone to

avoid inicting

harm as a moral

obligation. !t

mandates the right

not to be *illed,

right not to have a

bodily in-ury, or

pain inicted 8on9

oneself, and rightnot to have one+s

con6dence

revealed to others.

!n the course of caring for patients, there are situations in

which some type of harm seems inevitable, and we are usually

morally bound to choose the lesser of the two evils, although the

lesser of evils may be determined by the circumstances. or

e(ample, most would be willing to e(perience some pain if the

procedure in 'uestion would prolong life. However, in other cases,such as the case of a patient dying of painful intestinal

carcinoma, the patient might choose to forego $: in the event of

a cardiac or respiratory arrest, or the patient might choose to

forego life4sustaining technology such as dialysis or a respirator.

The reason for such a choice is based on the belief of the patient

that prolonged living with a painful and debilitating condition is

worse than death, a greater harm. !t is also important to note in

this case that this determination was made by the patient, who

alone is the authority on the interpretation of the 5greater5 or

5lesser5 harm for the self.

There is another category of cases that is confusing since a

single action may have two e)ects, one that is considered a good

e)ect, the other a bad e)ect. How does our duty to the principle

of nonmale6cence direct us in such cases; The formal name forthe principle governing this category of cases is usually called

the principle of double eect . A typical e(ample might be the

'uestion as to how to best treat a pregnant woman newly

diagnosed with cancer of the uterus. The usual treatment,

removal of the uterus is considered a life saving treatment.

However, this procedure would result in the death of the fetus.

3hat action is morally allowable, or, what is our duty; !t is argued

in this case that the woman has the right to self4defense, and the



action of the hysterectomy is aimed at defending and preserving

her life. The foreseeable unintended conse'uence 8though

undesired9 is the death of the fetus. There are four conditions that

usually apply to the principle of double e)ect/

<. The nature of the act. The action itself must not be

intrinsically wrong= it must be a good or at least morally

neutral act.

>. The agent’s intention. The agent intends only the good

e)ect, not the bad e)ect, even though it is foreseen.

?. The distinction between means and eects. The bad e)ect

must not be the means of the good e)ect,

@. Proportionality between the good eect and the bad

eect. The good e)ect must outweigh the evil that is

permitted, in other words, the bad e)ect.

The reader may apply these four criteria to the case above,

and 6nd that the principle of double e)ect applies and the four

conditions are not violated by the prescribed treatment plan.

'IDNE( TRANSPLANT/ "illon+s analysis of this case

demonstrates the e(ibility in applying the four principles.

espite the centrality of respect for persons, and the 8mista*en9

view of some critics that adherents of the four principles always

place the so called “American” principle of autonomy at the head

of the list, "illon demonstrates how considerations related to



bene6cence may -usti6ably override the autonomy of individuals

who would see* to participate in a free e(change. "illon argues

persuasively that there is no good reason to doubt whether poor

people who see* to sell their organs are, in general, able to ma*e

ade'uately autonomous decisions. But that does not constitutesucient reason to endorse the practice. !f the overall harms are

li*ely to e(ceed the e(pected bene6tsCfor the sellers, possibly

for the society as a whole, and maybe even for the recipients of

organsCit would be -usti6able to ban the sale of organs from live

donors. However, the conclusion relies on a set of empirical

assumptions and predictions of what is li*ely to occur.

)u*t!ce

)u*t!ce simplemeans the

rendering of what is

one+s due. A person

who is -ustly doing

an act to another

person gives the

latter what is his

due.

P!nc!p"e o#

+u*t!ce refers to a

moral principle by

which certain

actions are

determined and

deemed as -ust or

#ne of the most controversial issues in modern health careis the 'uestion pertaining to 5who has the right to health care;5

#r, stated another way, perhaps as a society we want to be

bene6cent and fair and provide some decent minimum level of

health care for all citi0ens, regardless of ability to pay. 7edicaid is

also a program that is designed to help fund health care for those

at the poverty level. Det, in times of recession, thousands of

families below the poverty level have been purged from the

7edicaid rolls as a cost saving maneuver. The principle of -ustice

is a strong motivation toward the reform of our health care

system so that the needs of the entire population are ta*en into

account. The demands of the principle of -ustice must apply at

the bedside of individual patients but also systemically in the

laws and policies of society that govern the access of a

population to health care.

!f selection is to be made, what *ind of recipients should be



un-ust, as due or

undue.

selected; How should they be selected; oes it not constitute

in-ustice against those who will not be selected; 3hat constitutes

-ust distribution of health resources; And what about burdens

health bene6ts bring about; Addressing said 'uestions is the

concern of the so4called distributive -ustice. And much wor*

remains to be done in this arena.

Conf,ent!&"!

ty

$on6dentiality is

commonly applied

to conversations

between doctors

and patients. egal

protections prevent

physicians from

revealing certain

discussions with

patients, even

under oath in court.

This physician4

patient

privilege onlyapplies to secrets

shared between

physician and

patient during the

course of providing

medical care.

3HE% T# BEAF $#%!E%T!A!TD 3!TH 7!%#&/

onnie was a <G4year4old high school student who was

struggling academically. He had always been a strong student,

but his grades had recently begun to decline. onnie told his

guidance counselor that he was distracted by his parents+ recentseparation and pending divorce. 3ith the guidance counselors

encouragement, onnie began therapy with a social wor*er,

7artha, who was employed by a nearby family service agency

that has a counseling program for adolescents. onnie and

7artha spent considerable time tal*ing about how distressed

onnie was about his parents+ marital conict and separation.

onnie also focused on his longstanding conicts with his fatherand his concern about his mother+s psychiatric problems.

Almost two months after they started wor*ing together, onnie

told 7artha that he had something important to tell her. He said

that he was concerned he had developed a drug problem. “!+ve

been doing a fair amount of ecstasy and amphetamines with my

friends on wee*ends,” he said. “! didn+t thin* !+d have a problem,

but now !+m really worried that ! might have an addiction.” onnie

https://en.wikipedia.org/wiki/Physician-patient_privilege








as*ed 7artha to help him with his substance abuse, but he

insisted that she not tell his parents about his drug use. “Dou+ve

met my dad, and you *now how afraid ! am of him, and ! can+t

bear the thought of adding to my mom+s worries. ! -ust don+t want

you to say anything to them. All ! want is some help,” he pleaded.

7artha faced a common ethical challenge encountered by social

wor*ers who provide services to minors/ whether or not to

disclose con6dential information to the minor+s parents 8or

guardians9, particularly when the minor client has e(plicitly as*ed

the social wor*er not to share the information. %early every social

wor*er who serves minors can thin* of times when he or she had

to decide whether or not to share sensitive information with a

client+s parents over the client+s ob-ections. sually, these

situations involve con6dential information that minors have

shared with their social wor*ers about drug and alcohol use,

se(ual activity, contraception, pregnancy, abortion decisions, and

mental health treatment.

There is no simple answer to 'uestions about social wor*ers+ethical obligations in these circumstances. #n one hand, minors

typically have a right 8somewhat limited9 to con6dentiality. &ocial

wor*ers understand that minor clients need to be able to trust

their therapists and counselors= otherwise, minors may be

reluctant to share clinically relevant information. &ocial wor*ers

understand that many parents believe they have a right to *now

about the ris*s their children face and believe that their children+s

clinicians have a duty to share critical information involving their



children+s safety.

F!,e"!ty idelity is a virtue

that refers to

integrity, which is

achieved by the

embodiment of

loyalty, fairness,

truthfulness,

advocacy, and

dedication that is

motivated by an

underlying principle

of care. %urses

must encompass

integrity in all that

they do .The nurse

practices 6delity by

remaining

committed and

*eeping promises.

A. ichter 8<IJI9 believes it is vital to tell the truth to a patient

because they have a right to *now. He therefore advocates

overriding the principles of non4male6cence 8whether the5full5 truth may in some ways be detrimental to a patient9

and bene6cence 8whether it is to the patients advantage

not to *now the full truth9 in favour of autonomy 8the right

to choose who we wish to be, to ma*e our own decisions

and to be in control of what is being done to us9. Fendall

8<IIK9 argues that 5an action can be harmful at the same

time as being bene6cial5 and draws an analogy betweentruth telling and chemotherapy treatment. 3hile

chemotherapy introduces to(ins that can cause e(treme

harm, the outcome of this treatment may well be bene6cial

for the patient. i*ewise, telling the painful truth can be

bene6cial by allowing patients and families to facilitate

planning and decision4ma*ing in regard to their lives and

future care.

The views of ichter and Fendall are representative of many

others and lead us to conclude that the debate about truth telling

in the area of healthcare is no longer around 2to tell2 or 2not to

tell2, but rather about who should tell, when to tell and how to tell.

B. $ase &cenario / 7erry was a @L4year4old mother of two with

a history of tumor and hospital visits= however, her last



doctor+s visit in #ctober left her and her family with

shattering news. octors diagnosed 7erry with metastatic

inoperable tumor. &ince 7erry last visit, her conditions

worsened due to malignancy and she became a victim of

nausea, vomiting, intestinal obstruction and slothfulness.3hen 7erry came to *now of her medical conditions, she

became stubborn and denied treatments the hospital

o)ered her/ e(ploratory laparotomy, insertion of a urinary

catheter, and insertion of nasogastric tube. The matter of

refusal of treatment between the medical sta) and 7erry

put her family in a hard situation. They encouraged 7erry to

agree to ta*e the hospital+s treatments= on the other hand,they also wanted to respect and honour her autonomous

wishes. !n due course, the medical team established a

terminal diagnosis for 7erry and informed this to her family.

Afterwards, the family as*ed the consultant to *eep this

information from 7erry. The consultant agreed and 7erry

sustained her stay in the hospital with the trust that she

was su)ering from tumor which can be cured. A wee* later,the holidays approached 7erry and her family conversed

plans for $hristmas as well as her discharge from the

hospital. Though 7erry+s family and doctors were well

aware of her prognosis, both groups willingly concealed the

truth and let 7erry believe her health condition was not

terminal. This created an uncomfortable situation for the

involved health care professionals involved in this tough



conict of interest. Eventually, 7erry+s disease too* control

of her life and she un*nowingly passed away one wee*

before her e(pected $hristmas holiday. Truth telling to

terminally ill patients is a common ethical dilemma in

health care ethics/ to inform or not to inform, is the main'uestion. %urses wor* closely with patients and thus are the

ones put in this diculty between their patient and their

patient+s family. 3ho should they listen to; &hould they

leave their patient in the dar* by not telling them truth;

The Ethical ilemma/ This case scenario presents a dilemma

when the nurse has to select between the mutually e(clusiveevents. The de6nite issue is whether a nurse by respecting the

family+s wish should *eep the truth from her terminally ill patient,

or by abiding the $ode of Ethics for %urses, should disclose the

truth to the patient. The %urses $ode of Ethics articulates the

ethics and values of the nursing profession by arming that

“nursing care is directed toward meeting the comprehensive

needs of patients and their families across the continuum of care,” in addition, “promoting, advocating for, and striving to

protect the health, safety, and the rights of the patient” .

Although the restriction of *eeping truth from patient was posed

by family, but nurses the primary person who deals with such

dilemmas. However, nurse+s responsibility is to be professional,

stay true to the lawfulness of their practice, and follow the

%ursing $ode of Ethics as well as hospital+s policy in truth telling.



-e&c!ty Meracity is a dual

concept that refers

to both the duty to

disclose pertinent

information and the

obligation torespect

con6dentiality.

!t refers to

a facet of moral

character and

connotes positive

and virtuous attribu

tes such

as integrity, truthful

ness, and

straightforwardness

, including

straightforwardness

of conduct, along

with the absence of lying, cheating,

theft, etc.

urthermore,

honesty means

being

trustworthy, loyal,

fair, and sincere.

A. $ase &cenario/ 7erry was a @L4year4old mother of two with

a history of tumor and hospital visits= however, her last

doctor+s visit in #ctober left her and her family with

shattering news. octors diagnosed 7erry with metastatic

inoperable tumor. &ince 7erry last visit, her conditionsworsened due to malignancy and she became a victim of

nausea, vomiting, intestinal obstruction and slothfulness.

3hen 7erry came to *now of her medical conditions, she

became stubborn and denied treatments the hospital

o)ered her/ e(ploratory laparotomy, insertion of a urinary

catheter, and insertion of nasogastric tube. The matter of

refusal of treatment between the medical sta) and 7erryput her family in a hard situation. They encouraged 7erry to

agree to ta*e the hospital+s treatments= on the other hand,

they also wanted to respect and honour her autonomous

wishes. !n due course, the medical team established a

terminal diagnosis for 7erry and informed this to her family.

Afterwards, the family as*ed the consultant to *eep this

information from 7erry. The consultant agreed and 7errysustained her stay in the hospital with the trust that she

was su)ering from tumor which can be cured. A wee* later,

the holidays approached 7erry and her family conversed

plans for $hristmas as well as her discharge from the

hospital. Though 7erry+s family and doctors were well

aware of her prognosis, both groups willingly concealed the

truth and let 7erry believe her health condition was not

https://en.wikipedia.org/wiki/Facet

https://en.wikipedia.org/wiki/Moral_character


https://en.wikipedia.org/wiki/Virtue

https://en.wikipedia.org/wiki/Integrity

https://en.wikipedia.org/wiki/Truth


https://en.wikipedia.org/wiki/Loyalty

https://en.wiktionary.org/wiki/fair#Adjective

https://en.wikipedia.org/wiki/Sincerity

https://en.wikipedia.org/wiki/Facet



https://en.wikipedia.org/wiki/Virtue

https://en.wikipedia.org/wiki/Integrity



https://en.wikipedia.org/wiki/Loyalty

https://en.wiktionary.org/wiki/fair#Adjective

https://en.wikipedia.org/wiki/Sincerity



terminal. This created an uncomfortable situation for the

involved health care professionals involved in this tough

conict of interest. Eventually, 7erry+s disease too* control

of her life and she un*nowingly passed away one wee*

before her e(pected $hristmas holiday. Truth telling toterminally ill patients is a common ethical dilemma in

health care ethics/ to inform or not to inform, is the main

'uestion. %urses wor* closely with patients and thus are the

ones put in this diculty between their patient and their

patient+s family. 3ho should they listen to; &hould they

leave their patient in the dar* by not telling them truth;

The Ethical ilemma/ This case scenario presents a dilemma

when the nurse has to select between the mutually e(clusive

events. The de6nite issue is whether a nurse by respecting the

family+s wish should *eep the truth from her terminally ill patient,

or by abiding the $ode of Ethics for %urses, should disclose the

truth to the patient. The %urses $ode of Ethics articulates the

ethics and values of the nursing profession by arming that

“nursing care is directed toward meeting the comprehensiveneeds of patients and their families across the continuum of

care,” in addition, “promoting, advocating for, and striving to

protect the health, safety, and the rights of the patient” .

Although the restriction of *eeping truth from patient was posed

by family, but nurses the primary person who deals with such

dilemmas. However, nurse+s responsibility is to be professional,

stay true to the lawfulness of their practice, and follow the



%ursing $ode of Ethics as well as hospital+s policy in truth telling.

Ethical Principle

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