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Bioethics I, II, III

TRANSCRIPTIONS
BATCH 2016

AY 2012 – 2013
COMPILED BY MARIE MAE PANTOLLA BATCH 2016
SUBJECT: BIOETHICS Bioethics goes beyond ethical issues in medicine to
COPY PASTE BY: MARIE MAE PANTOLLA include ethical issues in:
BATCH 2016 • Public health
• Population concerns
BIOETHICS 1 • Genetics
• Environmental health
The course involves the study of the fundamental concepts • Reproductive practice and technologies
of general ethics and the foundations of Bioethics. Here, • Animal health and welfare and the like
students are made aware of their moral responsibilities as
Christians as they exercise their profession. It is ISSUE AREAS IN BIOETHICS
emphasized that as medical students, they should know 1. The rights and duties of patients and health
where decisions are based in order to be ethical and professionals.
Christian-oriented physicians. The course also includes 2. The rights and duties of research subjects and
related values and virtues that are necessary for the researchers;
enhancement of morality in the practice of medicine. 3. The formulation of public policy, guidelines for clinical
care and biomedical research.
ELGA
The expected lasallian graduate’s attributes (ELGA) are: WHY IS THERE A NEED TO STUDY BIOETHICS?
• Ethically competent 1. there is a physician-patient relationship
• Ethically efficient 2. the physician is a healer of another’s body
• Imbued with the spirit of faith 3. the physician does not have a total right and/or
• Virtuous obligation over the patient
• Reveres life: promotes and defends life 4. the physician must be guided by principles
• Respectful towards the human person 5. the physician must be able to decide on certain
• Compassionate and safe physician actions/procedures without prejudice to the patient
• Ethically responsive
• Just HUMAN ACTS
• Responsible for oneself and responsible to OBJECTIVES:
others/patients 1. To define human act
• Respectful to human rights 2. To differentiate human act from act of man
• Effective communicator 3. To analyze the nature of the human act
4. Describe the kinds of voluntary acts
INTRO TO BIOETHICS 5. To describe the effects of voluntary acts
OBJECTIVES 6. Indentify the impairments of human acts or to
voluntariness
1. To define the different ethical sciences 7. To judge the imputability of a human act
2. To identify the similarities of the ethical sciences
3. To differentiate the ethical sciences from one HUMAN ACTS
another Actions that proceed from insight into the purpose of
4. To determine the scope of Bioethics one’s doing and from consent of free will

ETHICS VOLUNTARY ACT


That branch of philosophy that studies and draws • perfect – an act performed with full knowledge and
conclusions of the degree of goodness and badness of full consent of the will
human actions and conduct in relation to the purposes of • imperfect – knowledge and/or consent are not full or
human living. lacking
• actual – the act that proceeds from the present
CHRISTIAN ETHICS deliberation of the will
That branch of theology which studies, in the light of • virtual – the act is placed by a previous deliberation
human reason and of Christian Faith, the guidelines man that still persists in its effect
must follow to attain his final goal.
EFFECT OF THE VOLUNTARY ACT
BIOETHICS • Positive – the effect comes from an action that is
Is the systematic study of human conduct in the areas of done (committed)
life sciences and of health care, insofar as that conduct is • Negative – the effect comes from an action that is not
examined from the view point of moral values and done (omitted)
principles • Direct – the effect is intended in itself
• Indirect – the effect is not intended but merely
permitted as the inevitable result of an object directly
willed

1
IGNORANCE Concept:
• Invincible Ignorance – one is not able to • this kind of fear is intellectual fear as distinguished
dispel/remove the ignorance by a reasonable from the fear arising from the senses which is one of
diligence the passions
• Vincible Ignorance – the ignorance can be removed • intellectual fear does not generally escape the control
by reasonable diligence but it is not removed due to of the mind and will
negligence or bad will • generally it leaves the person free
Principles: • the evil that causes the fear may threaten the
1. Invincible Ignorance takes away or prevents the affected person or those associated with him
human act from being voluntary in regard to that
which is not known. So, a human act coming from Principles:
invincible ignorance is not voluntary in its cause. 1. fear does not destroy the voluntary character of an
2. Vincible Ignorance does not take away the action but it usually lessens the merit or guilt
voluntariness but diminishes voluntariness 2. even though an action done out of fear has an
involuntary aspect, it holds that a person does so by a
INATTENTION decision of his will and therefore performs a human
• an actual, momentary privation of knowledge act.
Principles: 3. grave fear – caused by a grave evil which one cannot
1. if a person does not attend at all to what he is doing, easily escape from – usually excuses from the
he does not accomplish a human act. obligations of divine or human laws. The reason for
2. if a person is only half-attending to what he is doing, this is that moral impossibility excuses from the
he performs an imperfect human act. compliance with such laws.

ERROR VIOLENCE
1. the origin of error may be traced from: • a compulsive influence brought to bear upon one
– deficient education against his will by some extrinsic agent
– influence of bad company
– misleading mass media Concept:
• violence is not caused by moral force but only by the
2. man is challenged to overcome the errors and search compulsive force of some physical or psychic agent
for the truth. • while internal resistance of the will is essential for
3. man must be able to reach views based on sound violence, external resistance is not always called for
reasons.
4. man, as an individual, must fight against errors, and Division:
the community must help one another to resist error. • absolute – if the will dissents totally and resists as
best it can and is meaningful
PASSION OR CONCUPISCENCE • relative – if the will dissents only partially or weakly
• a movement of the sensitive appetite which is and is perhaps deficient in its external resistance, too
produced by good or evil apprehended by the
imagination Principles:
Concept: • absolute violence excludes any voluntariness.
• there is no connotation of evil • relative violence does not impair voluntariness
• God has endowed man with these appetites which completely but lessens it
pervade his whole sensitive life
• they are instruments for the self-preservation of the DISPOSITIONS AND HABITS
individual and the whole human race 1. Disposition – an inclination that one has to certain
• passions become evil only if their force is not ways of action and conduct which have their roots in
controlled by reason one’s character an inherited propensities
• man has the urgent duty to check his sensitive 2. Habit –the facility or easiness and readiness of acting
appetites in a certain manner acquired by repeated acts

Division: Principles:
• antecedent – precedes the action of the will and at 1. a deliberately admitted habit does not lessen
the same time induces the will to consent voluntariness, and actions resulting there from are
• consequent - follows the free determination of the voluntary at least in their cause; person is responsible
will and is either freely admitted and consented to or if he consents by free decision to the habit.
deliberately aroused 2. an opposed habit lessens voluntariness and
Principles: sometimes precludes it completely.
1. antecedent passions always lessen voluntariness and
sometimes preclude it completely because it hinders
the reflection of reason and weakens its attention, at NORMS OF MORALITY
the same time, it strongly entices one to action and Objective Norm – Moral Law
entices the will to consent. The more intensive Subjective Norm – Conscience
concupiscence is, the weaker the intellect and will
become. MORAL LAW
2. consequent passions are either good or bad because OBJECTIVES:
they are either freely admitted and consented to or  To identify the objective norm of morality
deliberately aroused. They are voluntary in  To define the different laws
themselves.  To differentiate the different laws from one another
 To explain the nature of moral law
FEAR  To explain the nature of natural law
• the shrinking back of the mind on account of an  To explain the nature of human law
impending evil  To determine and justify the obligations towards the
laws
 To judge a human action according to the moral law

2
LAW aspirations of human nature inclusive of the
- ANY DIRECTIVE OR RULE OF ACTIVITY ultimate end

MORAL LAW “full reality of human nature”


- A DIRECTIVE RULE OF OBLIGATORY, GENERAL, The ends here refer to existential ends, and these
AND STABLE CHARACTER, ORDERING MAN’S are/include:
ACTIVITY TOWARD THE ULTIMATE END. 1. self-preservation which includes bodily integrity and
social respect
DIVISION OF MORAL LAW 2. self-perfection physically and spiritually which
(hierarchical order): includes: a) development of one’s faculties for the
improvement of the conditions of life, and b)
provision for one’s economic welfare by securing the
Divine Law necessary property or income
3. broadening of experience and knowledge
Natural Law 4. procreation and education of children
5. interest in the spiritual and material welfare of one’s
Human Law fellowmen as human persons equal in value
6. social organizations to promote common utility which
consist in the maintenance of peace and order and in
Moral Law Includes: the opportunity for all to attain full human existence
– obligatory demands by sharing proportionately in the welfare of society
– recommendations 7. promotion of cultural progress and creative evolution
– common laws which concern all men or groups of of the world
men 8. the knowledge and worship of God and the ultimate
– personal commands which result from an individual fulfillment of man’s destiny through union with Him
call addressed to an appointed person
– counsels “recognized by man’s reason”
– permission - the medium is reason alone but this does not
exclude the influence of grace.
CHARACTERISTICS OF A GENUINE MORAL LAW: GOOD
and HOLY PROPERTIES OF THE NATURAL LAW
A genuine moral law must be good and holy because the 1. Universality
moral law MUST GUIDE human activity to contribute to 2. Immutability
the REALIZATION OF THE FINAL GOAL of human history 3. indispensability
and of creation and that it should prevent man from
obstructing the attainment of this end. UNIVERSALITY
– the natural law binds all people at all times in all
CHARACTERISTICS OF A GENUINE MORAL LAW: GOOD places
and HOLY – no one is superior to the guidelines which show man
PRINCIPLES: the way
• a norm which does not contribute to the final end has – no one is beyond good and evil
no moral force binding the will. – no one is free from the obligation of fulfilling the duty
• a norm which results in the frustration of the ultimate to obey and abide with this law
good is morally evil and its observance unlawful. – the most universal principle of the natural law is:
GOOD MUST BE DONE AND EVIL MUST BE AVOIDED.
The Moral Law is based on the ORDER OF BEING What is good and worthy of man’s desire?
• Action follows being
1. a thing acts according to its nature. The following are guidelines:
2. the nature of a thing is the cause, while the 1. the golden rule
action is the effect. 2. maintain and promote your bodily and mental life.
3. maintain and promote social coexistence
The Moral Law is based on the ORDER OF BEING 4. give to everyone what is his due
• Application of this axiom to man’s activity
1. man’s moral obligation must be derived IMMUTABILITY
from and measured by the nature of his INDISPENSABILITY
being. – no one is dispensed from the natural law from the
2. God is the ultimate norm of moral law since side of human authority
He created everything. – there may be a suspension of the natural law but
3. the laws emerging from man’s nature have such suspension always demands an expressed
their origin in the Creator’s designs. positive divine revelation
4. the task of Christian Ethics is to recognize
man as he really is in his true nature and HUMAN LAW
with all his essential relations and to derive - IS AN ORDINANCE OF REASON FOR THE
therefrom the moral laws which are to COMMON GOOD, PROMULGATED BY HIM WHO
direct his activity. HAS THE CARE OF THE COMMUNITY.

NATURAL MORAL LAW Reasons for the necessity of human law


- IS THAT MORAL ORDER WHICH ARISES FROM 1. to make clear the requirements of the natural law
THE FULL REALITY OF HUMAN NATURE AND and the divine positive law for everybody
WHICH CAN BE RECOGNIZED BY MAN’S REASON, 2. to enforce obedience at least to those demands of
INDEPENDENT OF POSITIVE DIVINE REVELATION. the moral law which are of greater value for the
- “full reality of human nature” common good.
- spiritual – the effects of Christ’s saving work 3. to determine the moral law more precisely when
- comprises all the ends designed in the physical, several possibilities of fulfilling it are open to men.
psychical and spiritual inclinations and

3
OBJECT OF THE HUMAN LEGISLATION  To demonstrate the obligation towards
 The direct object of human law is the common conscience
welfare/good  To judge a human action according to the dictate
 Human legislation is supposed to create favorable of conscience
conditions for man’s life in the religious, cultural,
social and economic aspects.
 Human legislation has to safeguard the common good
by protecting the moral culture of the community, its
interior peace, security, social justice, and human
rights.

4 conditions that a regulation may become the object of


a law
1. the content of the law must be morally permitted.
2. the content of the law must be just
– the lawgiver must not go beyond his jurisdiction
– the law must not restrict the rights of the
subjects
– the law must distribute burdens and privileges The Concept of Conscience:
equally and according to the capacities of the  It is not a theoretical or scientific knowledge of moral
subjects values and of good and evil, but
– new penal laws cannot be extended to past  It shows to man what his nature is and what the
actions divine Spirit requires of him as his personal obligation
3. the law must be physically and morally possible. and then leads him to perceive the binding force of
– the law must be within the forces and means of these requirements.
a person  In most cases, the judgment of conscience is not
– the command of the law can be done with no reflexive but spontaneous. The judgment of
great difficulty conscience is expressly reflected upon especially in
4. the law must be useful and of benefit for the instances of doubt, or of resistance and disobedience
common good to the dictates of conscience.
 It concerns a person’s concrete action in a concrete
MORAL OBLIGATION TOWARDS THE LAW: situation.
PRINCIPLES:  It formulates general moral principles concerning the
1. on the nature and gravity of the moral obligation morality of human actions in the abstract without
– just laws bind in conscience by reason of their relation to the concrete activity of a person here and
intrinsic necessity and justice now.
– anyone who violates a just law is in conscience
bound to submit to a just punishment The Dictate of conscience Contains 2 Elements:
– a punishment is just if it measures up to the  the judgment on the morality of a concrete action
importance of the law for the common welfare which a person intends to perform or has performed,
2. on the extent of the moral obligation and
– the subject has the moral obligation to acquire  the command and obligation that what is recognized
by sufficient means a knowledge of the law as good must be done and what is recognized as evil
– the subject is obliged to use the ordinary means must be avoided. The obligation is categorical. It is
which are absolutely necessary for the not only right to follow it, it is obligatory to do so.
observance of the law
– the subject is bound to remove or anticipate Antecedent Conscience
obstacles which make the observance of the law - the judgment on the morality of an action and
proximately impossible, if this can be done the obligation to perform it or omit it is passed
without great inconvenience before the action is done. This conscience
commands, exhorts, permits or forbids.
CESSATION Consequent Conscience
1. of the obligation towards the law: - evaluates a deed already done or omitted. This
– when one ceases to be subject of the law conscience approves, excuses, reproves or
– when one is invincibly ignorant of the law accuses.
– when there is a physical impossibility
– when there is a moral impossibility Right Conscience
– a dispensation - the moral judgment agrees with the objective
– a privilege norm of morality
2. of the law: Erroneous Conscience
– through the act of a legislator or through - the moral judgment disagrees with the objective
contrary customs norm of morality. This can be:
– a new law abrogates a former law if it expressly
states it, or if it is directly contrary to the old law a. vincibly erroneous – it dawns on man that his
– the purpose of the law ceases to exist moral outlook might not be entirely sound or he
is aware of being careless and irresponsible in his
CONSCIENCE decision
Conscience judges on the morality of a concrete action b. invincibly erroneous – the person has no
commanding to do what is good and to avoid what is evil awareness of the possibility of error

OBJECTIVES: Other Kinds of Erroneous Conscience:


 To identify the subjective norm of morality 1. Perplexed
 To describe what is conscience 2. Lax
 To distinguish the division of conscience 3. Scrupulous
 To identify the kinds of conscience

4
Perplexed  Aware Lax
- when confronted with two alternative precepts, 3. MUST NOT BE OBEYED UNTIL SOME CLARIFICATION IS
it fears sin in whatever choice it makes. This is a OBTAINED, BUT ONE MAY ACT IF CLARIFICATION
disturbed conscience. There is a disturbance of CANNOT BE OBTAINED AND THE DECISION HAS TO BE
the capacity to form a judgment MAKE IMMEDIATELY:
 Vincibly Erroneous
Lax  Perplexed
- judges a thing to be lawful when it is actually  Doubtful
unlawful, moral when actually immoral, light or
venial sin when actually serious or mortal sin. FREEDOM OF CONSCIENCE
- There is a strict obligation to follow one’s certain
Scrupulous conscience; correspondingly, one has the right to
- judges something to be sinful when actually it is act according to one’s conscience.
not, or something to be grievous or moral when - The restrictions of the freedom of conscience is
actually light or venial when it happens that the dictate of conscience
runs in conflict with the demands of the
Certain Conscience common welfare.
- passes judgment without fear or error
Doubtful Conscience SOURCES OF MORALITY
- uncertain concerning the morality of an action OBJECTIVES:
1. To explain the meaning of “sources of morality”
WE MUST HAVE A RIGHT AND DELICATE (SENSITIVE) 2. To enumerate the sources of morality
CONSCIENCE PRESERVING OURSELVES INTACT WITH 3. To explain each of the sources of morality
CLEAR AND VIGILANT DISCERNMENT OF THE GOOD AND 4. To determine how the elements affect the morality of
EVIL. a human act
5. To judge a human act according to the sources of
The VINCIBLY ERRONEOUS CONSCIENCE morality
Before a person with this kind of conscience may act:
1. he must remove his erroneous state by SOURCES OF MORALITY
searching the truth; if this is not possible Sources defining the morality of human acts
because he is unable to do so, - these are the elements in the human act which
2. He must postpone the action; if the action determine its morality. These elements are
cannot be postponed, called sources of the morality of human acts
3. He must follow the safer line of action. because the human act derives its morality from
their agreement or disagreement with the moral
THE PERPLEXED CONSCIENCE norm.
The line of actions to be taken is:
1. if the decision can be delayed, postpone the action to These sources are:
obtain information and deliberate; if the decision OBJECT
cannot be postponed, CIRCUMSTANCES
2. One must choose what appears to be the lesser evil; if INTENTION
still this is impossible to settle/do,
3. Either of the alternatives may be done OBJECT
Principles: - Object of the human act is the effect which an
1. If this line of action is observed, there is no formal sin action primarily and directly causes. It is always
because it is impossible for the person to escape both and necessarily the result of the act,
alternatives of the perplexing situation; independent of the circumstances or of the
2. If this line of action is not observed, the person may intention. It is generally regarded as the primary
be guilty of formal sin because nothing was done to source for the judgment on the morality of an
correct the error. act.

The DOUBTFUL CONSCIENCE Effect of the Human Act is:


the line of actions to be done: 1. the physical, biological changes which an act brings
1. the action must be postponed until certainty is about;
reached; If the doubt cannot be solved directly, 2. The impact of the act on rights and claims of persons,
2. one may make a presumption whether of other persons or of the agent himself, and
the changes the act brings about in this sphere.
PRESUMPTION - a conjecture where the GREATER RIGHT
COMMONLY LIES and the lesser injustice is to be feared To determine the OBJECT of a specific action:
1. look into the matter the act is concerned with and the
REFLEX PRINCIPLES WHERE PRESUMPTION STANDS existing rights and claims of persons to this matter;
1. In doubt, presumption stands on the side of the 2. Define the changes which are to be brought about
superior. primarily and directly.
2. In doubt, stand for the validity of the act.
3. In doubt, amplify the favorable and restrict the CIRCUMSTANCES
unfavorable. - These are the particulars of the concrete human
4. In doubt, presumption stands for the usual and the act which are not necessarily connected with its
ordinary. object,
These CIRCUMSTANCES are:
BINDING FORCE OF CONSCIENCE WHO
1. MUST BE OBEYED: WHAT
 Certain WHERE
 Invicibly Erroneous WITH WHAT MEANS
 Right WHY
 Unaware Lax HOW
2. MUST NOT BE OBEYED: WHEN
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The CIRCUMSTANCES can alter the morality of human acts CARDINAL VIRTUES:
for better or for worse. They can influence the morality of - considered as “hinges” on which the whole
a human act. moral life turns

INTENTION / END PRUDENCE


- This is the reason for which the agent - disposes a man to discern correctly what
undertakes an act. The agent performs the measures he must take to realize the exigencies
action for the sake of this end/intention which of a virtue in concrete circumstances
he expects to achieve. JUSTICE
- The INTENTION/END can modify the morality of - to give what is due
an act in similar ways as circumstances do. FORTITUDE
- courage to stand/defend what one believes
VIRTUE TEMPERANCE
- A habit that gives both the inclination and the - gentleness; benevolence; moderation
power to do readily what is morally good.
VIRTUE IN MEDICAL ETHICS
OBJECTIVES: Virtue as lived morality or a lived dimension of morality,
1. To define virtue refers to a gathering of personal motives, feelings and
2. To explain the concept of virtue dispositions for a consistent lived expression of a virtue.
3. To specify the fundamental requirements for virtue “Becoming A Good Doctor”
4. To define, enumerate and explain the meaning of the by James F. Drane
requirements of the theological virtues p. 157
5. To define, enumerate and explain the meaning and Virtue is the personal appropriation of values made with
requirements of the cardinal virtues the help of reason
6. To apply the concept of virtue in medical practice
7. To enumerate and explain the meaning of the virtues Ibid., p. 164
of a physician
VIRTUE OF BENEVOLENCE
Connected with diagnosis and prognosis
- it is the character trait which disposes the doctor
to carry out beneficent acts
- It refers to the commitment or will to carry out
medical acts according to the highest ethical
standards
- It refers to wishing a patient well or being
disposed to attend to the patient’s needs

VIRTUE OF TRUTHFULNESS
Fundamental Requirements for Virtue Connected with medical communication
1. moral knowledge - it is the disposition to tell the truth, not only
– some insight and knowledge of the value it once but several times over;
endeavors to realize - The habit of telling the truth even when it is not
– education, instructions, formation convenient or does not serve a personal
2. prudence convenience;
– cautious deliberation - It disposes the doctor to prepare patients for full
– to look carefully into the concrete circumstances participation in decision-making regarding their
3. love of moral value own lives
– the beauty and goodness of the moral value
must be deeply sensed and truly loved VIRTUE OF RESPECT
– deepening and faithful pursuance of the right Connected with decision-making
fundamental option - it is the trained attitude or disposition to
4. dominion over the passions reverence those free acts by which patients carry
– moderating restraint out their best interests
- It disposes the doctor to handle differences with
Theological Virtues: the patient with sensitivity, avoiding deceit or
• Faith manipulation
• Hope
• Charity VIRTUE OF FRIENDLINESS
Connected with inevitability of feelings; affective
Theological Virtue - God is the dimension
 immediate object - there is pleasure in one another’s company,
confidences are shared, and there is an
LOVE / CHARITY exchange of benefits;
- is the most exalted, the most fundamental and - Feelings are shared and intimacies revealed
universal of all virtues appropriate only within this relationship

 can co-exist with: Affectionate relationship - controlling personal hostility


o failures that result from weaknesses: Understanding - looking beyond the patient’s acts, words
wrong attitudes which result from and behavior and seeing the interior world of thoughts
deficient insight into the real demands and feelings
of the moral value Forgiving
 cannot co-exist with:
o bad habit;
o fully deliberate adherence to a serious
vice
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VIRTUE OF RELIGION 3. Co-relate this principle with sanctity and inviolability
Connected with the idea that doctors are priests of life
- Reflection on the awesome dimensions of his 4. To determine the scope of reference of human
work dignity
- Recognition of what is “transcendent” in the 5. To explain respect for human dignity in the
patient (the mystery of life) dimensions of personhood
- Commitment to serving patients struggling with 6. To apply the principle in given cases/situations
life’s meaning 7. To judge the violation or non-violation of the principle
- Treating the patient as Christ would in given cases.
- “Other” - directed; the “other” is the patient
- It keeps doctors from confusing themselves with HUMAN DIGNITY
God, and from falling into the temptation of The dignity of the human person is the STRUCTURAL
moral self-righteousness NUCLEUS OF ETHICS
- It is the reality of God that keeps creatures
aware of “their place”.  In the sense that moral life is basically the
actualization of what it means to be a person in
FUNDAMENTAL BIOETHICAL PRINCIPLES relation to other persons and sentient beings.
1. Sanctity and Inviolability of Life  RESPECT for the dignity of all persons and each
2. Human Dignity person is the necessary condition for all morally good
3. Autonomy attitudes and acts.
4. Stewardship and Accountability
5. Totality BASES OF THE DIGNITY OF THE HUMAN PERSON
1. Every human person is crated in His image and
SANCTITY AND INVIOLABILITY OF HUMAN LIFE likeness.
OBJECTIVES: 2. Every human person is endowed with intelligence to
1. To explain the meaning of the principle of know and a free will to decide/choose.
sanctity and inviolability of human life 3. The creation of the human soul is a direct action of
2. To evaluate the bases for this principle God.
3. To formulate the general rule system bearing on 4. Every human person is called into existence in
the sanctity and inviolability of human life relation to God.
4. To apply the principle in given cases or situations 5. Each human person is unique and irreplaceable.
5. To judge violation or non-violation of the 6. Each human person is called to maturity and eternal
principle in given cases. life.

SANCTITY OF LIFE SCOPE OF REFERENCE OF HUMAN DIGNITY


- Interpreted as to mean that each individual, Respect for the dignity of the human person should be:
regardless of the state of health, is not to be 1. Concrete
used as means, and is to be treated with dignity 2. Universal
because he is valuable. 3. Egalitarian
4. Absolute
 Life is holy because God is the origin of life and 5. Partisan in favor of those who suffer from
the ultimate guarantor of the sanctity of human dehumanizing situations
life;
 Because man’s life comes from God he belongs Respect for the dignity of the human person should be:
directly and exclusively to Him; CONCRETE
 One must respect one’s own life and the life of  In the sense that it refers not to abstract
others not only because of this; human nature, but to concrete and actual
 Because of man’s eternal destiny human beings immersed in complexed and
conflictive historical realities
HUMAN LIFE UNIVERSAL
- the fundamental ethical value  that it applies to all persons, going beyond
MORAL INTEGRITY geographical and political boundaries
- the absolute ethical value EGALITARIAN
 In that it affirms the equality of all human
General Rule System Bearing on the Sanctity of Life persons in dignity, rejecting all
1. Survival and integrity of the human species – discrimination, whether this be based on
man ought to work towards his own survival race, religion, sex, ideology, generation,
2. Survival and integrity of family lineage social class or any other arbitrary criterion
3. Integrity of bodily life – the basic right to life ABSOLUTE
4. Integrity of personal, mental and emotional  Because it is inherent in human persons
individuality – the right to be oneself precisely as persons, and not for what they
5. Integrity of personal bodily individuality – possess, nor for what they can give, nor for their
integrity of the human body physical, intellectual and social capabilities, but
for what they are --- persons
CONCLUSION: Man’s life is holy because it comes  The human person is valuable most of all
from God and has an eternal because he is a person; he is an end in himself
destiny. and should never be used or manipulated as a
mere means for another end
INVIOLABILITY OF LIFE PARTISAN IN FAVOR OF THOSE WHO
Because life is holy it cannot be violated SUFFER FROM DEHUMANIZING SITUATIONS
 in the sense that it has a preferential option in
HUMAN DIGNITY practice in favor of the liberation of those
OBJECTIVES: human beings whose humanity has been
1. To explain the meaning of the principle of human disfigured by dehumanizing situations – the
dignity oppressed, the destitute and other marginalized
2. To evaluate the bases for this principle persons
7
 Actions performed that constrain a person’s
Human dignity capacity to act according to his decision
 entails respecting the human person in all the
concrete dimensions of his personhood: NON-VIOLATIONS OF THE PRINCIPLE OF AUTONOMY
1. his / her corporeity  When a person expresses his autonomous wish
2. his / her social nature to waive consent or delegate authority to others.
3. his / her reason and liberty The physician’s delegated prerogative refers to
the authority of a physician over his patient as
CORPOREITY an authority delegated to him by the patient
- Human beings exist corporeally. The biological  When respecting a person’s autonomy competes
bodies and the bases for their human with other moral principles
consciousness, and thus for their personhood,
and so participate in the dignity of the human THE ROLE OF THE HEALTH PROFESSIONAL
person The health professional should help the patient make
his/her autonomous choice and act on it by:
Social Nature
- Human persons are by nature social; they live  providing him/her with the information
together and interact with other persons in necessary to weigh the reason for his/her
society. opinion;
- Within society, the rights and responsibilities of  stating his/her own convictions and clearly
persons should be recognized, and as persons explaining the reason for this opinion;
they should be active participants in social and  not exercising coercion, manipulation, undue
cultural life in a relation of equality with other influence, or irrational persuasions;
persons.  respecting the patient’s autonomous choice;
 withdrawing from the case and helping the
REASON AND LIBERTY patient find another health professional who
- Human persons are characterized by reason and might be more successful in these particular
liberty, and are thus called to realize themselves situations when the health professional thinks it
responsibly as persons. is impossible to help the patient.
- They should be active and responsible subjects
of their own lives. STEWARDSHIP/ACCOUNTABILITY
- Consequently, they have a right to access to Man is not the independent lord of his life but only a
information that affects them. steward subject to the sovereignty of God, and he is
- Liberty of human persons must be respected as responsible for it because he is accountable to God. Man’s
long as its exercise does not violate/injure the bodily life is entrusted to his freedom
rights of other persons.
STEWARDHIP AND ACCOUNTABILITY
AUTONOMY OBJECTIVES:
One has the moral right to choose and follow one’s own 1. To explain the meaning the principle of
plan of life stewardship and accountability
2. To analyze man’s responsibility
OBJECTIVES: 3. To detect dangers and risks
1. To explain the meaning of the principle of autonomy 4. To distinguish different kinds of prerogatives
2. To describe the assets of autonomy 5. To determine the moral obligations in
3. To identify the role of the health professional in prerogatives
helping the patient make an autonomous choice 6. To co-relate this principle with human dignity
4. To co-relate this principle with the principle of 7. To apply the principle in given cases/situations
stewardship 8. To judge the violation and non-violation of the
5. To apply the principle in given cases/situations principle in a given case
6. To judge the violations and no-violation of the
principle in given cases. STEWARDSHIP
 Man is accountable in the way he uses his
IMPLICATIONS OF AUTONOMY autonomy/freedom and in the way he respects
1. This does not mean absolute freedom to do anything and maintains his own (and that of others’)
as one wishes; dignity.
2. To act morally, man still has to follow the guidelines  (Prudent) stewardship means seeing that the
of moral law and conscience; powers entrusted to people are gifts and that
3. One has a right to determine what will be done to the true meaning of these powers is to be found
him; in respecting the dignity of everyone and
4. One has a duty not to constrain another’s everything.
autonomous choices and actions;  Man must use his freedom responsibly, in
5. Human beings should be treated with dignity; conformity with the ends which are set forth by
6. Human beings should be allowed to make decisions the inclination of his own nature as a rational
for themselves. being.

POSITIVE ASSETS OF AUTONOMY DANGERS AND RISKS


1. Autonomy enhances a person’s worth and self-image  Earthly life lies constantly exposed to many
2. It protects a person from being used or abused by dangers. But human life is altogether impossible
others without a free risk of bodily loss in the quest for
3. In health care it develops a mature therapeutic life’s meaning. Excessive concern about bodily
alliance between health care professional and risks is not acceptable.
patient.  It is a matter of weighing values or ideals, and a
question of prudence;
VIOLATIONS OF THE PRINCIPLE OF AUTONOMY  The expected benefit must be proportionate to
 Actions performed that constrain a person’s the risk. The greater the love with which man
capacity to make a decision; risks his life, and the higher the service rendered
8
for the common good or for a particular
fellowman, the purer is the witness to faith,
hope and love, and so the more justifiable the
risk.

Absolute Prerogative
- One is said to have ABSOLUTE PREROGATIVE in a thing
when it is essentially subordinated to one’s final end, and
has become the object of one’s lawful rights.

Prerogative “for use”


- That restricted power which a man has, whereby he has
some right to use the thing, but with certain restriction,
which are imposed by the higher rights of others.

Delegated Prerogative
 Is the authority or power given by the patient to
his doctor by virtue of the patient’s right and
obligation as an individual to preserve his health
and bodily integrity.

Prerogative in Human Life


1. Man has, at most, only a “prerogative for use”
over human life
2. Absolute prerogative in human life is an
exclusively divine prerogative

TOTALITY
OBJECTIVES:
1. To explain the meaning of the principle of
totality
2. To determine the scope of the principle
3. To co-relate this principle with the principles of
the human dignity, stewardship and autonomy
4. To apply this principle to given cases/situation
5. To judge the violations and non-violations of this
principle in a given case

PRINCIPLE OF TOTALITY
The principle states that all the parts of the human body as
parts, are meant to exist and function for the good of the
whole body, and are thus naturally subordinated to the
good of the whole body

Implications of the
Principle of Totality
 When some part or function becomes
detrimental to the good of the whole body, it is
in accord with right order to remove such a part
or to suppress its function;
 Justified mutilation is limited or has restrictions

9
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SY 2011-2012
Subject: Bioethics
Topic: Beneficience
Lecturer: Dr. Melchor Vrias
Date of Lecture: 29 July 2011
Transcriptionist: Gluttinoids
Pages: 3

BENEFICENCE  You would need other to ask help from


 One has the obligation to help others further other physicians.
their important and legitimate interests.  Referral is also an obligation of the
 The term beneficence refers to actions that physician
promote the wellbeing of others. In the medical
context, this means taking actions that serve the 3. The state of the art in a given area as well as the
best interests of patients. availability of state of the art tools.
 One of the obligations of the physician and other  Limited by equipment and facilities
health care professionals is TO DO GOOD and to  If assigned in a barrio, there are limitations
do everything to benefit the patient in terms of diagnostic test a physician can
 Not absolutely good, there are some risks in request as well as th availability of
every procedure that are unavoidable medications
 Always do good as a physician
4. One’s obligation to avoid evil
Implications of Beneficence
 Sometimes we cannot avoid evil in the
1. There is an obligation to confer benefits that is, course of the treatment
doing or promoting good, and actively to prevent o Ex: Adverse effects of drugs are
and remove harm or evil. inevitable, but the drug is necessary
 The physician should be able to identify and will do more good than harm
both the benefits and harm that could be  The physician must inform the patient or
brought about by the the significant other about the risks (both
procedure/treatment known and unknown risk)
 The treatment should be more beneficial
than harmful to the patient.
Beneficence
 As a student, we should be mindful for we
have all the preparations, to be able to  Doing good and avoiding evil is NOT simply a
discern in the future what is good and question of principles but of practical wisdom of
what is harmful. knowledge, skills, and common sense weighing
the relevant aspects of the factual and social
2. There is an obligation to weigh and balance the situation as well as the concrete meaning of
possible good against the possible harm. human dignity in a particular time and space
 There is always a certain degree of harm in  You have to weight certain aspects, such as the
every procedure you perform in your patients social situations, how the treatment
patient. affects the relatives, the patient per se and the
 Make sure that the benefits outweighs the meaning of his dignity in a particular time and
harm place
 Recommend something that is better or  In doing good, consider the dignity of the
more beneficent patient.
 Always treat patient as a Human Being
The impossibility of doing all good - this arises from o E.g: In a brain dead patient, the relatives
limitations of: may say to continue treatment.. But the
doctor must explain that continuing with
1. The nature of time and space the treatment can be harmful.
 Doctors hold many clinics and manages
many patients in different places and
SPECIFICATION OF BENEFICIENCE
hospitals
 Distance limitation – the physician will not  The things necessary for the person to remain
be able to attend a patient may be if he is at human and maintain dignity are the top of the
home or at different place list of goods to be done.
 It would be more important for the patient
2. One’s own limitations. to die with dignity especially in terminal
 Limitations of a physician depends on the cases. For instance, they would rather die at
physician's expertise or specialization. home than stay in the hospital.

1
patients, in this case the employees, as
indicated by the company
Limits of Specification
1. Talent PATIENT’S GOOD
 It is a matter of situations in which the effort  Take the following into consideraration because
to do good/better or to preserve the good patients use one or combination of these goods
may conflict with the good of other human in making a decision:
beings
o As physicians, sometimes you really want
1. The Ultimate Good
to do good, but keep in mind that the
patient and his relatives have the right to  The meaning and destiny of human existence;
choose, this includes their choice to  The positions taken with reference to
refuse the treatment. relationships with other human beings, the
o So no matter how much you want to do world and God;
good, the obligation to do good is over  The “ultimate concern” – the one to which we
ridden when the patient or the relatives turn for final justification of our acts if all
doesn’t want to continue with the secondary or intermediate reasons fail
treatment.  If the other good fail this would be our last
o Betterment of Patient < Betterment of resort, to turn to our Creator.
the Family  This value supersedes the biomedical good and
the patient’s view of his own good
- Ex. when treatment is expensive &
would bankrupt the patient’s family
– patient forgoes treatment) 2. The Biomedical Good
 The good that can be achieved by medical
 There is tension between respecting freedom intervention into a particular disease state;
and securing what a health care professional
 The statement of what can be achieved based on
may consider the best interests of the patient.
strictly scientific and technical assessment
o Medical benificence can come in conflict
 Ultimate good supercedes the medical good
with the autonomy of the patient.
 The good that is usually used by health care
o You may know what is best for the
professionals
patient, but the patient's autonomy
o The biomedical good is the basis of the
dictates that he doesn't want to continue
physicians on why a patient should follow
with the treatment.
the decisions of the physician
o Autonomy of the patient shall prevail,
given that the patient is competent.
3. The Patient’s View of his Own Good: His Best
Interest
2. Most goods that we have to do are specified by:
 The patient’s subjective assessment of the
a. Law
quality of life the intervention might produce;
 Law: patient’s right
 Whether of not this quality of life is consistent
 Law of child’s abuse – Doctors are with the patient’s life plan and goals;
required to report child abuse.
 The patient’s life plan is highly personal
b. Custom  The choices that are to be made according to his
 Some customs and principles limit your life plan may run counter to biomedical good or
obligation to do good what the physician thinks is a good life for the
o Custom includes tawas, can't take a patient.
bath during menstrual periods.  The initial good the patient use
o Religion – Cannot do blood  If an information is disclosed, this good is used
transfusion on Jehova’s witnesses; when the patient is making a decision.
one religion forbid medical  If the probable result of the treatment is in
intervention conflict with the patient's life plan and goals, the
c. Relationship and Roles patient may not adhere with the treatment.
 doctor-patient relationship, patient-
relative relationship, patient-spouse 4. The Good of the Patient as a Human Person
relationship can be limiting  The good that is grounded in his capacity as a
d. Agreements human person to reason, to choose and to
 Agreements like contracts. express those choices in speech with other
 Example, company physicians are limited humans;
by the fact that they should disclose  Freedom to choose
certain information regarding his  This value supersedes the biomedical good and
the patient’s view of his own good

2
PATERNALISM sometimes competent, sometimes not) you
 Involves acting without consent. Or even over- may constrain them by giving sedative to
riding the patient’s wishes, wants or actions, in calm them and make them competent
order to benefit the patient or at least to prevent
harm to the patient 2. If the Health care professional overrules the
 Physicians used this principle before patient for the convenience or profit of the
 Physicians can overlook the autonomy and rights provider
of the patient.  Example: Like nurses in a hurry in shifting
and give a drug immediately, some drugs
Two (2) Elements of Paternalis are painful when administered in fast rate,
1. The absence of consent or over-riding of consent it's not paternalism because the provider
2. The beneficent motive has other obligation to do and not to give
care and compassion to the patient, this is
 The welfare of the patient
inhumane at times.

Types of Paternalism
3. If the health care professionals refuses to go
1. Strong Paternalism along with the patient’s wishes because these
 Also called extended paternalism wishes are against the conscience or professional
 The health care provider attempts to standard of the provider, and vice versa.
override the wishes of a competent person  If the patient has the right to refuse
treatment, the physician also has right to
2. Weak Paternalism refuse a patient.
 Also called limited or restricted paternalism  This occurs when the patient is non-
 Consent is missing or the health care compliant because he/she doubts the
provider overrules or overrides the wishes of physician as a competent professional.
an incompetent or a doubtfully competent  This doesn't apply in emergency cases
patient. though, a physician can't refuse a patient in
 Doubtfully competent patient: alcohol/ drug an emergency case
intoxicated patient, in sedatives, effect of
illness ( high-grade fever, depression)
 Sometimes called cooperative paternalism Paternalism is justified:
when one of its purposes is to restore the 1. If the harm is prevented from occurring or the
person’s competence so that the patient benefits provided to the patient outweigh the
may give informed consent. loss of independence and the sense of invasion
 Example: Over-ride by giving IV fluid and IV caused by the interference.
antipyretic to lower the fever making the 2. If the person's condition seriously limits his/her
patient competent again and making them ability to choose autonomously.
capable to make competent decisions 3. If the interference is universally justified under
relevantly similar circumstances.
Strong paternalism is ethically rejected if:  Example: sedatives can be given to violent
 The competence of an individual to make patients, restraining restless patient (tied to
decisions for another competent individual railings), this is universally justified and may
would require both knowledge of the other do without the consent of the patient
person’s values and of all the factors influencing
their lives. Rule of thumb involving Paternalism:
 Health care professionals do not have the right  Decisions about health, life and death are not
to enforce value and judgments to the patients merely medical decisions but involve the good of
on the grounds that the “doctor knows best” the society and the good of third parties, as well
 It would be a rare health care professional who as the values of the patient.
knew all the factors influencing the life of the  Consider that it is not only the physician who
patient. decides, also consider the value and situation of
- Unless the patient tells you “bahala ka na the patient (socially, emotionally...)
Doktor”. However, you still need to inform the
patient.
End of Transcription

It is NOT Paternalism
1. When the health care provider acts to prevent
"Your life is the manifestation of your dream; it is an art. And you
the patient from causing serious injury to others. can change your life anytime if you aren't enjoying the dream.
 Ex: psych patients, though incompetent Dream masters create a masterpiece of life; they control the dream
(especially waning patients,who are by making choices.”

3
SY 2011-2012
Subject: Bioethics
Topic: Cooperation
Lecturer: Dr. Melchor V. G. Frias
Date of Lecture: September 9, 2011
Transcriptionist: Polkadots
Pages: 2

Cooperation person.
• Any physical or moral concurrence with a • Almost always sinful or immoral.
principal agent in a sinful deed. (principal agent: • If the surgeon and the assistant are both
attending physician) engaged in actually aborting the fetus, the
* In Medicine, unlike in other circumstances, cooperation cooperation of the assistant is said to be
means a negative thing. immediate material cooperation.
• The participation of more than one person in • Usually translates into formal cooperation.
the same immoral or criminal action. * exception: when one is being threatened, such as when
• Circumstances may arise in which a man is the action is done at gun point or in resident training,
associated, to a greater or lesser degree, with when threatened of training termination (in this case you
someone else in a situation which is contrary to can refuse and report about the threatening to the
right order. administration)
• Depends on the degree of participation in the
medical practice 2.2 Mediate Material Cooperation
• When one provides means and other help for
Types of Cooperation the sinful deed or evil act without joining the
1. Formal Cooperation evil act itself.
• When one externally concurs in the sinful deed • Concurrence in the sinful action of another not,
of another and at the same time internally however, in such a way that one actually does
consents to it. the act with the other or concurs in the evil
• When one takes part in the immoral action of intention of the other but, while merely doing
another while at the same time adopting the something which is good or indifferent in itself,
evil intention of his associate. the action also supplies an occasion of sin to
• If the intention of the anesthetist is the same as another, i.e. supplies some assistance, means,
that of the surgeon in an illicit operation (e.g. or preparation for the sinful action of another.
contraceptive sterilization), the cooperation of *Example: a circulating nurse who prepares the
the anesthetist is called formal cooperation. equipment and facilities for surgery--she is just doing
* one internally consents to and physically agrees to her job, which is good/indifferent in itself. I this case,
do the action the gravity of her participation is less than the people
actually involved, eg, the2nd assistant (junior intern)
• Always wrong, sinful or immoral
who did the retraction, but greater than for example,
• The cooperator is equally guilty with the
the institutional worker who just wheeled in the
principal agent.
patient to the OR.
• The morality of mediate material cooperation is
2. Material Cooperation
to be sought using the principle of double
• When one externally concurs in the sinful deed
effect:
of another without internally consenting to it.
1. Good effect-- one’s own freedom of action, plus
• Generally illicit, since the evil of sin should not the value of doing this or that action not wrong in itself.
be supported by any means, but on the 2. Evil effect -- usually has a double aspect: (1) one’s
contrary, opposed and suppressed action constitutes an occasion of sin for someone else;
* Participation in a situation such as when one is forced (2) there may be some evil coming upon a third party
to do the action or one didn’t actually know what was
(patient) as a result of the action.
being done (ergo, without intention). However, if you
know that an act is wrong, you should refuse to do it
Norms for Material Cooperation
because even if you refuse, your practice should not be
threatened. • Permissible if 2 conditions are verified:
2 types of Material Cooperation 1. The act by which cooperation is rendered may
2.1 Immediate Material Cooperation not be sinful in itself.
• When one concurs in the sinful deed or evil act 2. There should be a sufficient cause for granting
itself. an assistance which is to serve an evil purpose.
*For the circulating nurse, she is just doing his/her job
• When one person actually performs the
and doing her job is not wrong in itself. Also, she may not
immoral action in cooperation with another

1
be aware that an illicit operation (e.g. abortion) will be
done.
• In estimating the sufficiency of the reason for
material cooperation, consider:
1. The gravity of the other’s sin.
* abortion vs. contraceptive surgery
2. The closeness of the cooperation to the sinful
act. (proximate or remote)
* proximate: assisting resident vs. junior intern
vs. circulating nurse
remote : do not actually participate on the
action but provide some help for fulfillment of
procedure
3. The indispensability of the cooperation.
(necessary or unnecessary)
* for example: retraction during the surgical
procedure by junior intern --the surgery can be
done without that help.
4. One’s obligation to prevent the wrong-doing
* if the action is wrong, the obligation of the
doctor to prevent the wrongdoing is higher than
that of the nurse

2
BIOETHICS)II) !
!
TOPIC:!CONFIDENTIALITY! !
! !
OBJECTIVES:! " Sometimes!the!harm!that!comes!
! Explain!the!aim,!meaning!and!implications!of! from!concealing!a!natural!secret!
Confidentiality,! outweighs!the!harm!that!is!being!
! Differentiate!the!types!of!Obligatory!Secrets,! avoided.!
! Explain!the!exceptions!to!Confidentiality,! !
! Apply!the!principle!in!given!situations,! PROMISED)SECRET)
! Judge!what!is!ethically/unethically! ! Knowledge)that)has)been)promised)to)
acceptable!as!the!principle!is!applied!in!given! be)concealed.)
situations! " Generally,!the!promise!has!been!
! exacted!because!the!matter!is!also!
Fundamental)aim:! a!natural!secret.!
! To!foster!communication!of!important,! " The!evil!of!revealing!the!secret!
sometimes!intimate!information!which!will! arises!from!the!harmful!effects!of!
help!a!health!care!professional!aid!a!patient.! breaking!promises.!
! To!foster!trust!in!the!physicianKpatient! " The!secret!may!be!revealed!if!the!
relationship.! good!to!be!attained!offsets!the!evil!
" Excludes!unauthorized!persons!from! that!results.!
gaining!access!to!patient!information! !
" Requires!persons!who!have!such! PROFESSIONAL)SECRET)
information!legitimately!refrain!from! ! Knowledge)which,)if)revealed,)will)
communicating!it!to!others! harm)not)only)the)professional’s)client,)
! but)will)do)serious)harm)to)the)
If)confidentiality)is)broken,)relationships)are)at) profession)and)to)the)society)which)
stake:) depends)on)that)profession)for)
! PatientKphysician! important)services.)
! Patient!&!all!other!healthcare!providers! " The!consequences!should!patients!
! Reputation!of!physician!in!community! lose!faith!in!the!confidentiality!of!
! Physician!&!other!patients! their!dealings!with!the!health!care!
) system!can!be!very!harmful.!
If)confidentiality)is)broken,)the)following)could) " The!condition!of!the!patient’s!body!
be)threatened:) is!private!and!is!shared!only!with!
! Privacy! those!he!chooses!to!help!him,!but!
! Personal!autonomy! not!with!anyone!else.!
! Decision!making!process!for!physician!and! )
patients! " There!is!an!implied!
! Patient’s!responsibility!for!his!own!health! promise!to!keep!the!
! Public!health!values) ) secret!by!virtue!of!the!
) profession.!
Confidentiality)is)concerned)with)keeping) !
secrets:) Exceptions)to)confidentiality)
! Secret)–!knowledge!which!a!person!has!a! ! Those!commanded!by!statute!
right!or!obligation!to!conceal! law!
! The!obligation!to!keep!secrets!arises!from!the! ! Those!arising!from!legal!
fact!that!harm!will!follow!if!the!knowledge!is! precedent!
revealed.! ! ! Those!arising!from!a!particular!
) patientKprovider!relationship!
Three)types)of)Obligatory)Secrets:) ! Those!due!to!proportionate!
! Natural!Secret! reasons)
! Promised!Secret! !
! Professional!Secret! *********************************************!
! NMMAIKBATCH!2016!
NATURAL)SECRET) )
! The)information)involved)is)by)its)nature) )
harmful)if)revealed) )
" There!is!obligation!to!avoid!harming! )
others!unless!there!is!proportionate!)
reason!for!risking!or!permitting!the! )
harm.! )
! !
! !
!

!
BIOETHICS)II) !
!
TOPIC:!ETHICS!IN!RESEARCH! !
! !
OUTLINE:)! " Justice)!
I.)ETHICS)IN)RESEARCH)! # Requires!that!cases!considered!
! General!Ethical!Guidelines!! to!be!alike!be!treated!alike,!and!
! General!Bioethical!Principles!! that!cases!considered!to!be!
! Basic!Elements!of!Research!Ethics!! different!be!treated!in!ways!that!
! Ensuring!Quality!Ethical!Research!! acknowledge!the!difference!!
! Ethical!Considerations!in!a!Research/Study! !!
Protocol!! ELEMENTS)OF)RESEARCH)ETHICS)!
! Authorship!! ! Informed)Consent)!
" For!all!biomedical!research!
II.)ETHICAL)BREACHES)IN)SCIENTIFIC)RESEARCH)!
involving!humans,!there!must!be!a!
! Scientific/Research!Misconduct!! voluntary!informed!consent!of!the!
! Dealing!with!Misconduct! prospective!subject!!
! " Waiver!of!informed!consent!is!to!
ETHICS'IN'RESEARCH' be!regarded!as!uncommon!and!
! exception,!and!must!in!all!cases!be!
GENERAL)ETHICAL)GUIDELINES)FOR)HEALTH) approved!by!an!ethics!review!
RESEARCH! committee![Guideline!4!–!Council!
! Health!research!involving!human!subjects! for!International!Organizations!of!
includes!research!on!identifiable!human! Medical!Science!(CIOMS),!2002]!!
material!or!identifiable!data![Principle!1!–! !
Declaration!of!Helsinki,!2004]!! ! Risk,)Benefits)and)Safety)!
! Considerations!related!to!the!wellKbeing!of! " Health!research!is!only!justified!if!
the!human!subject!should!take!precedence! there!is!a!reasonable!likelihood!
over!the!interests!of!science!and!society! that!the!populations!in!which!the!
[Principle!1!–!Declaration!of!Helsinki,!2004]! research!is!carried!out!to!stand!to!
! It!is!the!duty!of!the!researcher!to!protect!the! benefit!from!the!research!results!
life,!health,!privacy!and!dignity!of!the!human! [Principle!19!–!Declaration!of!
subjects!and!to!safeguard!scientific!integrity!! Helsinki,!2004]!!
! !
GENERAL)BIOETHICAL)PRINCIPLES)! ! Community)!
! All!research!involving!human!participants! " Conclusion!or!termination!of!the!
should!be!conducted!in!accordance!to!four! research!care!activity!should!not!
basic!ethical!principles:!! preclude!the!possibility!of!
" Respect)for)persons)! administering!extended!
# Autonomy,!which!requires!that! community!care![Bhutta,!2000]!!
those!who!are!capable!of! !
deliberations!about!their! ! Privacy)and)Confidentiality)!
" Every!precaution!should!taken!
personal!goals!should!be!treated!
with!respect!for!their!capacity! to!respect!the!privacy!of!the!
for!selfKdetermination!! participant!and!the!
confidentiality!of!the!
# Protection)of)persons)with)
participant’s!information!!
impaired)or)diminished)
!
autonomy,!which!requires!that!
! Disclosure)of)Research)Results)!
those!who!are!dependent!or!
vulnerable!be!afforded!security! o Must)occur)when)ALL)of)the)ff)
against!harm!or!abuse!! apply:!
! " The!findings!are!scientifically!
" Beneficence)! valid!and!confirmed!!
# Ethical!obligation!to!maximize! " The!findings!have!significant!
possible!benefits!and!to! implications!for!the!subject’s!
minimize!possible!harm!and! health!concerns!!
wrongs!! " The!course!of!action!to!
! ameliorate!or!treat!these!
" NonPMaleficence)! concerns!is!readily!available!
# [do!no!harm]!holds!a!central! when!research!results!are!
position!in!the!tradition!of! disclosed!to!its!subjects!!
medical!ethics!and!guards! !
against!avoidable!harm!to! !
research!participants!! !

!
! !
! Standard)of)Care)! Act!of!1998!and!its!
" Particular!needs!of!the!community! implementing!rules!and!
and!medically!disadvantaged!must!be! regulations!!
recognized!in!determining!the! !
standard!of!care!that!must!be! ! National)Ethical)Guidelines)for)
provided!them!as!research!subjects!! Health)Research)2006:)!
! " Special)Ethical)
! Compensation)of)Research)Subjects)! Guidelines:))
" Compensation!given!to!subjects!for! # Clinical!trials!on!drugs,!devices!
costs/expenses!incurred!in!taking!part! and!diagnostics!!
in!a!study;!free!medical!services!and! # Herbal!medicine!research!!
compensation!for!the!inconvenience! # Complementary!and!alternative!
and!time!spent!should!not!be!so!large! medicine!research!!
as!to!induce!the!prospective!subjects! # Epidemiological!research!!
to!consent!to!participate![Guidelines!7! # Social!and!behavioral!research!!
–!CIOMS,!2002]!! # Research!involving!traumatized!
! populations!!
! Subjects)groups)that)require)special) # HIV/AIDS!research!!
considerations)! # Research!on!assisted!
" Some!populations!require!special! reproductive!technology!!
protections!because!of!characteristics! # Genetic!research!including!
or!situations!that!render!them! stem!cell!research!!
vulnerable!! !
!
! International)Guidelines)!
! Absence)of)Direct)Benefit)!
" World!Medical!Association’s!
" Risk!from!research!interventions!that!
Helsinki!Declaration!of!1964!
do!not!hold!out!the!prospect!of!direct!
(revised!and!amended!in!1975,!
benefit!for!the!individual!subject!
1983,!1989,!1996,!and!2000)!!
should!be!no!more!likely!and!no!
" The!WHO!Council!of!
greater!than!the!risk!attached!to!
International!Organizations!of!
routine!medical!or!psychological!
Medical!Sciences!(CIOMS)!2002!!
examination!of!such!persons!!
! " The!International!Conference!on!
Harmonization!Good!Clinical!
ENSURING)QUALITY)RESEARCH)!
Practice!Guidelines!(1996)!!
! Role)of)the)Ethics)Review)Committee)! !
" Review!the!scientific!merit!and!ethical! ETHICAL)CONSIDERATIONS)IN)A)
acceptability!of!any!research!involving! RESEARCH/STUDY)PROTOCOL)!
human!participants!! ! Provision!for!management!of!adverse!
! reactions/effects!!
! Research)Protocol)! ! Stopping!of!the!study!in!case!harmful!
" Should!adequately!address!the!four! effects!are!demonstrated!!
ethical!principles!and!should!be!
! Potential!benefits!outweigh!potential!
sufficiently!detailed!to!serve!as! harm![literature!review,!previous!trials,!
documentation!of!the!study! records]!!
! ! Indemnification))
! Qualifications)of)Investigators)! " Amount!and!methods!of!
" Persons!engaged!in!health!research!
reimbursement!of!trialKrelated!
involving!human!subjects!should!be! expenses!of!study!participants!!
scientifically!qualified!!
" Guarantee!of!medical!
!
care/financial!indemnification!of!
! Protections)of)the)Environment)and)
study!participants!in!case!of!
BioSafety)!
trialKrelated!injuries!!
" In!conduct!of!biomedical!or!behavioral!
! Informed)Consent)!
research,!appropriate!caution!shall!be!
" English!or!Tagalog;!dependent!of!
exercised!to!avoid!harm!or!damage!to!
location!!
the!environment![Principle!12!–!
" Who!may!solicit!consent?!Who!
Declaration!of!Helsinki,!2004]!!
may!give!consent?!!
!
! Welfare)of)Animals)! " Statement!that!the!study!is!
" In!regards!to!the!use!of!animals!for! investigative!in!nature!!
research,!animal!investigators!shall! " Specify!number!of!participants!in!
abide!by!RA!No.!8485K!Animal!Welfare!! the!study!!
! !

!
" Express!the!purpose/objective!of!the! " NonKqualified!can!be!listed!in!!!!!!!!!
study!! acknowledgement!or!in!
" Disclose!probability!of!random! appendix!!!(with!permission))
assignment!to!treatment!and!trial! " Order!of!authorship!to!be!
treatments!! decided!jointly!(first!24!+!last!
" Explain!the!procedure!of!the!study! one!if!>25!listed!in!Medline)!
including!all!invasive!procedures!! " Watch!out!for!“personality”!
" Expected!duration!of!subject’s! influence!
participation!including!followKup! !
visits!! ! Who)and)what)comes)under)
" Benefits!to!the!subject!! ‘Acknowledgement’?)
" Alternative!procedure/course! " Those!that!do!not!qualify!for!
treatment!that!may!be!available!! authorship!like!general!support!
" Disclose!risk,!discomforts!and! by!departmental!chair!
inconveniences!associated!with!the! " Those!rendering!technical!help,!
study!! or!financial!and!material!support!
" Responsibilities!of!the!subject!! " Relationships!that!may!pose!a!
" Statement!of!voluntary!participation!! conflict!of!interest!e.g.,!financial!
" Study!participants!have!the!option!to! relationships!with!the!industry!
withdraw!from!the!study!anytime!! " Others!like!scientific!adviser,!
" Guarantee!of!confidentiality!! critical!review!of!study!proposal,!
" Circumstances/reasons!for!the! data!collection!or!participation!
termination!of!the!subject’s! in!clinical!trial!
participation!! !
" Statement!regarding!indemnification!! ****************************************!
" Contact!person!! )
! INTEGRITY'AND'ETHICAL'BREACHES'IN'
AUTHORSHIP)! SCIENTIFIC'RESEARCH'
! There!is!no!universally!agreed!definition!of! '
authorship.!As!a!minimum,!Authors!should! OBJECTIVES:!
take!responsibility!for!a!particular!section!of! ! Identify!specific!situations!of!
the!study!! breaches!in!integrity!and!ethics!
! All!persons!designated!as!“authors”!should! in!scientific!research.!
QUALIFY!for!authorship!! ! Define!specific!situations!of!
! Should!have!participated!sufficiently!in!the! breaches!in!integrity!and!ethics!
work!to!take!PUBLIC!RESPONSIBILITY!for! in!scientific!research.!
the!content!! ! Discuss!appropriate!actions!in!
! dealing!with!breaches!in!the!
! Who)Qualifies?! integrity!and!ethics!of!scientific!
)(Substantial!contribution!to):)! research.!
" Conception!and!design;!or!analysis! !
and!interpretation!of!the!data!! Introduction:)
" Drafting!the!article!or!revising!it! ! It!is!essential!to!define!and!develop!best!
critically!for!important!intellectual! practice!in!the!integrity!and!ethics!of!
content!! scientific!research.!
" Final!approved!of!the!version!to!be! ! The!crucial!aim!is!to!find!practical!ways!
published!! of!dealing!with!the!issues.!
! ! Intellectual!honesty!ought!to!be!actively!
! Who)does)Not)Qualify?! encouraged!and!used!to!inform!
" Participation!solely!in!acquisition!of! publication!ethics!and!avoid!
funds! misconduct.!
" Just!collection!of!data! ! Guidelines!should!be!developed!–!
" General!supervision!! advisory!rather!than!prescriptive!!!!!!!!!!!!!!!!!!!!!!!!!!!!
" Performing!statistical!tests! [The!COPE!Report,!2003])
" No!‘laundry!list’! ! Serious!ethical!breaches!occur!in!at!
least!1.0%!of!all!clinical!researches.!
" No!‘gift’!authorship!
! Issues!are!identified!and!reported!by:!
!
" Anonymous)callers:!33.0%!
! Group)or)corporate)author) " Whistle)blowers)at)study)site:!
" Multicentre!trials/research! 33.0%!
" Should!fully!meet!the!criteria!for! " Ethics)committee)and/or)
authorship! sponsor:)20.0%![Gitanjali,!
) 2003]!

!
! !
! Behaviour!by!a!researcher!that!falls!short!of! " When)is)a)Secondary)
good!ethical!and!scientific!standards.! Publication)acceptable?)
! Significant)misbehaviour)that:!! # Articles!that!need!to!reach!the!
" Improperly!appropriates!the! widest!possible!audience!or!are!
intellectual!property!of!others,! intended!for!a!different!group!
" Impedes!the!progress!of!research,!! of!readers!
" Risks!corrupting!the!scientific!record! # Competing!manuscripts!based!
" Risks!compromising!the!integrity!of! on!the!same!study!
scientific!practices.! $ Differences!in!analysis!or!
! Misrepresentation) interpretation!
" Fraud! $ Differences!in!reported!
" Omission!of!facts! methods!or!results!
! Misappropriation) # Competing!manuscripts!based!
" Plagiarism! on!the!same!database!
" Use!of!confidential!information!from! [IMCJE,2008]!
review!of!manuscript!or!grant! !
application! ! Failure)to)Publish)
! Interference) " Failure!to!report!findings!of!any!
" Obstruct!research!of!another!by! carefully!done!study!of!an!
damaging!/!taking!away!research! important!question,!relevant!to!
related!property!of!another!–! readers,!whether!the!results!for!
apparatus,!reagents,!writings,!data!etc.! the!primary!or!any!additional!
! outcome!are!statistically!
FRAUD) significant.!
! Descriptive/Analytic)Study)or) !
Experimentation) PLAGIARISM)
" Planning!K!stealing!idea! ! Unreferenced!use!of!others’!published!
" Conduct!K!fabrication! and!unpublished!ideas,!including!
" Statistics!K!manipulation!of!data! grant!applications,!and!submission!
" Reporting!K!suppression!of!negative! under!“new”!authorship!of!a!complete!
findings![Gitanjali!B,!2003]! paper.!
! ! It!may!occur!at!any!stage!research.!
! Publication) ! It!applies!to!print!and!electronic!
" Gift!authorship! versions.![Gitanjali!B,!2003];!
" Duplicate!or!repetitive!publications! [The!COPE!Report,!2003]!
" Failure!to!publish! ! Copying!word!for!word!
! ! Paraphrasing!
! Study)Design)and)Ethical)Approval!! ! Quoting!based!on!secondary!sources!
" Good!Research!should!be!well!justified,! ! Taking!ideas!without!citation!
well!planned,!appropriately!designed,! ! Putting!one’s!name!to!work!written!by!
and!ethically!approved.!To!conduct! another!
research!to!a!lower!standard!may! !
constitute!misconduct.! DEALING)WITH)SCIENTIFIC)MISCOUNDUCT)
" ! PRINCIPLE)
! Data)Analysis) ! The!general!principle!confirming!
" Data!should!be!appropriately!analyzed,! misconduct!is!intention!to!cause!others!
but!inappropriate!analysis!does!not! to!regard!as!true!that!which!is!not!true!
necessarily!amount!to!misconduct.! ! The!examination!of!misconduct!must!
Fabrication!and!falsification!of!data!do! focus,!not!only!on!the!particular!act!or!
constitute!misconduct.! omission,!but!also!on!the!intention!of!
! the!individual.!
! Authorship) ! Deception!may!be!by!intention,!by!
" As!a!minimum,!authors!should!take! reckless!disregard!of!possible!
responsibility!for!a!particular!section!of! consequences,!or!by!negligence.!
the!study.! ! Codes!of!practice!may!raise!awareness.!
! !
! Redundant)or)Duplicate)Publication) DEALING)WITH)SCIENTIFIC)MISCOUNDUCT)
" Publication!of!a!paper!that!overlaps! INVESTIGATING)MISCONDUCT)
substantially!with!one!already!published! ! Editors!are!ethically!obligated!to!
in!print!or!electronic!media.! pursue!the!case.!
" When!2!or!more!papers,!without!full! ! It!is!for!the!editor!to!decide!what!action!
cross!reference,!share!the!same! to!take.![The!COPE!Report,!2003]!
hypothesis,!data,!discussion!points,!or! !
conclusions![The!cope!report,!2003]!! !

!
) !
DEALING)WITH)SCIENTIFIC)MISCONDUCT) !
! Monitoring! !
! Audit! !
! Ethics!committee!overview! !
! Regulatory!inspection) !
) !
! International) !
" Office!of!Research!Integrity!in!US!to! !
investigate!allegations!of!research! !
misconduct! !
" Committee!of!Publication!Ethics!(COPE)! !
guidelines!on!good!publication!practice! !
" ICH!–!GCP!guidelines!for!clinical!trials! !
! !
! Philippines) !
" Training!workshops! !
" Philippine!Ethical!Guidelines!for! !
Biomedical!Research! !
" National/Institutional!ERBs! !
! !
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BIOETHICS)II) !
!
TOPIC:)TRUTH!TELLING! !
) !
OBJECTIVE:! ! Why)tell)the)truth?!
! Define!and!explain!truthfulness!and!truth! " There!is!evidence!that!patients’!–!
telling!in!the!practice!of!medicine,! coping!skills!are!enhanced,!
! Explain!reasonable!expectation!of!the!truth! cooperation!with!treatment!is!
and!the!factors!that!affect!it,! increased,!levels!of!anxiety!are!
! Explain!patients’!right!to!the!truth,! reduced.!KEll!et.!al.,!1989!
! Apply!the!principle!in!given!situations,! " Patients!have!the!right!to!the!
! Judge!what!is!ethically/unethically! truth.!
acceptable!as!the!principle!is!applied!in!given! !
situations! ! The)Right)to)the)Truth!
! " Informed!Consent!
Truthfulness)in)Ethics) " Truth!by!Purchase!
! A!fundamental!human!value,!a!basic!ethical! " Important!NonKmedical!
principle,!a!moral!virtue!allied!to!justice.!The! Decisions!
virtue!of!veracity!inclines!persons!to!manifest! !
both!in!their!lives!the!convictions!of!their! Truth)Telling)
minds.)) ! Given!the!contextual!complexity!of!
! truth!telling,!ethical!concerns!regarding!
Truthfulness)in)Bioethics) information!disclosure!demand!
! As!autonomous!and!relational!human!beings,! sensitivity,!thoughtfulness,!and!skillful!
patients!and!their!families!have!a!right!to! communication!from!clinicians,!
information.! patients,!and!ethicists.!!
! Generally)summed)up)in)two)commands:! !
" Do)not)Lie) **********************************!
# “If!you!communicate!do!not!lie”! NMMAIKBATCH!2016!
" You)must)communicate)with)those) !
who)have)a)right)to)the)truth) !
# “You!must!communicate,!if!the! !
other!person!has!a!right!to! !
communication.”!! !
! !
TRUTHFULNESS) !
! Lying) !
" Speech!against!mind! !
# If!you!communicate!something! !
at!odds!with!what!you!believe! !
to!be!true! !
# Falsehood) !
KSpeech!against!the!mind!in! !
those!circumstances!in!which! !
the!other!has!a!“reasonable! !
expectation!of!!!the!truth.”! !
! !
! Reasonable)Expectation)of)the)Truth! !
" Expectations)vary)according)to) !
these)factors:) !
# Place!of!communication! !
# Roles!of!communicators! !
# Nature!of!the!truth!involved! !
! !
! Why)tell)a)lie?) !
" Belief!that!disclosure!can!set!off!a! !
destructive!interplay!of!psychological! !
and!physical!processes!that!result!in! !
worsening!of!patients’!conditions.! !
" The!power!of!suggestion!can! !
exacerbate!pain!and!side!effects! !
unnecessarily.! !
! !
! !
!

!
BIOETHICS)II) !
!
TOPIC:!PRINCIPLE!&!ISSUES!IN!PEDIATRICS! !
! !
OBJECTIVES:! " Helps!train!them!in!decisionK
! Explain!principles/issues!in!Pediatrics,! making.!
! Apply!the!principle/issue!in!given!situations,! " Achieves!compliance!and!
! Judge!what!is!ethically/unethically! cooperation.!!
acceptable!as!the!principle/issue!is!applied!in! ! Having!a!voice!in!deciding!reinforces!
given!situations.! his!sense!of!himself!as!a!person!and!
! helps!prepare!him!for!the!independent!
PRINCIPLES)AND)ISSUES)IN)PEDIATRICS) decision!maker!he!will!someday!be.!
! Making!Decisions! )
! Telling!the!Truth! ADOLESCENT)AGEPSPECIFIC)VALUES)
! Relating!to!Patients! ! What)are)a)person’s)“real’)values)and)
) goals?)
PARENT’S)RIGHTS) ! What)weight)should)be)given)to)ageP
! The!Foundation!of!Parent’s!Rights:! specific)values?)
" Historical!precedent:!rights!of!parents! ! Adolescent!choices!are!typically!
over!children!are!grounded!on!the! characterized!by!what!might!be!called!
property!rights!of!fathers.! ageKspecific!values.!
" They!are!the!ones!charged!by!society! ! Values!that!are!held!only!during!the!
with!responsibility!for!the!welfare!and! teenKage!years!or!given!high!priority!
upK!bringing!of!children.! only!during!that!time.!
" Parents!are!the!people!who!live!most! ! Concern)with)body)image)
directly!with!consequences!of!their! ! Acceptance)by)peers)
child!rearing.! ! Striving)for)independence)
" Parents!have!a!genetic!tie!to!their! ! Hold)little)appeal)for)parents!–!likely!
children.! to!weigh!longKterm!benefits!heavily!
" Parents!make!the!bestKqualified! than!shortKterm!unpleasant!
decision!makers.! experiences.!
" The!intimacy!of!family!life!is!among! ! Temporary!–!children!outgrow!them!
the!greatest!personal!values.! and,!in!their!own!adulthood,!will!most!
! likely!repudiate!them.!
! Limit)of)parent’s)rights) ! May!be!retained!into!adulthood!–!but!
" Criteria!for!child!abuse/neglect.! for!good!reasons,!not!out!of!
" Certain!life!threatening!situations! developmental)need.!
! !
CONSULTING)THE)CHILD) ! ISSUE:)
! Are)children)competent)to)make)decisions)) " !!!The!adolescent’s!preference!
for)themselves?) should!be!overridden!when!it!
" Not!fully!rational! conflicts!with!typically!adult!
" Not!mature! judgments!of!value.!
" Not!experienced! # One!cannot!assume!
! universality!of!adult!values.!
! Children’s)lack)of)competence)can)be) # Adolescents!may!not!adopt!
challenged:) typical!values!
" Decision!making!is!a!developmental! # The!best!one!can!do!is!appeal!
process! to!typical!adult!values!–!
" Children!generally!make!the!same! “reasonable!person”!standard!
treatment!choices!as!adults! ! ISSUE:)
" Decision!making!is!dependent!on!life! " !!!Choosing!for!adolescents!against!
experience! their!wishes!assumes!that!their!
! own!stated!preferences!are!not!
! Voluntariness)in)consulting)children) their!“real”!values.!
" The!patient!as!a!child! # Some!adolescents!do!know!
" Pressures!from!parents! what!adult!values!they!will!
" The!doctor!as!a!friend! adopt.!
o For)assent)to)be)genuine,)there)must)be) # Some!adolescents!have!goals!
the)possibility)of)dissent.) that!require!commitment!and!
) narrow!choices.!
! Benefits)in)trying)to)get)child)assent) !
" Helps!them!see!the!reasons!for!the! !
medical!decision.! !
" Provides!a!model!for!human!relationships.! !

!
! !
# Let!adolescents!choose!for! We!would!think!it!wrong!to!lie!to!adult!
themselves!or,!if!parental! patients?!
consent!is!needed,!use!the! !
subjective!standard!for! " )))Lying)to)Children)–)
substituted!judgment.! Justifications:)
! # All,!or!almost!all!lying!to!
! Difficult!judgments!must!be!made!by!the! children!is!seen!as!benevolent!
wouldKbe!paternalist!about!the!seriousness! deception.!
of!an!adolescent’s!life!plan!and!the!relation! # To!protect!them,!prolong!their!
between!medical!choices!now!and!the! innocence!and!get!them!to!do!
possibility!of!fulfilling!that!plan!in!the!future.! things!that!will!benefit!them.!
! We!need!a!better!justification!to!impose!adult! # Because!one!does!not!trust!
ageKspecific!values!of!adolescents,!especially! their!judgment!
when!these!values!do!not!lead!to!choices!that! # Because!their!experience!is!
are!irrational!in!the!sense!of!being! limited!and!their!goals!are!
incompatible!with!the!adolescent’s!own! short!term.!
perceived!life!goals.! !
! " !!!Denying!children!the!truth!
INFORMING)PARENTS) always!harms!them!to!some!
! Why)tell)the)truth?) degree!by!slowing!their!progress!
! Physician’s)point)of)view) toward!developing!their!own!
" Truth!telling!is!a!protection! autonomy.!
" Builds!trust!/!good!patientKdoctor! " !!!Some!benevolent!deceptions!in!
relationship! medicine!may!not!be!harmful,!
! but!some!can!do!harm,!and!
! Parents’)point)of)view)) trying!to!decide!the!balance!of!
" Correct!and!full!information!is!a! benefit!to!harm!or!vice!versa!is!a!
necessity! helpful!and!morally!appropriate!
" Psychological!benefit! way!to!decide!questions!of!
) telling!the!truth!to!a!child.!
! Delaying)or)Withholding) !
" Reasons!must!stem!from!concern!for! LOYALTY)TO)PARENTS)
the!parent!or!child!and!not!the! ! The!doctorKpatient!relationship!is!built!
doctor’s!own!personal!reasons.! on!mutual!trust!!
" If!the!information!may!affect!a! " Parents’!trust!in!the!
parent’s!decision,!then!it!is!wrong!to! pediatrician!promotes:!
withhold!or!delay!it.!! # Honesty!and!cooperation!
" Treating!without!parental!consent!or! # Confidence!to!accept!the!
withholding!truth!from!parents! medical!help!that!their!child!
# Emergency!situations! needs!
# Information!may!do!serious! ! When)are)Pediatricians’)obligations)
harm! to)parents)legitimately)overridden)
! by)other)obligations?)
TELLING)THE)CHILD) ! The!pediatrician’s!first!loyalty!is!to)the)
! Is!Benevolent!Deception!about!serious!illness! child!
acceptable!or!justified?) ! Pediatricians!owe!loyalty!to!parents!by!
" As!long!as!they!are!not!in!conflict!with! virtue!of!their!status!as!guardians!of!
good!medical!practice.! their!children!and!this!status!is!
" As!long!as!they!do!no!harm! conferred!by!the!state.!
! ! When!parents!do!not!fulfill!their!
! Reasons)for)Telling) responsibility,!they!lose!their!status!as!
" Accepting!this!principle!suggests!some! guardians!and!thus!lose!their!claim!to!
conditions!under!which!it!might!be! the!loyalty!of!pediatricians.!
justified!to!tell!the!child!the!truth!even! ! Situations!that!present!clear!and!
against!parents’!wishes.! imminent!serious!danger!to!the!child’s!
" Will)not)telling)be)more)harmful?) life!or!wellKbeing,!whether!posed!by!
" What)will)benefit)the)child?) parents!directly!or!by!conditions!that!
" Will)not)telling)do)more)good)than) the!parents!cannot!correct,!demand!that!
harm?) pediatricians!put!into!motion!whatever!
) is!required!to!protect!the!child!!
! Lying)to)Children) !
" Why!is!it!that!we!consider!it!justified! !
or)even!required!to!lie!to!children!in! !
situations!where!! !

!
) !
! In)cases)of)clear)danger,)the)pediatrician’s) !
loyalty)is:) )
" First!to!the!child! )
" Second!to!the!state! !
" Third!to!the!parents! )
! )
SAYING)NO) !
! Patients!do!have!legitimate!claims!on! !
physician’s!time,!energy,!and!attention.!But! !
what)limits)may)a)physician)set)against) !
Parents?)! !
" The!ultimate!case!of!setting!limits!is!to! )
refuse!parent’s!request!to!treat!their!child.! !
" The!ultimate!test!of!a!physician’s!right!to! !
say!no!may!come!at!the!end!of!life.! !
! )
! Are)there)circumstances)where)the) )
pediatrician)should)take)the)initiative)and)
)
refuse)to)treat?)
" If!treatment!is!futile!and!inhumane! )
)
" If!it!causes!significant!suffering!to!the!
child) )
) )
! There!is!no!obligation!to!treat!if!the!treatment!is!
)
futile,!even!if!it!causes!the!child!no!suffering!or!
)
harm.!
)
! Parents!cannot!demand!useless!or!inappropriate!
)
treatment.!However,!there!might!be!good!reasons!
for!not!refusing:! )
" For!the!parents’!sake! )
" For!organ!donation!! )
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JUSTICE
Julius Ceazar H. Reyes, MD, DPSA
December 13, 2013; 8:00 – 10:00 AM
Bioethics

OUTLINE
 Ethical principles  Utilitarian
 Justice  Libertrian
 3 principles of justice  Egalitarian
 Theories of justice

ETHICAL PRINCIPLES  Rules and principles that govern the distribution


 Respect for autonomy of social benefits and burdens
 Beneficence  Condition of scarcity and competition
 Non-maleficence  Material principles of distributive justice
 Justice  To each person an equal share
 To each person according to need
JUSTICE  To each person according to effort
 Moral rightness based on ethics, rationality, law,  To each person according to contribution
national law, religion or equity  To each person according to merit
 Act of being just or fair  To each person according to free market
 Formal principle (Aristotle): equals must be exchanges
treated equally, unequal must be treated  The Right to Health Care: Decent minimum of
unequally Health Care
 One-tiered system
3 PRINCIPLES OF JUSTICE  Distribution is based on needs; needs
are met by equal access to basic
 Allocation of resources
services
 Triage  Two-tiered system
 Distributive justice  Better services might be made
available for purchase at personal
1. Allocation of resources expense
 hospital beds
 As a doctor, you must choose what to prioritize THEORIES OF JUSTICE
first
1. Utilitarian
2. Triage  A theory in normative ethics holding that the
 It is applied when there is too many patients in proper course of action is the one that maximizes
one hospital utility, specifically defined as maximizing
 The doctor will decide who will or will not be happiness and reducing suffering
treated  Maximizing value
 Doctors as gatekeepers to determine treatment  Trade-offs & balances
 Greatest good for greatest number  to benefit those who are genuinely
 One's contribution to society or "social worth" in need
 Military or civilian disaster:
 Those who cannot be expected to survive even 2. Libertarian
with treatment  Economic benefits must be in proportion to one’s
 Those who will recover without treatment contribution to the production of those benefits
 The priority group, those who need treatment in
order to survive 3. Egalitarian
 To make more equal the unequal situation of
3. Distributive justice naturally disadvantaged members
 Which of the available drugs will you prescribe  Distinction between UNFAIR and UNFORTUNATE
 How many drugs will you prescribe

-END-

TRANSCRIPTION DETAILS
Pictures of previous
BASIS RECORDINGS + NOTES + DEVIATIONS 5-10% CREDITS Craig-recordings
PPT, PDF
REMARKS Contents are lifted from pictures of PPT and 2013 PDF file available since no PPT file was given.
-DLSHSI Medicine Batch 2016 Transcriptions. Version 1.0.0.0.2 Build 2220-

Transcriber/s: Eliza Marie Herrera


Formatting: Nicxz Icaro D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 1
Editor/s: Nicxz Icaro, Craig Angelo Reyes
BIOETHICAL PRINCIPLES IN OBSTETRICS 1-2
Julius Ceazar H. Reyes MD, DPSA
December 6 & 13, 2013; 8:00 – 10:00 AM, 8:00 – 9:00 AM
Bioethics

OUTLINE
PART 1 PART 2
 Procreation  Prenatal Diagnosis
 Two principles of procreation  Legitimacy and criteria of therapeutic procedures of
 Conjugal act human embryo
 Perspectives of conjugal act  Principles in pregnancy
 Unitive
 Procreative

PART 1

PROCREATION 2. The gift of human life must be actualized in


 The process by which an organism produces marriage through the specific and exclusive
others of its biological kind acts of husband and wife in accordance with
 The sexual activity of conceiving and bearing the laws inscribed in their persons and in their
biological offspring union.
 Actualization of marriage is where the concept of
TWO PRINCIPLES OF PROCREATION procreation or sexual intercourse comes in. This is
a requirement in marriage.
1. It requires the part of the spouse responsible  It is not gratifying if a woman refuses to have
collaboration with the fruitful love of God. sexual intercourse with her husband in the context
marriage, but there is a proper way to this. The
refusal of sexual intercourse becomes grounds for
 Responsibilities of the spouses:
annulment.
1) Know and understand their sexuality
 The man or husband is aware that he is  When we say specific and exclusive, there must be
a man and the wife is aware that she is no one else but the husband and wife. (No extras!)
a woman.  It has to be in accordance with the natural
laws and nature of marriage.
2) Know and understand the unity of  Within marriage, the child has to be born
marriage inside a “legitimate union”.
 When a man and a woman enter  A child has to be born in the context of marriage
marriage, they become one. to be considered legitimate.
 Being legitimate is the right of the child.
3) Know and understand their personality  A child born from live-in partners is still
 You cannot enter a marriage without considered illegitimate, but if they marry the child
knowing yourself or your spouse’s may be considered legitimate.
personality.  Legitimacy is important even in laws of
society, for the dignity of the human person.
4) Know and understand their duties with  A child born in the context of marriage has more
their children dignity that a child born out of the context of
 It does not mean that just because a marriage.
man and a woman enters marriage
they may keep on procreating without CONJUGAL ACT
knowing that they have duties towards  The act of sexual intercourse between two
their children such as education or opposite sexes
quality of life.
 Is it okay to have a lot of children? Yes,
as long as the parents are capable of
providing their children with their basic
rights (education, food and shelter,
etc.)

Transcriber/s: Gladys Hulipas


Formatting: Nicxz Icaro
Editor/s: Nicxz Icaro, Craig Angelo Reyes D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 3
THE COMMUNION OF PERSONS IN MARRIAGE AND THE CONJUGAL ACT
William E. May

A man and woman become husband and wife when they “give” themselves to one another in and through the act of irrevocable personal
consent that makes them to be spouses. And in consenting to marriage, to being husband and wife, they consent to all that marriage
implies and therefore the consent implicitly to the conjugal act, the act “proper and exclusive to spouses.” In and through the conjugal act
husband and wife literally become “one flesh”, “one body.” In and through this act they come to “know” each other in a unique and
unforgettable way, and they come to know each other precisely as male and female in their masculinity and femininity.

Entering marriage means that the spouses are giving consent to perform intercourse.
“… The man does not force himself upon the woman, but gives himself in a receiving manner. The woman does not
simply submit herself to the man, but receives him in a giving manner.”
-Robert Joyce

PERSPECTIVES OF CONJUGAL ACT  What the obstetrician may have done is to


 UNITIVE = “love giving” monitor the progress of the pregnancy until
 Husband and wife render mutual help and the pregnancy reaches the age of viability,
service to each other through an intimate and then oophorectomy may be performed.
union of their persons and their actions If the fetus does not survive upon reaching
 It will not end after sexual intercourse the age of viability, let the fetus die the
and must go beyond that natural way.
 Husband and wife see their “self-worth” by  If the at some point the mother experiences
being loved bleeding or rupture, then you may perform
 Husband and wife share intimacy oophorectomy even if the fetus is not viable.
 Intimacy does not only refer to physical
closeness, it is when one becomes CASE 2
willing to be vulnerable to each other X.M., 16 year old G1P0, 16 weeks AOG, was
diagnosed with endometrial cancer stage 4. As the
 PROCREATIVE = “life giving” patient’s attending obstetrician, you informed her on
 This is why the church is against the risk of harmful effects of chemotherapeutic drugs
contraception because in contraception, the to the fetus. However, if chemotherapy will not be
procreative power of conjugal act in given, there is a greater chance that the mother will
marriage is abolished die.
 The natural ordination of the conjugal act
towards the creation of human life  If you’re the obstetrician, who will you choose?
(“matrimonial right”) Will you proceed with chemotherapy and let the
 The result is another human life. baby die? Or delay the management and let the
 By principle, human life will start when mother die eventually?
the sperm of the father will meet the  Both the life of the mother and fetus is of
ovum of the mother. Any insult or equal reverence/value.
attack to that human life is unethical  There is no direct answer. You are not
and immoral. supposed to choose whether the life of the
 In abortion, we destroy human life mother or the life of the fetus. You may
which is the product of the conjugal delay the treatment; wait for the age of
act. Hence abortion is immoral and viability. Once the fetus is at the age of
unethical. viability, deliver the baby, institute the
chemotherapeutic treatment to the mother;
CASE 1 if the baby will not survive outside the
R.M., a 21 year old female, sought consult at the out- mother, let the baby die the natural way. In
patient department for amenorrhea. Pregnancy test that way, you are not choosing between the
was done revealing a positive result. So the patient was mom and the baby.
requested for vaginal ultrasonography and revealed a  If the management is very urgent and must
left ovarian pregnancy approximately 7 weeks AOG. be given immediately, use the Principle of
She was immediately brought to the operating room Double effect. You may institute the
and underwent direct oophorectomy. chemotherapeutic agents in this case
provided that your intention is to cure and
 Was the decision of the physician acceptable? not to terminate the pregnancy. But if the
 Technically, the obstetrician should not have intention is to institute therapy and
immediately proceeded with the eventually terminate the therapy, that is
oophorectomy; the ectopic pregnancy at bad.
this point has no risk or danger to the
mother.

Transcriber/s: Gladys Hulipas


Formatting: Nicxz Icaro
Editor/s: Nicxz Icaro, Craig Angelo Reyes D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 2 of 3
PART 2
PRENATAL DIAGNOSIS PRINCIPLES IN PREGNANCY
 Prenatal diagnosis must respect the life and
integrity of the embryo and the human fetus and  PRINCIPLES OF INVIOLABILITY OF LIFE
must be directed towards its safeguarding or  No one has the right to end someone’s life
healing as an individual.  Physicians cannot terminate the life of a
 If the prenatal diagnosis will destroy the patient because they have no right.
integrity of the embryo, then the  When in doubt, always side with life.
management is not justified, unacceptable  Always apply this principle in obstetrics.
or immoral.
 Prenatal diagnosis is opposed to the moral law  PRINCIPLES OF DOUBLE EFFECT
when it is done with the thought of possibly  Criteria for evaluating the permissibility of
inducing an abortion due to malformation or acting when one’s otherwise legitimate act
congenital anomalies or hereditary illness. will also cause an effect one would normally
 For example, during the prenatal diagnosis, be obliged to avoid
you were able to diagnose the fetus would  Always applicable in obstetrics especially
have anencephaly; do not terminate the when the life of the mother and the life of
pregnancy. Proceed with the pregnancy, the fetus is at risk.
deliver the baby and let the baby die the  BOTH LIVES ARE EQUAL IN VALUE
natural way. But do nothing to terminate the  The mother’s life and the fetus’s life are of
pregnancy. equal importance
 As much as possible, save both lives

 WHICH LIFE IS TO BE SAVED?


 There is no direct answer.
 For as long as both lives can be saved, then
save the mother and the fetus.
LEGITIMACY AND CRITERIA OF THERAPEUTIC
PROCEDURES OF HUMAN EMBRYO
 NATURE OF DISORDER OR TRAUMA
 Strictly therapeutic
 If you were able to assess that one will really
 If the therapeutic efficacy of the
not survive, then that is the only time that
management is questionable, do not
you may choose.
institute that therapy to the mother.
 Explicit objective is healing of maladies CASE
(chromosomal defects) A 16 week pregnant mother went to the emergency
 If a therapeutic management would be able room because of massive bleeding or spotting.
to solve the chromosomal defect, then carry Ultrasound showed that there is a separation of the
on as long as it is strictly therapeutic and placenta and the implantation site (placenta previa).
would not destroy the integrity of the The mother is already hypotensive upon reaching the
embryo. ER. Will you terminate the pregnancy?
 Directed to the true promotion of the personal  The first step is to manage the hypotension. The
well-being of an individual fetus cannot be delivered because it is not yet at
 Does not harm the integrity of the embryo. the age of viability (20 weeks).
 Does not worsen the embryo’s condition of life  Improve the condition of the mother.
 Delicate and particular precaution in embryonic  Assess the condition of the fetus. If there is only
life are called for partial separation, do conservative management.
If more than 50% of the placenta is separated,
then you may remove the product of conception

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BIOETHICS IN SURGERY
Malen M. Gellido, MD, FPCS, FACS
January 10, 2014; 8:00 – 10:00AM
Bioethics

OUTLINE
 Mutilation  Elective surgery
 Surgery  Therapeutic surgery
 Principle of totality  Palliative surgery
 Principle of double-effect  Incidental surgery
 Non-maleficence/beneficence  Suppression or excision of a healthy organ
 Autonomy/informed consent

MUTILATION  Example #1: Removal of an appendix

 Maim or distort (Livy)


 Example #2: Mastectomy
 Amputate (Ovid)
 Diminish or lessen (Cicero)
 The act of depriving a limb, member or important
part; deprival of an organ (Dorland’s medical
dictionary)
 The removal of an organ or the suppression of its
function

SURGERY
 Entails a positive invasion of the body’s integrity
 Surgery = Mutilation
 By virtue of principle of totality, it is morally
acceptable

PRINCIPLE OF TOTALITY
 The parts of a physical entity, as parts, are
ordained to the good of the physical whole. Since PRINCIPLE OF DOUBLE EFFECT
this good of the whole is the fundamental reason  Often invoked to explain the permissibility of an
of, and reason for, the existence of the parts, action that causes a serious harm, such as the
 There is no violation of right order in the death of a human being, as a side effect of
destruction of the parts, when this is necessary for promoting some good end
the whole
 All parts of the human body are meant to exist  Example #1
and function for the good of the whole body, and  A pregnant woman with uterine cancer has to
are thus naturally subordinated to the good of the undergo surgery to remove the uterus. The good
whole body. effect is that the mother may be cured with the
 Therefore, when some part or function becomes removal of the uterus but the bad effect is the
detrimental to the good of the whole body, it is termination of the baby.
morally acceptable to remove such part or to  The act itself is good which was the removal
suppress its function. of the cancerous uterus, the good effect and
not the evil effect is the one intended by the
agent

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 Example #2 ELEMENTS OF INFORMED CONSENT:
 A patient terminally ill from cancer has metastasis 1. Disclosure of information
to the bones which is causing extreme 2. Comprehension of information
excruciating pain. Usual doses of analgesics is no  Explain all the details of the nature of
longer effective. Morphine, which is an opioid disease, urgency of the treatment,
used to relieve intense or chronic severe pain, was treatment options, recent publications,
given to relieve the patient from suffering benefits, costs
regardless of the incremental dosage. 3. Voluntariness
 Patient is not coerced (scared by the
 Example #3 surgeon)
 A patient bleeding from gastric ulcer, vomiting  Do not force the patient to agree on the
blood, and in hypotensive shock. He had procedure if he/she is not willingly
myocardial infarction a few weeks before. If consenting
operated, chances of dying is 90%. The bleeding
has to be stopped immediately by doing surgery 4. Competence
 Consent given voluntarily by the patient
FOUR CONDITIONS: himself
 The act itself is good or indifferent  If patient is incompetent, legal guardian or
 The good effect and not the evil effect is the one immediate family member is the one to be
directly intended by the agent asked for consent.
 The good effect is not produced by the evil
effect. The good effect must follow from the NOTE: ALL SURGERIES NEED INFORMED CONSENT
action at least as immediately as the harmful
effect ELECTIVE SURGERY
 There is proportionate reason for permitting the  Not urgent surgery or Scheduled at own
foreseen evil to occur convenience or leisure
 Cosmetic surgery
 Example #1 1. May be done:
 Performing a surgery to remove a life-threatening  if the risk is low
uterine cancer from a pregnant woman may be  if the functional integrity is maintained
permitted, since the action is not evil in itself,  even if the other organs that are affected by
even though it may cause death of the fetus. the removal are rendered functionless
secondary to a more important surgery
 Example #2 2. May not be done:
 Giving increasingly high doses of morphine in  if the risk is high
terminally ill patients to relieve suffering, even  if it does benefit the patient
though this might bring about end of life.  if there is no medical usefulness

PRINCIPLE OF NON-MALEFICENCE THERAPEUTIC SURGERY


1. Since it is a necessary surgery, because it is
 “Primum non nocere” –“first do no harm”
curative, then it should be done.
 One ought not to inflict evil or harm
2. Informed consent is necessary
 Related to the following human rights:
 Right not to be killed
 Examples:
 Right not to have bodily injury or pain
 Colon cancer: colectomy
inflicted
 Appendicitis: appendectomy
 Right not to have one’s confidence revealed
 Breast cancer: mastectomy
AUTONOMY/INFORMED CONSENT
PALLIATIVE SURGERY
AUTONOMY  Relieve symptoms
1. Since it is not designed to prolong life but
 The moral right to choose and follow one’s own
make the patient more comfortable (the
plan of life
condition cannot be cured), it is an optional
 Freewill, Free to choose anything you want
surgery.
to do
2. Informed Consent is necessary
3. If proper disclosure of information has been
INFORMED CONSENT
made and the patient still requests it, it may
 The willing and uncoerced acceptance of a
be done but always weigh the benefits and
medical intervention by a patient after adequate
the risks.
disclosure by the health professional of the nature
of the intervention, its expected risks, benefits
 Example #1
and alternatives available
 Bleeding gastric cancer with gastric outlet
 Signing of consent form is just signing and
obstruction, the cancer obstructed the pylorus
NOT securing. The act of securing a consent
and food cannot proceed to the duodenum.
from the patient is the actual
Surgery is done for the patient to enjoy the
communication between the doctor and the
pleasure of eating food normally and not by tube.
patient. The signing is just an evidence that
the patient really consented.

Transcriber/s: Nicxz Icaro D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 2 of 3


Formatting: Nicxz Icaro
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UNNECESSARY SURGERY  Example #4
1. It is unethical to perform surgery with no real  Colectomy, removal of the right side, patient also
medical indication but which might be has asymptomatic gall stones, since the part is
undertaken for some unworthy motive such as already opened might as well remove the
financial gain or face-saving. gallbladder but still ask for an informed consent
2. A surgeon is culpable when, because of inability or from a family member if the patient is
lack of knowledge to preserve or repair an injury, incompetent or if not anticipated.
performs an amputation/mutilation rather than
ask for assistance or make a referral. SUPPRESSION OR EXCISION OF A HEALTHY ORGAN
3. Although it would be easier to amputate, the  Justifiable if the normal organ exercises an
surgeon is bound to conserve as much as possible influence on another diseased organ
a part, or all of the part of the body that is injured.
 Example #5
 Example #2  Hormonal treatments are usually used in breast
 Cholecystectomy (surgical removal of gallbladder). If cancer which works by blocking the effects of
a patient with gall stones is asymptomatic, 90% does estrogen on breast cancer tumor cells. Since
not progress to cholecystitis so usually the ovaries produce estrogen, removal of the ovaries
gallbladder is not removed. A doctor should not may be an option. However, it is only effective or
scare or force the patient to have a surgery if it’s not advised for pre-menopausal women
medically necessary.
INCIDENTAL SURGERY CLINICAL CASES
1. The removal of the part of the body does not 1. Incidental Appendectomy
pose a serious threat to the patient’s life. 2. Strictly Elective Appendectomy
2. It is done during the course of a main surgery.  No symptoms involve but insisted on having
3. The part removed has no integral function in the it remove
body. 3. Elective Tonsillectomy
4. The part removed enhances physical 4. Circumcision of the Newborn
appearance.  Not unnecessary nor incidental
5. Oophorectomy in breast cancer
 Example #3  There are Pro’s and Con’s since hormonal
 Gynecologist will remove mucinous tumor of medications may also be taken
ovaries, but these are notorious for involving the
appendix, so even if the appendix is normal
looking they will ask them to remove it.

-END-

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BIRTH REGULATION
Rev. Fr. Danilo Tiong
December 20, 2013; 8:00 – 10:00 AM
Bioethics

OUTLINE
 Birth regulation
 Responsible parenthood
 Contraception

BIRTH REGULATION 4. The morally acceptable use of contraceptive


methods should be the result of the free and
SOME ETHICAL CRITERIA TO TAKE INTO ACCOUNT responsible discernment of the spouses
FOR THE ACTUAL MORAL DISCERNMENT  When the spouses discern: they talk, they
REGARDING BIRTHREGULATION: dialogue about their fertility, they talk about their
sexual love together, and they talk about
1. The exercise of responsible parenthood should be themselves.
such as to respect human life.  What if after discerning the couple agreed to use
the pills? it still depends on the circumstances
 This does not mean you have to be PRO-life but
they are in or situation, their health, social status
RESPECT LIFE because it’s coming from God
and many things.
 The fundemental bioethical principle is
SANCTITY and INVIOLABILITY to life
The spouses should keep in mind that their mutual
(Reverence or respect for human life)
self-giving and the resulting procreation should be an
2. The moral evaluation of the various methods of expression of authentic personal love
contraception should be made not from an  It’s not only biological, not only ligation, pills or
excessively biological point of view of human family planning. It should be coming expression
of authentic personal love, from that authentic
sexuality, but from a complete vision of
personal love, they discuss, and they discern and
marriage and human love.
talk.
 Regulating birth is not just physical or biological  Their mutual self-giving, specially the physical,
but also spiritual or moral
should be intimate and sacred. And from that
 We cannot separate sexual love from human sacredness and intimacy, the resulting pro-
love because it’s a part of it. When we look at a creation should be there for an expression of
person, when he/she acts according to that love. authentic personal love. Children are expression
It is the whole thing of himself including his own of authentic personal love.
sexuality. Sexuality is not gender, it is the whole
sexual makeup of the entire person, how he looks
at things, perceive things, relate with people and
RESPONSIBLE PARENTHOOD
with God.
 When we talk about Human love were talking  The right and duty of increasingly humanized
about a responsible human love, real sexual love, population ethically entails the principle of
mature love, complete love not just love that see responsible parenthood, with the corresponding
in the streets or hear in songs need for family planning. Children should be the
 Marriage is not just having a child; it’s only a part product of the mature and responsible love of
of it. Marriage is when two people in complete married couples.
mature love come together and decide to be  Right and duty cannot be separated
together for life because they decide that the  Responsible parenthood is a principle and not a
other would be the parent of his/her children means for contraception.
coming from a real love and as part of sexuality. It  When we talk of responsible parenthood it might
starts with sex, starts with attraction but ends up imply the number of children or spacing of birth
with something.  The term responsibility should echo the
 Sexual intercourse may have its end, what fundamental bioethical principle of
remains is the real love. STEWARDSHIP and ACCOUNTABILITY
 Marriage is not a sacrifice; marriage is a gift of  Responsible parenthood is not family planning;
oneself because of a supplying love in which you family planning is a part of responsible
want that person to be the parent of your child parenthood.
and to live with him/her for the rest of your life.  Family planning is NOT a necessity.

3. From the technical point of view, none of the  Society has the obligation to create adequate
available methods of contraception satisfies all conditions for the exercise of responsible
the criteria for an ideal method. parenthood by the spouses.
 There would be no ideal method  Society must create adequate conditions. Society
 One method may be effective for one couple but including government should not fight but should
not for the other give proper respect on how other people look at
 There should be openness between husband and these things.
wife

Transcriber/s: Eliza Marie Hererra


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 The actions of the community should respect the  The spouses have the obligation to make the
dignity of the human person and the value of ultimate ethical discernment regarding the
personal decisions. exercise of their fecundity, taking into
consideration
 If a particular couple has a particular decision, we  The orientation of conjugal love toward
don’t condemn them. fecundity
 Includes both the dignity of the spouses and of  The various values which are involved
the unborn  Religious, cultural, social, family &
 Personal decisions are valuable which include the moral values
decisions of the spouses after proper discussion  The circumstances of their situation.
and are therefore respected  Don't plan on having 6 children if you
 “The product of human reproduction is not a can't provide them food adequately
potential person but a person with potentials”  Why have only one child when you can
raise 3? This plan may arise from
personal selfish reasons
CONTRACEPTION
 Spouses should consider monetary and
 The deliberate prevention of conception.
social situation
 The essential action of contraceptive methods is
to prevent fertilization by precluding the meeting
of ovum and spermatozoa.

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HUMAN SEXUALITY 1-2
Danilo A. Ballesteros, MD, MBAH, DPPS
February 7 & 14, 2013; 8:00 – 10:00 AM
Bioethics

OUTLINE
PART 1  Man’s sexual constitution in general
 Importance of sexuality  Nature of sexual love
 Sexual morality  Purpose of sexual love
 Sex  Social aspect of sexual love
 Sexuality  Christian Attitude Towards Sex and Sexuality
 Sexual orientation  Fields of modesty
 Sexual Identity  Principle of personalized sexuality
 Gender
 Gender identity PART 2
 Meaning of human sexuality  Principal values of human sexuality
 Old testament  Encyclical letters, papal lecture
 New testament

PART 1
IMPORTANCE OF SEXUALITY  There are important moral restrictions on sexual
 The human person is so deeply influenced by his activity
sexuality that this latter must be regarded as one  It is morally objectionable to the extent that it is
of the basic factors shaping human life incompatible with a justified moral rule or
 The person’s sex is the source of the biological, principle
psychological and spiritual characteristics which  Infliction of personal harm
make a person male or female, and thus are
extremely important in the maturation and SEX
socialization of the individual  Two common designations:
 Moral corruption is on the increase 1. The biological aspect of one’s personhood,
 Boundless exaltation of sex the individual’s biological makeup based on
 Teachings, moral norms and habits faithfully the appearance of genitals
preserved have been called into doubt 2. Genital behavior, i.e. What we think, feel
 The Sources of Moral Knowledge and do sexually
 Conscience
SEXUALITY
SEXUAL MORALITY  It encompasses both sex, i.e. who we are and
what we think, feel and do sexually, as well as the
CONVENTIONAL SEXUAL MORALITY meanings given to sex.
 Sex is morally legitimate only within the bounds  “What our body means to us, how we understand
of marriage Defense: ourselves as a woman or as a man, the way we
 Social utility feel comfortable in expressing affection – those
 A stable family life is absolutely are part of our sexuality… Un this broadest sense,
essential for the proper raising of sexuality is how we make sex significant”
children and the consequent welfare of (Whitehead and Whitehead 1989:45)
society as a whole  It does not necessarily include genital intercourse
 Natural law theory or related sexual practices.
 Actions are morally appropriate insofar
as they accord with our nature and end SEXUAL ORIENTATION
as human beings and morally  Sexual orientation refers to the emotional and
inappropriate insofar as they fail to erotic preference for the category of people –
accord with our nature and end as heterosexual, homosexual, or bisexual – how an
human beings individual prefers to relate sexually or intimately.
 Procreation is the natural purpose or
end of sexual activity SEXUAL IDENTITY
 Sexual identity refers to the individual, gay,
THE LIBERAL VIEW lesbian, or bisexual. “Self-identification” is the
 Reject as unfounded the conventionalist claim operative word which is indicative of whether the
that non-marital sex is immoral individual considers him-/herself as male or
 Reject the related claim that sex is immoral if it female.
cuts off the possibility of procreation  Sexual identity is related to but different from
 Nor are willing to accept the claim that sex gender identity
without love is immoral

Transcriber/s: Eliza Marie Hererra, Nicxz Icaro


Formatting: Nicxz Icaro D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 4
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GENDER THE PURPOSE OF SEXUALITY:
 A socially constructed designation.  Procreation (Gen. 1:28)
 Mutual companionship (Gen. 2:18) and to
GENDER IDENTITY complete (completion) each other (the sexes)
 This refers to the individual’s subjective sense of (Gen. 2:21 ff.) The completion of each other is
being a man or woman. It is the individuals inner both biological and spiritual.
sense of self as a man or woman  This completion and mutual companionship
culminates in the mutual self-giving by which they
SEXUAL LOVE IS: form so intimate a union that they can be called
 Exalted as a human value “one flesh”. (Gen. 2:24)
 Willed by the Creator
 Wholly good BECAUSE OF SIN:
 State of integrity is lost
LIMITATION OF SEXUAL LOVE:  The entire order of creation is disturbed
 An easy, unpreoccupied enjoyment of sexual love  The relationship of the sexes is disturbed
and its spontaneous regulation by the instincts of  The carefree naturalness of the sexes in their
human nature. mutual relationship is lost.
 The fallen state of man cannot be ignored  Sexuality is experienced as a vulnerable
possession which man must protect against abuse
REALITY OF HUMAN SEXUALITY: by others and also by himself
 Its creative powers of enriching love
 Its eroding forces of dehumanizing abuse MAN’S SEXUAL CONSTITUTION IN GENERAL
 Man and woman complement each other. Any
CHRISTIAN VIEW OF SEXUALITY: contempt of the other sex is unfounded conceit
 God created man male and female (principle of and ultimately an offense of the Creator
differentiation)  The erotic is a marvellous and creative power in
 The woman is a human person like Adam man. But its force can be terrifying. When sexual
(principle of equality) desires and genital satisfaction are detached from
 The original goodness of sexuality (principle of the totality of eros and human love, evil can be
value) revealed.
 Only when integrated in the totality of man’s
MEANING OF HUMAN SEXUALITY being is sexuality good, amiable and constructive.

BIBLICAL VIEW – OLD TESTAMENT NATURE OF SEXUAL LOVE


 Gen 1:27 “God created man… created them.”  The attraction and love of the sexes finds its
 Man is God’s image expression in the act of sexual love.
 Differentiated in two sexes  Sexual love aims at a partner of the other sex.
 The entire man is created good. Sexuality, as a Every other form of sexual actuation is:
gift of God, is wholly acceptable.  Incomplete
 Man’s nature must primarily be understood from  Directed to the beloved
the nature of God, and not from the nature of the  Immature
animal.  To be able to have sexual desire or
fulfillment with another sex and to be
BIBLICAL VIEW – NEW TESTAMENT able to love the opposite sex with one’s
 Jesus Christ treated women equally with men whole being
 The early church was concerned with self-control  Perverse
and discipline in sexual life  Outside of what is natural
 Fornication and adultery are listed as vices and are  Pleasure is not the purpose/aim of sexual function.
condemned (I Thes.4:4-8; I Cor. 6:9 ff.) Pleasure is the divinely instituted allurement of
 Christians must sanctify their bodies and sexuality human beings to use their sexual powers and
because they are the temples of the Holy Spirit (I thereby to maintain and to propagate life.
Cor. 6:13-20)  J. Grundel: “Sexuality cannot and may not
 Married people are to maintain mutual love for become purely the means to private satisfaction
each other (I Peter 3:1-7). And there is parallelism of instinct nor a sort of easily available drug. It
between the bond that unites Christ with the gives man a goal beyond himself.”
Church and the bond of marriage (Eph. 5:21-33).
 There is a recommendation of virginity.

Transcriber/s: Eliza Marie Hererra, Nicxz Icaro


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PURPOSE OF SEXUAL LOVE CHRISTIAN ATTITUDE TOWARDS SEX AND
1. Propagation of mankind through procreation of SEXUALITY
children.  The Christian attitude towards sex and sexuality is
 This is the innate, ultimate purpose of man’s RESPECT AND REVERENCE.
sexual faculties  The nature of SHAME in the realm of sexuality is
 This is the nature-ordained end of sexuality fundamentally that of a protective instinct, built in
 It includes education of children by nature between a person and his fellow
2. A means to express mutual love  The moral virtue which disposes a man to meet
 Expresses mutual love and esteem the demands of shame in the realm of sexuality is
 Deepens the intimate unity of husband and wife MODESTY.
 Truly a human action that signifies and promotes  Modesty is a readiness to keep away from all
the mutual self-giving dangers rising against a person’s sexual integrity.
 If a person accepts this act in its whole Modesty is the protection and custodian for
significance and value as suited and intended for chastity.
the procreation of children he/she will be ready  FIELDS OF MODESTY
for such intimate love only with a partner whom  Conversation
he/she would like to be the father/mother of  Literature/reading
his/her possible child  Media (TV, radio, movie theatre)
3. Creates a community  Looks touches
4. Mutual love is enhanced and more perfectly  Fashion (dress)
achieved when man and woman are bound  Chastity is the moral force which keeps order in
together by a permanent union of common life. the sphere of sexual activity.
 Chastity is not only continence but is an attitude
SOCIAL ASPECT OF SEXUAL LOVE of reverence for the mystery of life and for the
1. Since sexuality orders a man toward other human personal dignity of the partner.
beings and since its complete actualization  Chastity shapes and orders the sexual powers in
involves a partner, in necessarily affects the social such a way that they are truly able to serve the
life of a community scholar human relation of conjugal partnership and the
2. Nobody can arbitrarily use another for the social need of the propagation of the community
satisfaction of one’s own sexual desires. He/She
has to respect the rights of the partner: PRINCIPLE OF PERSONALIZED SEXUALITY
 To his/her body  The gift of sexuality must be used in keeping with
 To the free disposition of him-/herself its intrinsic, indivisible, specifically human
 To a treatment worthy of a person teleology.
 To responsible care
 It must be a loving, bodily, pleasurable expression
3. Sexual relations give life to children who are the
of the complementary, permanent self-giving of a
future of the community. A sound family life is an
man and a woman to each other which is open to
essential condition for the guarantee of a healthy
fruition in the perpetuation and expansion of this
youth.
personal communion through the family they
4. Human sexuality possesses specific qualities
responsibly beget and educate
which demand a control of its energies for social
 Sex is a search for sensual pleasure and
living
satisfaction, releasing physical and psychic
tensions
 Sex is a search for completion of the human
person through an intimate personal union of love
expressed by bodily union
 Sex is a social necessity for the procreation of
children and their education in the family so as to
expand the human community and guarantee its
future beyond the death of individual members
 Sex is a symbolic mystery

Transcriber/s: Eliza Marie Hererra, Nicxz Icaro


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PART 2
PRINCIPLE OF PERSONALIZED SEXUALITY
 The gift of sexuality must be used in keeping with ENCYCLICAL LETTERS, PAPAL LECTURES
its intrinsic, indivisible, specifically human  Humanae vitae
teleology  Encyclical Letter of His Holiness Pope Paul VI on
 It must be a loving, bodily, pleasurable expression the Regulation of Birth
of the complementary, permanent self-giving of a  Evangelium vitae
man and a woman to each other which is open to  Encyclical Letter of the Supreme Pontiff John
fruition in the perpetuation and expansion of this Paul II on the Value and Inviolability of Human
personal communion through the family they Life
responsibly beget and educate.  Theology of the human body
 Pope John Paul II
PRINCIPAL VALUES OF HUMAN SEXUALITY
 Sex is a search for sensual pleasure and HOW HEALTH CARE PROFESSIONALS CAN HELP
satisfaction, releasing physical and psychic  Provide for an understanding of the unitive-
tensions procreative meaning of sexuality in marriage
 Sex is a search for completion of the human  Provide information on essential biological facts
person through an intimate personal union of love on sexual differences and equality, pregnancy and
expressed by bodily union birth
 Sex is a social necessity for the procreation of  Provide information on why people have a need
children and their education in the family so as to for children and on problems of sterility and the
expand the human community and guarantee its limits on the right to have children
future beyond the death of individual members  Provide information on the problems of
 Sex is a symbolic mystery responsible parenthood in present-day society,
natural family planning methods and alternative
SEX OUTSIDE MARRIAGE IS ETHICALLY WRONG methods and ethical evaluation of all birth
 Selfish pursuit of pleasure apart from love regulation methods
 Casual or promiscuous relations  Explain the rights of the unborn child
 May express love but not a committed love  Discuss the problems of genetic defects and the
involving true self-giving supportive attitude toward defective persons and
 Adultery or premarital sex may be committed, consider problems in psychosocial development
but practiced in a way contradictory to its natural
fulfillment in the family
 May be committed, but practiced in a way
contradictory to its natural fulfillment in the
family

-END-

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Transcriber/s: Eliza Marie Hererra, Nicxz Icaro


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Editor/s: Craig Angelo Reyes
CONFLICT-OF-INTEREST: DOCTORS
AND THE PHARMACEUTICAL
INDUSTRY
by
Angelica D Francisco, MD
DEPRESSION-SEROTONIN THEORY
LOW SEROTONIN LEVELS  DEPRESSION
ANTIDEPRESSANTS
• SELECTIVE SEROTONIN REUPTAKE
INHIBITORS, SSRI
2010
WebMD
“ Rate your risk for depression: could you be
depressed?”
10Qs
“I feel sad or down most of the time”; “I feel tired almost everyday”; “I have
trouble concentrating”; “I feel worthless or hopeless”
ANSWER “NO”
LOWER RISK: YOU MAY BE AT RISK FOR MAJOR DEPRESSION
DEPRESSION-SEROTONIN THEORY
ZOLOFT
“Zoloft may help correct the chemical
imbalance of serotonin in the brain.”
DEPRESSION-SEROTONIN THEORY
PAROXETENE (PAXIL )
“If you have experienced some of these
symptoms of depression nearly everyday,
for at least 2 weeks, a chemical
imbalance could be to blame.”
Objectives
• To identify the key ethical challenges in the
relationship between health professionals and
the pharmaceutical industry
• To define a conflict-of-interest situation and
describe why such situations are especially
troubling in medical practice
Doctors and the Pharmaceutical
Industry
“… AN INHERENT CONFLICT OF INTEREST
BETWEEN THE LEGITIMATE BUSINESS GOALS
OF MANUFACTURERS AND THE SOCIAL,
MEDICAL AND ECONOMIC NEEDS OF
PROVIDERS AND THE PUBLIC TO SELECT AND
USE DRUGS IN THE MOST RATIONAL WAY.”

(WHO Europe, 1993)


Conflict-of-Interest
“A person is in a conflict of interest situation if
he/she is in a relationship with another in
which s/he has a moral obligation to exercise
her judgment in that other’s service and, at
the same time, s/he has an interest tending to
interfere with the proper exercise of judgment
in that relationship.”

(Davis, 1982)
Key Ethical Principles
1. Respect for autonomy
-informed decision-making
2. Non-maleficence
-”do no harm”
3. Beneficence
- maximum benefit
4. Justice
-distributive fairness
PHYSICIAN’S FIDUCIARY DUTY
TO PROMOTE PATIENTS’ WELFARE ABOVE ALL
ELSE
1. BE LOYAL TO PATIENTS
2. ACT IN THEIR PATIENTS’ INTERESTS
3. MAKE THEIR PATIENTS’ WELFARE THEIR FIRST
CONSIDERATION
4. KEEP PATIENT INFORMATION CONFIDENTIAL
The revenues of the 12 largest pharmaceutical manufacturers on the Fortune 500
list range from $67.2 billion (Pfizer) to $5.5 billion (Celgene).

Source: http://www.drugchannels.net/2014/06/profits-in-2014-fortune-500.html
GSK FINED USD3 Bn, 2012
• GlaxoSmithKline fined $3bn after bribing
doctors to increase drugs sales
• Sales reps in the US encouraged to mis-sell
antidepressants Paxil and Wellbutrin and
asthma treatment Advair

Simon Neville The Guardian, Tuesday 3 July 2012


GSK FINED USD3 Bn, 2012
• Psychiatrists and their partners were flown to five-star hotels, on all-
expenses-paid trips where speakers, paid up to $2,500 to attend, gave
presentations on the drugs. They could enjoy diving, golf, fishing and other
extra activities arranged by the company.
• GSK held eight lavish three-day events in 2000 and 2001 at hotels in
Puerto Rico, Hawaii and Palm Springs, California, to promote the drug to
doctors for unapproved use.
• Those who attended were given $750, free board and lodging and access
to activities including snorkelling, golf, deep-sea fishing, rafting, glass-
bottomed boat rides, hot-air balloon rides and, on one trip, a tour of the
Bacardi rum distillery, all paid for by GSK.
• Air fares were also covered for doctors and spouses, in most cases, and
speakers at the event were paid $2,500 each.

Simon Neville The Guardian, Tuesday 3 July 2012


Another Glaxo Scandal In China: Bribing
Docs To Prescribe Meds?
• Glaxo sales reps allegedly provided doctors with
speaking fees, cash, dinners and paid trips in return for
prescribing various drugs. The allegations, the paper
writes, were made by an anonymous tipster, who sent
emails to the Glaxo board, senior execs and compliance
officers earlier this year.
• One example: sales reps there urged doctors to
prescribe the Lamictal epilepsy drug to patients with
bipolar disorder, which is an unauthorized use and one
patient became seriously ill, writes the paper, which
reviewed some of the documents. Glaxo acknowledged
an adverse event occurred, but maintained it was not
due to off-label marketing.
June 2013
Source: http://www.drugs.com/news/another-glaxo-scandal-china-bribing-docs-prescribe-meds-45062.html
NEWER NOT NECESSARILY BETTER…
“Disease mongering”
• Payer L.
“to inflate a common condition to the level of pathology”
“trying to convince essentially well people that they are sick, or
slightly sick people that they are very ill.”

• R. Moynihan. EDUCATION AND DEBATE Selling sickness: the


pharmaceutical industry and disease mongering.
Commentary: Medicalization of risk factors BMJ 2002; 324

• Joseph Lister, Listerine & halitosis

Dossey L. Creating Disease: Big Pharma and Disease Mongering. Huffington Post
http://www.huffingtonpost.com/dr-larry-dossey/big-pharma-health-care-cr_b_613311.html
“Disease mongering”
• Taking a normal function and implying that there’s something
wrong with it and that it should be treated
• Describing suffering that isn’t necessarily there
• Defining as large a proportion of the population as possible as
suffering from the disease
• Defining a condition as a deficiency disease or as a disease of
hormonal imbalance
• Recruiting doctors to spin the message
• Using statistics selectively to exaggerate the benefits of treatment
• Promoting the treatment as risk-free
• Taking a common symptom that could mean anything and making it
sound as if it is a sign of a serious disease

Dossey L. Creating Disease: Big Pharma and Disease Mongering. Huffington Post
http://www.huffingtonpost.com/dr-larry-dossey/big-pharma-health-care-cr_b_613311.html
“Disease mongering”
• ERECTILE DYSFUNCTION
• FEMALE SEXUAL DYSFUNCTION
• BIPOLAR DISORDER
• ATTENTION DEFICIT HYPERACTIVITY DISORDER
• RESTLESS LEG SYNDROME
• OSTEOPOROSIS
• SOCIAL ANXIETY DISORDER (SOCIAL SHYNESS
• IRRITABLE BOWEL SYNDROM
• BALDING
• AGING
Dossey L. Creating Disease: Big Pharma and Disease Mongering. Huffington Post
http://www.huffingtonpost.com/dr-larry-dossey/big-pharma-health-care-cr_b_613311.html
“Disease mongering”
• INCIDENCE OF CONDITION HAS BEEN EXAGGERATED IN
PURSUIT OF CORPORATE PROFITS
• PSYCHOLOGICAL COSTS
• FINANCIAL COSTS
• PERSONAL/SOCIAL COSTS

Dossey L. Creating Disease: Big Pharma and Disease Mongering. Huffington Post
http://www.huffingtonpost.com/dr-larry-dossey/big-pharma-health-care-cr_b_613311.html
Influence of pharma on physicians
• 8 out of 10 received gifts, usually free food at
their workplace
• 8 out of 10 received free medicine samples
• 4 out of 10 had their expenses paid to attend
meetings and conferences
• 3 out of 10 were paid consultants, on a
company speakers bureau or advisor board

Source: Campbell, 2007


Non-traditional forms of marketing
Physicians and “Gifts”
• GIFTS, FREE MEALS, TRAVEL SUBSIDIES,
SPONSORED TEACHINGS, SYMPOSIA
• OBJECTIVE: …TO IDENTIFY THE IMPACT ON
THE KNOWLEDGE, ATTITUDES AND BEHAVIOR
OF PHYSICIANS

Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000 Jan 19;283(3):373-80.
Physicians and “Gifts”
• INCREASING REQUEST OF PHYSICIANS FOR
ADDING THE DRUGS TO THE HOSPITAL
FORMULARY
• CHANGES IN PRESCRIBING PRACTICES
• DRUG COMPANY SPONSORED CME
HIGHLIGHTED THE SPONSOR’S DRUGS

Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000 Jan 19;283(3):373-80.
Physicians and “Gifts”
• ATTENDING SPONSORED CME EVENTS AND
ACCEPTING FUNDING FOR TRAVEL OR
LODGING FOR ATTENDING SYMPOSIA WERE
ASSOCIATED WITH INCREASED PRESCRIPTION
RATES OF THE SPONSOR’S MEDICATION
• ATTENDING PRESENTATIONS GIVEN BY
PHARMACEUTICAL REPRESENTATIVE
SPEAKERS WERE ASSOCIATED WITH
NONRATIONAL PRESCRIBING.

Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000 Jan 19;283(3):373-80.
Gift Economy
• Coffee mugs, free lunches
• Pen lights
• Knap sacks
• Stethoscopes
• Pocket textbooks
“… few doctors accept that they themselves have been
corrupted. Most doctors believe that they are quite
untouched by the seductive ways of industry marketing;
that they are uninfluenced by the promotional
propaganda they receive; that they can enjoy a
company’s ‘generosity’ in the form of gifts and hospitality
without prescribing its products. The degree to which
the profession, mainly composed of honourable and
decent men/women, can practice such self deceith is
quite extraordinary. No drug company gives away its
shareholders’ money in the act of disinterested
generosity.”

Rawlins, 1984
Effect of free samples on Rx
If promotion did not affect
treatment decisions, would
pharmaceutical companies pour
billions of dollars into marketing
targeting professionals, i.e. MDs,
each year?
• Codes of conduct for pharmaceutical companies
developed by industry organisations tend to be voluntary
but are often backed up by complaints procedures
• Most such codes prohibit companies from giving doctors
inducements to prescribe their products
• Many doctors' organisations offer guidance about
commercially funded researchJournal editors have issued
a statement aimed at preventing suppression of
unfavourable findings
• Guidance on good publication practice for pharmaceutical
companies was lacking until recently
• Dialogue between the interested parties is needed before
further guidance on the doctor-industry relationship is
issued
BMJ. 2003 May 31; 326(7400): 1196–1198.doi: 10.1136/bmj.326.7400.1196PMCID: PMC1126055
How to dance with porcupines: rules and guidelines on doctors' relations with drug companies
Elizabeth Wager, publications consultant1
Merck ordered to pay $321 million criminal fine for
illegally marketing Vioxx painkillerThursday, April 26, 2012
by: Ethan A. Huff

Drug giant Merck & Co., creator of the human


papillomavirus (HPV) vaccine Gardasil, has been
ordered by a federal judge in Boston, Mass., to fork
over $321 million in criminal fines for illegally
marketing Vioxx, a dangerous painkiller drug that was
pulled from the market in 2004 because taking the
drug doubles a patient's risk of having a heart attack
or stroke.Learn more:

http://www.naturalnews.com/035690_Merck_Vioxx_marketing.html
Patients’ Attitudes on Gifts to MDs
Sample: 486 Patients

Type of Gift Percent Awareness “Not alright”


Free drug sample 87 7.6
Ballpens 55.3 17.5
Medical books 34.6 16.9
Infant formula 28.6 44.2
Dinner at a 22.4 48.4
restaurant
Coffee maker 13.8 40.7

Blake RL Jr, Early EK. Patients' attitudes about gifts to physicians from pharmaceutical companies.
J Am Board Fam Pract. 1995 Nov-Dec;8(6):457-64.
Patients’ Attitudes on Gifts to MDs
• 32.5% DISAPPROVE OF MDs ACCEPTING
PAYMENT BY PHARMACEUTICAL COMPANY OF
MEDICAL CONFERENCE EXPENSES
• 28-43% DISAPPROVED OF MDs ATTENDING
SOCIAL EVENTS SPONSORED BY
PHARMACEUTICALS
• 70% BELIEVED GIFTS INFLUENCE MDs
PRESCRIBING MEDICATIONS
• 64% BELIEVED GIFTS TO MDs INCREASE
MEDICATION COSTS
Patients’ Attitudes on Gifts to MDs
CONCLUSION
APPROVAL RATES WERE HIGH FOR GIFTS
CONSIDERED TO BE TRIVIAL OR THAT HAVE
POTENTIAL VALUE TO PATIENT CARE;
DISAPPROVAL RATES WERE RELATIVELY HIGH FOR
GIFTS THAT HAVE SOME MONETARY VALUE BUT
HAVE LITTLE OR NO BENEFIT TO PATIENTS.
OPINIONS ABOUT GIFTS WERE RELATED TO
PERCEPTION OF EFFECTS ON PRESCRIBING
BEHAVIOR AND COSTS.
PHAP CASES: TOP FIVE INQUIRIES

Categories Particulars EC Ruling Remarks


1. CME Request to allow Committee cannot The ruling is
sponsorship of grant a waiver of any also in
conferences in Boracay existing rule in the consonance
and other venues present code. PHAP with the
deemed to be would like to preserve emerging global
entertainment and the integrity of the trend.
relaxation sites healthcare profession
by avoiding any undue
perception of influence
by the pharmaceutical
industry on their
prescribing habits and
Section 13.0 of the
Code is one of the
many safeguards
established for such
intention.
PHAP CASES: TOP FIVE INQUIRIES

Categories Particulars EC Ruling Remarks


2. Clarification Clinics are not
Independence on donation of considered
of Healthcare appliances, etc. institutions
Professionals to clinics of and hence,
doctors equipment or
appliances
cannot be
loaned or
donated.
PHAP CASES: TOP FIVE INQUIRIES

Categories Particulars EC Ruling Remarks


3.Promotional/ Clarification re Rulings are
Educational / applicability of Sec. applicable only to
Materials 4.5.4 as well as prescription or
Circular 065-05 ethical drugs and
not on OTC.
However, OTC
advertising is
allowed on
condition that
adverse effects are
also mentioned in
the promotional
materials.
PHAP CASES: TOP FIVE INQUIRIES

Categories Particulars EC Ruling Remarks


4. Post Request to EC did not find
Marketing consider adjusting justification to
Surveillance the investigator’s grant the request.
fee for the conduct
of the post
marketing
surveillance from
P1k to P5k
PHAP CASES: TOP FIVE INQUIRIES

Categories Particulars EC Ruling Remarks


5. Gift-giving Whether companies Reiterated Nov. 10, 2010
guidelines can give gifts during guideline , which stated,
the holiday season. “recognition of and in due
respect to the Philippine
Medical Association Code, the
Committee advised to follow
the PMA rule on gifts. In this
case, no contributions or gifts
should be given to physicians
to avoid compromising their
policy on this matter.
However, since the PMA does
not apply to other healthcare
professionals, we enjoin you
to please be guided of the
existing ruling under the
PHAP Code.”
BMJ. 2003 May 31; 326(7400): 1196–1198.doi: 10.1136/bmj.326.7400.1196PMCID: PMC1126055
How to dance with porcupines: rules and guidelines on doctors' relations with drug companies
Elizabeth Wager, publications consultant1
American Medical Student
Association’s PharmFree Pledge
“I AM COMMITTED TO THE PRACTICE OF MEDICINE IN
THE BEST INTEREST OF PATIENTS AND IN TH PURSUIT
OF AN EDUCATION THAT IS BASED ON THE BEST
AVAILABLE EVIDENCE, RATHER THAN ON ADVERTISING
OR PROMOTION.
I, THEREFORE, PLEDGE TO ACCEPT NO MONEY, GIFTS OR
HOSPITALITY FROM THE PHARMACEUTICAL INDUSTRY;
TO SEEK UNBIASED SOURCES OF INFORMATION AND
NOT RELY ON INFORMATION BY DRUG COMPANIES;
AND TO AVOID CONFLICTS OF INTEREST IN MY
MEDICAL EDUCATION. (AMSA, 2001)
ASSIGNMENT
READ ARTICLES BY:
• Brennan TA, etal. Health Industry Practices
that Create Conflicts of Interest
• Dana J, Loewenstein G. A social science
perspective on gifts to physicians from
industry.
• Moynihan R. Who pays for the pizza?
ASSIGNMENT
Position paper: Choose ….
“There is no ethical conflict in physicians
receiving gifts/money from pharmaceutical
companies.”
OR
“It is ethically unacceptable for physicians to
accept gifts/money from pharmaceutical
companies.”
ASSIGNMENT
• 2 pages, font arial/calibri 11, 1.5 space
• 1” margins
• Submit on: 7October 2014 (Faculty Rm, 3rd F)
References
• Angell, M. The truth about drug companies. How they deceive us and what to do
about it. 2004
• Blake RL Jr, Early EK. Patients' attitudes about gifts to physicians from
pharmaceutical companies. J Am Board Fam Pract. 1995 Nov-Dec;8(6):457-64.
• Goldacre B. Bad Pharma. Harper Collins Publishers, 2012.
• Health Action International. Understanding and Responding to Pharmaceutical
Promotion: A Practical Guide
http://www.haiweb.org/10112010/DPM_ENG_Final_SEP10.pdf
• Quan SF. , Do You Have A Minute? The Dilemma Posed by Physician Interaction
with the Pharmaceutical Industry J Clin Sleep Med. 2007 June 15; 3(4): 345–346
• Rodwin MA. Medicine, Money & Morals: Physicians’ Conflicts of Interests. Oxford
University Press, 1993
• Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift?
JAMA. 2000 Jan 19;283(3):373-80.
END-OF-LIFE CARE
Paul Dexter C. Santos, MD, FPCP, FPSMO
October 13, 2014; 10:00 AM – 12:00 NN
Bioethics III

OUTLINE  PVS: Permanent Vegetative State


 Case 1  Unable to interact with the environment,
 Brain States “eyes-open” state (vs. COMA which is a
 Brain Death “closed-eyes” state)
 Artificial Nutrition/Hydration (ANH)
 Cannot be classified as conscious
 Brain Death and Organ Donations
 COMA NA DILAT
 Case 2
 Medical Futility  Permanent if > 3months after an anoxic
 Case 3 injury or >12months following traumatic
 Withdrawing/Withholding Life-Prolonging injury
Treatments  Anoxic – no oxygen to the brain for
 Euthanasia and Assisted Suicide 30minutes or more
 Allowing to Die  Patients with cardiorespiratory
 Case 4 arrest
 Terminally Ill  Brain Death
 Case 5  Irreversible cessation of all brain function
 Challenging Autonomy
(cortical and brain stem)
 Advanced Directives
 EEG – flat line
 Legally dead
CASE 1  Cardiac Death
 Cessation of cardiac physical and electrical
A 45 year old man had a motorcycle accident last activities
year and is presently in a permanent vegetative state. He  In the advent of advanced life support
is dependent on a feeding tube where he is being fed and systems, it is difficult to base the actual
hydrated. He has been in this state for more than 12
occurrence of death with cardiac death
months and the family is experiencing “caregiver fatigue”.
The family members know that there is really no chance of  Brain death = actual death
the patient returning to previous functionality and
productivity and they made a court appeal if they can BRAIN DEATH
already remove the feeding tube.  Clinical determination
 Absence of cortical function:
 Unresponsive and unarousable
a) What is the condition known as the “permanent
 Absence of brain stem function:
vegetative state”?
 Absent reflexes (gag, papillary,
b) What will be your opinion with regards to the
corneal), no spontaneous breathing
withdrawal of the feeding tube? Please defend
 EEG: No brain activity
your answer.
 In the clinics, usually doctors rely on
c) Is ARTIFICIAL NUTRITION AND HYDRATION
clinical like the PE findings and the like
(ANH) comprise proportionate (ordinary) or
disproportionate (extraordinary) treatment?
ARTIFICIAL NUTRITION/HYDRATION (ANH)
 There is no wrong answer as it is still a subject
of debate  As per the Catholic Church
 Is an ORDINARY treatment and IS
MANDATORY
BRAIN STATES
 Life prolonging measures should not be given
 MCS: Minimally Conscious State
IF THEY ARE INEFFECTIVE
 State of wakefulness
 In CASE 1 – ANH can prolong the life of
 Fluctuating awareness of self and
the patient as per doc; family should
environment
also be considered in decision making
 Potential for re-activation or “emergence”
 For some dying patients, ANH may increase the
being able to do or be able to respond to
stimuli discomfort
 Bloating
 Abdominal cramps
 Diarrhea
 In these situations, doctors should carefully
evaluate and communicate with the patient and
relatives
 In these situations, ANH may not be given
since it contributes to the discomfort of the
patient

Transcriber: Nicxz Icaro


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 TERRI SCHIAVO Case MEDICAL FUTILITY
 Ruled to be in permanently vegetative state  Hippocrates: “Refuse to treat those who are
after anoxic brain injury overmastered by their disease, realizing that in
 Long legal battle in the US which eventually such cases, medicine is powerless”
resulted in a decision to remove the feeding  Clinical action serving no useful purpose in
tube in 2005 attaining a specified GOAL for a given patient
 Husband wants tube removed but the family  GOALS should be established:
(parents and siblings) countered  Cure or palliation?
 Florida court agreed to remove feeding tube  Keep alive or return to full functionality
March 18, 2005  Goals to be discussed with patient and
 George Bush signed an emergency law on relatives
March 21, 2005 allowing the parents of Terri  Important to SPECIFY THE GOAL to the
to appeal the court’s decision RELATIVE
 Schiavo died March 31, 2005  Example: Goal for intubation is to provide
oxygenation
BRAIN DEATH AND ORGAN DONATIONS  If for palliation, specify to the relative that it
 Importance of knowing the time of brain death will not make the patient well and go back to
is for organ donation work
 Those who are brain dead but whose circulation is
supported by artificial means, can be approached CASE 3
for the possibility of organ donation
 Obtaining consent from relatives should be done
A 70 year old male has multi-drug resistant
in a humane and empathic manner
staphylococcal pneumonia and has stayed at the intensive
 May be present in some living wills care unit for 2 weeks. He is on mechanical ventilator and
inotropic drugs to maintain his blood pressure. All possible
SUMMARY antibiotics were already used and the patient is not
 FOR ANH responding to treatment. The blood pressure is declining
 Should not be removed since it is an ordinary despite maximum inotropic support, and his level of
treatment that can provide nourishment to oxygenation is dropping despite full oxygen support. He is
the patient. mostly unconscious but can be awaken for short periods.
His family is contemplating on stopping inotropic support
 But still depend on the morality of the
and mechanical ventilation.
individuals involved and the legality of the
process in the country
a) Will stopping mechanical ventilation and inotropic
CASE 2 support constitute euthanasia?
b) Are these measures (inotropic, mechanical
ventilation) considered extraordinary measures to
An 85 year old male with stage IV lung cancer prolong life?
went to the emergency room for difficulty breathing. His X-
 Inotropic – disproportionate
ray showed multiple lung masses and nodules occupying
aggregately about 70% of his lungs. He also developed c) c. Would you agree in discontinuing these
severe sepsis from a concomitant pneumonia and his treatments?
kidneys are failing due to the infection. At this time, the
patient will require intubation with mechanical ventilation, WITHDRAWING/WITHHOLDING LIFE PROLONGING
and hemodialysis from a strictly medical point of view. The TREATMENTS
relatives of the patient said “do everything” despite the  Withdrawing
doctors stating the incurable state of the cancer.  An act of commission
 Decide and commit to discontinue an
a) As a relative, what further information would you ongoing treatment
require from the doctor to help you in making  Withholding
decisions?  An act of omission
 Pros and cons of the treatment  Treatment is not given in the first place
 Cost of treatment  Legally, there’s no legal difference (BMA 1999)
 Survival and success rates  Ordinary (proportionate) means vs. extra-ordinary
b) As a doctor, what treatment goals would you set (disproportionate) means of sustaining life
for the patient?  No obligation for doctors to provide
 Palliative – support or minimize the disproportionate, ineffective or even experimental
discomfort, treatment of other symptoms treatment
c) Would you strongly recommend mechanical  Withdrawing disproportionate treatment –
ventilation and hemodialysis? Why or why not? NOT CONSIDERED EUTHANASIA since the
 YES – since the family stated to do disease will take the natural course
everything, and as long as the family can
sustain the treatment financially

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EUTHANASIA AND ASSISTED SUICIDE  BIOETHICAL PRINCIPLES
 Taking deliberate action to end a life of another  Beneficence: acting in the best interest of
person on compassionate grounds the patient
 The primary objective is to achieve the death of  Non-Maleficence: first do no harm
the person and not merely allowing death to  Autonomy: patient’s right to choose or
occur refuse treatment
 Illegal in most countries  Justice: decision of who gets what
 Legal: NETHERLANDS, BELGIUM, treatment
SWITZERLAND
 Church: euthanasia is a homicide act which no CASE 5
end can justify
 Maximize pain management, hospice care and
A 75 year old man who was a chronic smoker has
psychological counseling been living with emphysema for the past 7 years. The past
 DIGNITAS CLINIC, SWITZERLAND 6months, he has been dependent on oxygen at home, but
 Sir Edward Downes and wife Joan would still have difficulty breathing even on light
 Conductor – BBC Philharmonic Orchestra movements. The past week, he called his lawyer to write
 Died July 10, 2009 via assisted suicide at the down his will and advanced directives. His will states that if
Dignitas Clinic in Switzerland ever his breathing becomes severely labored, he would not
 Suffered from progressive deafness and blindness want intubation and mechanical ventilation to be done.
 Lady Downes had Stage IV pancreatic cancer And if ever his heart and circulation stops, he would not
want CPR to be done. One day, he slipped while inside the
ALLOWING TO DIE bathroom and went unconscious after hitting his head on
 It is the condition or the disease that causes the the floor. His wife brought him to the emergency room.
death of the person, not the deliberate acts of The doctors advised intubation and mechanical ventilation
the doctor to control the swelling of the brain due to the trauma.
Intubation has a good chance of saving the patient’s life.
 Discussed in the context of medical futility and The patient’s wife brought up the will that no intubation
withholding of extra-ordinary means of should take place.
prolonging life

a) What will you do in this situation? Defend your


CASE 4 answer.
 Respect the will
A 45 year old male lawyer is diagnosed with  Proceed with the intubation since the
Stage IV pancreatic cancer. You told him that though the circumstance is different from what is stated
disease is incurable by modern medicine, treatment can in the will
still be given to control cancer spread and add a few to
several months to his overall survival. After a long
discussion, he decided not to take any form of treatment
CHALLENGING AUTONOMY
whatsoever and just let the disease take its course.  If the person is not capable of reasoning
 If other people believe that the person is misinformed
 If the decision of the person is not in accordance to his
a) As his physician, are you obliged to convince him known values and beliefs
to undergo treatment?  Patient’s decision should not be overturned just
 Obliged to give information not to convince because it does not conform with societal norms
b) He was admitted several months later due to lung (autonomy will be meaningless)
and liver failure due to spreading cancer. This time
he asks you to “do everything” and invokes his ADVANCED DIRECTIVES
right to self-determination and autonomy. What  Advanced decision are legally binding
 Must be made by an adult who is well informed
will you do?
 Validity of long standing advanced refusals may be
 Can do in the context of the situation
questioned if treatment options are substantially
 Give goals, treatment options and outcomes different
 Consider if circumstances are different from what is
TERMINALLY ILL stated in the will
 When the state of one’s health deteriorates to  If there is no written will and the patient becomes
an irreversible and fatal condition incapacitated to decide, then the “presumed wishes” of
 Right to life… right to death with dignity the patient have to be implemented (doctrine of
substituted judgment)

-END-

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MATERNAL-FETAL CONFLICTS IN BIOETHICS 1
Maria Carmelita J. Nadal-Santos, MD, FPOGS
November 5, 2014; 9:45 AM – 11:30 AM
Bioethics III

OUTLINE WHEN DOES IT BECOME ILLICIT?


 Disclosure  LICIT is morally acceptable; if it is ILLICIT, it
 Termination of Pregnancy becomes erroneous or illegal
 Is Termination of Pregnancy Morally Acceptable?  When you say when it becomes morally illicit?
 Abortion
 It is asking the question “Kailan hindi
 Erroneous Justifications
nagiging tama?” or “When does it become
morally bad?”
DISCLOSURE  It becomes acceptable (acceptable means you
 Any facility identified as Catholic assumes with are free of moral responsibilities and it is the
this identification the responsibility to reflect in right thing to do) if:
its policies and practices the moral teachings of  INTRAUTERINE CONDITIONS become
the Church unfavorable for the developing fetus to
 NOT A MATTER OF OPINION continue specially if the fetus has reached
 The medical profession is always at the SERVICE the period of viability.
OF LIFE  If the conditions inside the mother’s
 Many moral problems of relevance today womb make it dangerous for the fetus to
stems from conflicts arising from the life of stay longer and the fetus is already
the mother and the fetus viable, then there is no sense to prolong
the pregnancy, so terminate the
In telenovelas, characters are always given the option to pregnancy. The decision becomes easier
choose between the mother and the baby, but in real life, when the fetus is already viable.
this is not really an option. So yung mga nasa drama na  In cases of:
nagsasabing wala tayong magagawa at kailangan mamili  Pre-eclampsia
kay mommy at kay baby is wrong because the rights of the  Since the intrauterine conditions are
baby is totally and completely the same as the rights of the not good for the fetus, you terminate
mother, the same rights each and every one of us has. and prepare the fetus. Give antenatal
steroids, antihypertensive
medications, so on and so forth.
TERMINATION OF PREGNANCY  Oligohydramnios
 Terminate the pregnancy. No need
There is always a bad connotation when you say for resuscitation, such as intra-
“termination of pregnancy” but it is actually only a amnionic infusion or any other heroic
terminology that says to put an end to pregnancy. There is no methods because the baby is already
moral responsibility. It only means to stop the pregnancy viable.
from progressing, regardless of the age of gestation. It can be  Premature rupture of membranes
medical (use of drugs), operative or surgical.  The danger in dealing with PROM are
the intrauterine infections or
chorioamnionitis
 Putting an end to the progression of pregnancy
 To stop the pregnancy from progressing The late Dra. Ferrolina once told Dra. Nadal, “Carrie,
 Regardless of the age of gestation mabuti ng ilabas mo ng buhay kesa mamatayan ka sa loob
 Covers different methods ng tiyan. Pagnilabas mo yang premature, problema ng pedia.
 Medical, operative or surgical Pero pag namatay yan sa loob ng nanay, ikaw ang may
procedures kasalanan niyan.” [HAHAHA. WHAT AN ADVICE :))]

IS TERMINATION OF PREGNANCY MORALLY


MATERNAL INDICATIONS
ACCEPTABLE?
 Hemorrhagic conditions in pregnancy
 IT DEPENDS ON THE SITUATION
 i.e. Placenta previa –
You cannot do anything with placenta
WHEN DOES IT BECOME ACCEPTABLE? previa. You are faced with a placenta totally
 When you say acceptable, it is RIGHT covering the internal os. You cannot predict
 It is not acceptable if you’re not at peace with your when the mother will contract or when she
conscience or if it’s only considered acceptable will have internal hemorrhage. If the baby is
because it is what the majority does viable, terminate. There is no need for the
mother to bleed to death. Opt for elective
cesarean section instead, terminate right
away and don’t wait for the full 39 weeks
gestation period. At times, the pregnancy is
terminated if there is already sonographic
signs of fetal maturity and if the fetal weight
is good.

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 Medical conditions CLASSIFICATION OF ABORTION
 i.e. Eclampsia a) Spontaneous
 Tonic-clonic seizure is an indication for b) Induced / Direct / Provoked / Intentional / Artificial
termination of pregnancy because the / Voluntary
intrauterine conditions are no longer c) Indirect Abortion
favorable. d) Threatened Abortion
 Termination of pregnancy becomes morally e) Inevitable Abortion
illicit when it is willed as the principal end or as a f) Therapeutic Abortion
means to an end as in direct induced abortion.

WHEN DOES LIFE BEGIN? A. SPONTANEOUS ABORTION


 FERTILIZATION  Accidental / involuntary / ovular / causal
 At the level of the fallopian tube pa lang,  Occurs as a result of natural causes:
life na yan.  Involuntary
 Biological and genetic truth  No moral value
 Genetic code of the fertilized ovum is  Free from any human responsibility
DISTINCT from that of the father and of the  “Nakunan”
mother (totally different human being)  There is no dilemma with regard to
spontaneous abortion
ARE YOU CONVINCED OF THIS FACT? ARE YOU
CONVINCED ENOUGH THAT YOU CAN MAKE A B. INDUCED / DIRECT / PROVOKED / INTENTIONAL /
STAND FOR IT? ARTIFICIAL / VOLUNTARY ABORTION
(If you answer yes, it should not only come from the mouth but  Results from voluntary human intervention
from the heart. Naks naman!) purpose is to terminate pregnancy
 A FUTURE DOCTOR WHO IS COMMITTED  You become accessory to the crime even if you only
WITH THE CONVICTION TO PROTECT AND give an advice or if, for example, the patient asks
DEFEND LIFE (conception to natural death) you to buy “pampalaglag” at Quiapo and you don’t
 You have to realize from the depths of your refuse, then you are already an accessory. If a
heart that fertilization and life is patient comes to you for advice, that is the golden
synonymous because you will be giving opportunity to advice the patient on what to do.
Not to condemn them for their acts, but to
advice to people about the implications. Are
understand and help them.
you a doctor who will prescribe
 Directly willed as the principal end, or as a
contraceptives? Because that is the
means to an end, regardless of whatever
implication of contraceptives, they prevent
means.
ovulation. But if you will look at the
 The intention is there, para malaglag.
prescribing information, it is not 100%
That is morally unacceptable.
anovulation. What becomes of the 2-3%?
 ALWAYS IMMORAL
There is fertilization.
 An excommunication is attached to those
directly responsible for creating the decision
“Human life must be respected and protected and implementing the decision to induce
absolutely from the moment of conception. From abortion
the first moment of his existence, a human being  Life threatening conditions, resulting from
must be recognized as having the rights of a this type of abortion, will be treated in the
person – among which are inviolable right of every hospital but said treatment shall not be
innocent being to life.” ~Congregation for the deemed as approval of such abortions.
Doctrine of the Faith, DONUM VITAE  If treated, it is because the mother is
also a patient, a human being in need
 “You have to guide your family, friends, loved ones of treatment
and every soul around you on what is the right  The mother will be referred for
thing to do because you want to be morally upright counseling.
doctors, di ba? Being a doctor is a gift and you have
to use it wisely, correctly, giving glory to God, who DIRECT / INDUCED ABORTION
is the source of our life. It is God’s love who is giving  Can be LEGAL or ILLEGAL and CRIMINAL
us this wonderful experience, this wonderful life.”  LEGAL
~Dra. Nadal
 Is what civil law permits in certain
cases, not punishing those who
ABORTION
perform it (Singapore, USA, Japan,
 Termination of a pregnancy at any time after
China)
fertilization and before viability of the fetus
 This is NOT SYNONYMOUS WITH
 Abortion is until 20 weeks; beyond 20 weeks,
LICIT (which is not being punishable by
it is not termed as abortion anymore
the law)
 An aborted embryo should be respected as  Coincides with the so called
deceased human person and should be blessed if THERAPEUTIC ABORTION
requested or permitted by the family.

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Legality is not the same with being morally upright. There C. INDIRECT ABORTION
will be no repercussions from the law but it will not save you  Foreseen but merely permitted, side effect of a
from being responsible for your actions. These legal abortions procedure which is directed toward some good
at times coincide with what is so called the therapeutic end and legitimate purpose
abortion. It may sound good because that means you’re  Is not wanted nor sought directly
treating the mother, but it is actually a form of induced
 It lacks voluntariness, the essential characteristic
abortion.
by which a man becomes responsible for his acts.
 It is rather the consequence of an unavoidable
 ILLEGAL circumstantial accident
 Prescribed and prohibited by civil law  In cases of ectopic pregnancy, the dangerously
 CRIMINAL pathologic part of the mother may be removed
 Punishable by law and the loss of the embryo is indirect or incidental
 In our country, it is illegal and is to the surgery
punishable by law.  Remove the dangerously pathologic part of
the mother, which is the fallopian tubes,
PURPOSE OF CLEARING CONFUSION regardless of which part. It may be removed
 At the level of public opinion, to identify [and and the loss of the life of embryo is indirect
differentiate] the LICIT with the LEGAL and incidental to the surgery.
 DIRECT ABORTION IS ALWAYS ILLICIT
and NO HUMAN LAW can make it good or Dra. Nadal once had a case wherein the patient came in
legitimate to justify it, because the right to because of right lower quadrant pains. There was an
life comes directly from God and not from adnexal mass with cardiac activity, but because of the
the parents, nor from society, nor from any Principle of Double Effect, knowing that the patient will not
other authority survive knowing that the fallopian tube cannot facilitate the
 No matter how much you look at it, to growing embryo, will you subject the patient to emergency
kill the life of another being, especially laparotomy right away, knowing that the cardiac activity of
the baby is still there? Yes, because if you don’t, it will rupture
one without defenses, is always
and cause hemorrhage on the mother. Transfusion would
irrevocably and undeniably wrong. have to be done, which would endanger the mother’s life
more. You are not trying to abort the baby directly, but
Minsan, kung sino pang tama, siya pa yung nahihiya. because it would eventually abort and the fallopian would
Kahit ikaw na lang ang nagiisa, kapag tama ka, wagi ka pa rupture, you can already proceed to do laparotomy. The evil
din, because at the end of our life, we will be judged effect there is the removal of the growing embryo, but the
according to what we’ve decided and what we’ve done with good effect is that you saved the life of the mother from
your life. At the end of the day, you can face God and you extensive hemorrhage. The intention is good because ectopic
can say. “Lord, I have loved you and I have defended you.” pregnancy is aborted even if nothing is done.
Because it is God working in us that should prevail.
 Another example is the removal of bleeding
“Life must, from its conception, be safeguarded cancerous uterus because you cannot do
with the greatest care; abortion and infanticide are anything. The mother is tremendously
abominable crimes.” ~Gaudium et spec, no. 51 cf. no bleeding, the fetus will eventually abort so
27 remove it.

 Human life is beset with conflicts of values


 Total respect for human life and condemnation because there are actions which aside from
of direct/induced abortion is NOT confined to producing a good effect, cause an unwanted evil
Christians effect which are inseparable.
 It is conviction and a rule of conduct shared by  “Principle of double effect”
non-Christians, founded on what a PERSON is  Intention of the agent is morally good, the
and should be evil effect is foreseen and permitted but not
 The right of life comes from God, not from wanted, is avoided in so far as possible
parents or from society.  Removal of a bleeding, cancerous uterus in a
pregnant woman
Dra. Nadal once had a patient, currently pregnant at the
time, who was a G9008 who wanted to have the baby D. THREATENED ABORTION
aborted. Dra. Nadal advised her patient that had her  Signs and symptoms of premature expulsion of
parents not been generous with her, then she would not be
a non-viable fetus (bleeding, cramps)
here at all. Having a baby may be expensive but the
happiness they give parents is priceless.  No moral problem, but by how long must a mother
go in terms of bed rest? General inactivity?
Some say, “dugo pa lang naman yan doc eh, walang laman.”  Principle of Charity
Knowing that life begins with fertilization, you know that life  Mother is obliged to undergo this sacrifice to
is already there. try to preserve the pregnancy as long as there
is real hope of saving the infant
 Mothers and fathers can be very
heroic!

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Dra. Nadal once had a patient with incompetent ERRONEOUS JUSTIFICATIONS
cervix. Cerclage was done and the patient has to be in
complete bed rest because if the uterus will contract, it will PSYCHOLOGICAL WELL-BEING
dilate the cervix and can tear up the cervix, leading to  Little basis
bleeding. Dra. Nadal did the cerclage 12 weeks AOG after  Psychiatrists know well that modern therapy can
ultrasound with viable fetus. The husband asked her how solve any psychiatric problem precipitated by
long the patient has to be in bed rest, to which she answered
pregnancy
until the patient gives birth. The husband was concerned who
will do the household chores. During one of the check-up (sa  Abortion has caused a lot of mental
house ng patient kasi complete bed rest), she saw the disturbances
husband heating water for him to bathe his wife. So you see,  “The women for whom abortion is justified
if you marry the right person, it is heaven made. So the are the very same ones who carry the
principle of charity here is that the mother is obliged to highest risk of mental disorders once
undergo this sacrifice to try to preserve the pregnancy as long abortion is performed” ~WHO
as there is real hope to save the infant.
The problem with induced abortion is because
they are not ready to have a family secondary to Dra. Nadal had a patient who wanted to have induced
premarital sex. The bottom line is when you love the person abortion and no matter how much she tried to persuade her,
you have to love them as a person with dignity. Don’t allow she went ahead with it. After that she had some sort of
the relationship to be at the level of sex. You have to control postpartum psychosis because every night she would hear a
your sexual appetites, because if not, that will result to baby crying. Psychological trauma would affect them more.
unwanted pregnancy that will destroy your innate self
because that is abuse of yourself, just like taking drugs. Sex is FREEDOM TO DECIDE FOR ONE’S BODY
not supposed to be left and right. It has to be controlled
because you have this innate dignity. Do you agree?
 Feminists’ outcry:
Sabi nila, if you cannot do the act in front of  “My body belongs to me”
your parents, then don’t do it. Set limitations so that the  They believe that the fetus as a mere
standard is set and you avoid temptations. No matter how appendage of the mother’s body which
strong you are, if you put yourself in that situation, sabi nga can be removed according to her free
nila, “I am but human.” decision
 The new human being in her womb
E. INEVITABLE ABORTION possesses its own genetic apparatus
 Abortion cannot be prevented anymore distinct from that of the mother.
 Membranes are ruptured, minimal to profuse  She may have the right to her body but
vaginal bleeding (depending on the placental not over the unborn who is another
separation or attachment) human being and not just a part of her
own
 Moral difficulty:
 It is not morally acceptable if the fetus is
RAPE OR INCEST
not dead.
 It is also not morally acceptable to hasten  Reason why some hospitals justify giving
the inevitable abortion morning-after pills
 Abortion does not necessarily remove nor
 Ensure minimal bleeding, vital signs of the mother
reduce the trauma; on the contrary it
are stable, conservative management – letting
increases it
nature take its place
 To kill the innocent to atone for the fault of
 In cases wherein the obstetrician rightfully judges
the father is always illicit
separation of the placenta so irrevocably
progressed, to empty the uterus in an attempt to
save maternal life, fetal death is neither sought *Who among you thinks or agrees that the rapist should be
nor intended for punished by death? Then why kill the innocent child? The
fetus has no reason to pay with his death for the sin of his
father. He is innocent.
F. THERAPEUTIC ABORTION
 The current permissive legislature considers as
an indication for abortion any pregnancy which EUGENICS (Greek, “EUGENESIA”, “to engender
endangers the life of the mother well”)
 Risks to life of the mother is anything that  To procreate healthy offspring (positive) and
affects the physical or even psychological health avoid the birth of defective offspring (negative)
of the mother  Prenatal diagnostic tests:
 Aside from the physical, they may also say  Amniocentesis
that they are not yet ready to become a  Chorionic villi sampling
mother.  Ultrasound
 Undoubtedly pregnancy can occasionally  It becomes illicit, when selective induced abortion
aggravate maternal health to such a degree as to is intended
endanger her life but INTENSIVE OBSTETRIC  A diagnosis of malformation or hereditary disease
CARE has allowed may pregnancies to continue must not be equated with a death sentence
in spite of complications  Life is valued not for its normality nor future
productivity but for its intrinsic dignity
“To save the life of the mother is a lofty goal, but to
directly kill her baby as means to achieve this is not -END-
permissible.” ~Pope Pius XII, Address, Oct 29, 1951 But wait… There’s more.

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MATERNAL-FETAL CONFLICTS IN BIOETHICS 2
Maria Carmelita J. Nadal-Santos, MD, FPOGS
November 10, 2014; 10:00 AM – 12:00 NN
Bioethics III

OUTLINE BIOETHICAL CONSIDERATIONS IN


 Principles of Inviolability of Human Life
 Principles of Double Effect SPECIFIC CONDITIONS
 Ectopic Pregnancy
 Bioethical Considerations in Specific Conditions: ECTOPIC PREGNANCY
 Chorioamnionitis  Any gestation developing outside the uterus
 Eclampsia  Implantation of the ovum in the fallopian tube
 Hemorrhages of Pregnancy presents a SERIOUS pathological situation 
 Hydatidiform Mole RUPTURE  SHOCK  DEATH
 Cancer
 Utilizing the PRINCIPLE OF DOUBLE EFFECT
 Dangerous maternal tissue may be surgically
PRINCIPLES OF INVIOLABILITY OF HUMAN LIFE
removed, the loss of the fetus is indirect
 Destruction of one life CANNOT become a mere
incidental to the surgery
means to saving the life of the other
 It is a SECONDARY ABDOMINAL PREGNANCY
 Each life is equally important with its own
 Moral aspect – it must be permitted to
dignity
advance if possible to viability
 Actual crisis of DANGEROUS
PRINCIPLES OF DOUBLE EFFECT
HEMORRHAGE
 Choosing a decision that produces a good effect
 Surgical intervention to control the
(intention is morally good) but there is an
bleeding is permissible provided NO
inseparable unwanted evil effect which is
DIRECT ATTACK is made on the fetus
foreseen and permitted but NOT wanted and is
 If there is bleeding then do blood
avoided as much as possible
transfusion and try to be conservative
 So the thing here is that the evil effect is unwanted
but you allow it because it will eventually happen
as much as possible
but you do not intend – you are not the cause, you  If there is minimal bleeding and the
are not the reason why it is happening it’s just the vital signs are stable, then you allow
effect the pregnancy to continue
 If there is tremendous hemorrhage
WHICH LIFE IS TO BE PREFERRED? WHICH LIFE IS TO threatening the life of the mother,
BE SAVED? then you can intervene right away; but
 Maternal and fetal life are treated with equal in ectopic pregnancy, since there is no
reverence and the inviolability of each is equally possibility that the life of the baby reach
respected viability, so you could already
 Example: Mother with uterine cancer, not intervene
bleeding, needing chemotherapy 12 weeks AOG.  The same principles apply to other types of ectopic
What will you do? The life of the mother at this pregnancy of ovarian and cervical pregnancies.
point in time is not at stake, thus giving
chemotherapy which is fetotoxic is already giving
CHORIOAMNIONITIS
preference to the mother so there is violation of the
rights and the life of the baby. In 14 weeks AOG  PROM occurring before viability of the unborn
with uterine cancer, do you think the baby can child is accompanied by the threat of
survive? INTRAUTERINE INFECTION
 Answer: Yes, it can progress and can turn out  No moral issue – if viable fetus  DELIVER
to be a mature human being- it is very easy  MORAL DILEMMA
for us to decide in preferring the mother  Fetus is not viable
especially if the pregnancy would still need a  Serious infection
very long time but if you are guided with the
 Maternal and Fetal
principle that each life is valuable then you
would consider otherwise.  It is ideal to continue the pregnancy until
viability
Ang common na iniisip ng tao ay kapag baby yan pwede na,
 Antibiotics to control infection
kasi ang preferred ay nanay, total ang intention ay mabuti –
MALI!!!  Medical intervention to hasten fetal lung
maturity
 Unless the life of the mother is threatened  Diagnostics:
like in placenta previa, especially if the baby
 Blood tests, fetal surveillance studies
is premature, so you don’t have any choice.
As long as you prefer the baby you are not (ultrasound)
morally responsible for it.
 The moral approach to maternal-fetal conflicts is
toward medical or surgical intervention which
offer to achieve both maternal and fetal safety

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EXAMPLE: 22 weeks AOG, ruptured bag of water what  Some obstetrical texts advise immediate
will you do? termination of pregnancy even when there is no
hope that the fetus can survive outside the uterus.
Answer: Don’t deliver right away. You have to do your  Such procedure is viewed as DIRECT
diagnostics – do CBC. Try as much as possible to control ABORTION and in violation of the uniquely
infections by giving antibiotics and try to give divine prerogative of absolute dominion
dexamethasone or steroids for fetal lung maturity. Also, do
over human life
your fetal surveillance studies. Prepare an Intensive Neonatal
Care / environment that would offer a better chance of
 Like the mere presence of convulsion in
survival than the baby be left alone to survive in the infected 22 weeks AOG, you cannot terminate
uterus. Or in some cases, transfer to a perinatology hospital the pregnancy because such
intervention is tantamount in doing
Advice that Dra. Nadal gave to her Colleague: If the direct abortion because we could still
parents really want to deliver the patient in 29 weeks old, control convulsion.
then they should transfer into higher perinatal center who  The PRINCIPLE OF DOUBLE EFFECT CANNOT
has a better success rate than our hospital. If they don’t want BE USED HERE because the evil effect (removal
to continue with the pregnancy then okay but refer so that
of the fetus) is directly willed since it is envisioned
the fetus has bigger chance of survival. It’s not a matter of
losing money because you refer but a matter of exhausting all as a necessary means to produce the good effect
possible help to the parents and to the baby. Even if you end (control of eclampsia).
up losing the patient, it is okay as long as you were able to
give the best care to the baby available here in the HEMORRHAGES OF PREGNANCY
Philippines.  Conservative and expectant management when
possible to achieve both maternal safety and
fetal salvage
“If the available intensive neonatal care is judged  With the use of ultrasound, we can already
to be incapable of prolonging the extra-uterine life diagnose early the presence of placenta previa
of the baby for any considerable length of time, it , so at early age we could already advise to go
is clear that the emptying of the uterus, even to on bed rest, to be closely monitored by an
avert serious danger for the mother, would simply obstetrician and she will be prepared early
be a direct abortion which the fact that the infant enough that she needs to be delivered in the
is going to die anyhow would neither justify nor hospital.
change.” ~Thomas J. O’Donnel, SJ  Use the PRINCIPLE OF DOUBLE EFFECT
 What is Important is the moral distinction
-No matter how young the baby is, we give life to the unborn.- between DIRECT AND INDIRECT
ABORTION
ECLAMPSIA  To DIRECTLY kill the fetus or to uproot it
 Begins with uncontrolled hypertensive from its site of implantation is never
condition of the mother morally acceptable
 Growing increase in number of elderly
gravida EXAMPLE: 15 weeks AOG with fear of hemorrhage, not
 Poor prenatal care bleeding, and was diagnosed with placenta previa.
 Poor compliance in medicines (superstitions,
poverty) If you do outright hysterectomy, it is tantamount to direct
abortion. However, if a 24 weeks AOG mother is bleeding,
vital signs are deteriorating, need to transfuse volumes of
When is the best time to have baby? In Doc’s opinion, it is blood. Do you think it is justifiable to be conservative? No. It
after residency so that we can graduate on time and is justifiable to deliver the baby right away.
concentrate daw.  BUT FIRST GET MARRIED WITH THE
RIGHT PERSON!!! 
Looking for a stress reliever? No problem.

 If left untreated can result in MATERNAL


DEATH and FETAL DEATH
 Pulmonary edema
 Cardiac arrest
 Cerebral hemorrhage
 Hypoxia
 No moral difficulty if unborn child is viable 
TERMINATE PREGNANCY
 MORAL ASPECT
 If eclampsia occur before the fetus is viable:
 Control hypertension
 Control convulsions
 Monitor organ function
 Fetal surveillance studies
 Prepare NICU, neonatal intensivist (if in
case that you cannot control the
hypertension and convulsion)
Last push. Go get ‘em. 

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ABRUPTIO PLACENTA PLACENTA PREVIA
 Degree of separation of placenta varies from  After viability, uterus may be emptied
slight (harmless) to complete (fetal distress to  Preparation
fetal death) to maternal death  Give steroids
 MORAL ASPECT  Prepare NICU
 If maternal hemorrhage is mild, not  PRAY
endangering the mother’s life and fetus is  Prepare the intensivist
not viable  expectant management
 No steps can be taken which would HYDATIDIFORM MOLE
indirectly expose the life of the fetus to any  Expectant management when diagnosed with
considerable danger the presence of a living fetus (Incomplete H-
mole)
Using ultrasound with color Doppler studies, we can know if  For complete H-mole, you evacuate right away
the baby needs immediate delivery or not. If in the initial using your suction curettage
ultrasound is already severe and the baby is in danger, deliver  Evacuation, by dilatation and suction
the baby right away. curettage, hysterectomy or hysterotomy are
morally acceptable and indicated with a fetal
 ELEMENT OF PROPORTION in the PRINCIPLE death in utero, regardless of the stage of
OF DOUBLE EFFECT pregnancy
 There should be a due proportion between
the good that is intended and the evil that is CANCER
permitted.  Extirpation of a cancerous uterus in a pregnant
 To avert a slight danger from the mother woman as in indirect abortion
(hemorrhage) by a procedure which would  For example, the mother needs chemotherapy
expose the fetus to considerable danger and the baby is very far from viability and you
would violate this proportion allow chemotherapeutic agents knowing
 The ideal thing here is that the that it is fetotoxic, so it is indirect abortion
proportion is not balance and the principle of double effect cannot be
 There should be more good than evil applied in this situation.

EXAMPLE 1: 21 weeks AOG with vaginal spotting in


placenta previa, knowing that spotting is tolerable, would
you terminate pregnancy?

No, because the bleeding is minimal and can still be


controlled.

EXAMPLE 2: A patient with cervical cancer, 20 weeks


AOG, massive bleeding, vital signs deteriorating, and no
blood available, what will you do?

If it is possible to transfer the patient to a hospital


equipped with a better blood transfusion and neonatal
center. But in 20 weeks AOG, you can already terminate the
pregnancy. When maternal life is in danger from
hemorrhage it is normally permissible to try to control the
bleeding even if it is foreseen that this will result in fetal
death.

Based on the PRINCIPLE OF DOUBLE EFFECT, the good


effect (directly willed) here is the control of hemorrhage,
while the evil effect (not directly willed, foreseen) is fetal
death is a side effect of the attempt to control the
hemorrhage. THERE IS NO MORAL ISSUE HERE. Removal
of dead fetus can be done at any stage of development, and
the ideal mode of delivery in this case is vaginal.

-END-

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BIOETHICAL ISSUES AND GUIDELINES IN PEDIATRICS
AND QUALITY OF LIFE
Melchor Victor G. Frias IV, MD, MSc, FPPS
December 1, 2014; 08:00 AM – 10:00 AM / 10:00 AM – 12:00 NN
Bioethics III

OUTLINE
A. Bioethical Guidelines and Issues in Pediatrics: B. Key Facts on Disability and Health
Impaired Newborns  Definition
 Guidelines on To Treat or Not to Treat  Guidelines
 Guidelines on Initiating Versus Withdrawing  Issues
Treatment
 Issues
 Philippine Ethical Guidelines in the Immediate
Care of Extremely Premature and Extremely Low
Birth Weight Neonates

A. BIOETHICAL GUIDELINES AND ISSUES IN PEDIATRICS: IMPAIRED NEWBORNS


1. GUIDELINES ON TO TREAT OR NOT TO TREAT  The burden of proof is on the proponent of not
treating
MODERN MEDICAL TECHNOLOGY:  An advantage of viewing the immediate
 May be life saving treatment of newborns as emergency is that
 May present ethical dilemmas emergency treatment is always acceptable,
 Most of these medical technologies may be scarce, even without parental consent.
therefore the principle of justice comes in, which  Once you satisfy all the criteria for emergency,
discerns the benefit of these medical technologies you won’t need to consult for parental
given to premature babies
consent.
 May be risky and costly  Immediate treatment can buy time to clarify
 Risks are involved due to some procedures that are
diagnosis and prognosis, and to inform and
invasive and mostly expensive
consult with parents.
 Generates issues that cause agony and
disagreements among:
2. GUIDELINES ON INITIATING VERSUS
 Physicians/pediatricians/neonatologists
WITHDRAWING TREATMENT
 Medical staff
 Parents
INITIATING VERSUS WITHDRAWING TREATMENT
 Ethicists
 It used to be thought that initiating treatment
IN EMERGENCY SITUATIONS, TREAT meant a commitment to continued treatment.
 Physicians were too cautious in using artificial
 Emergency situation:
life support
 Unanticipated and life threatening
 A sudden referral in the emergency room or  Psychological difference
in a delivery room with a premature baby  Moral difference
 Lack of immediate treatment will increase
risk to health CLEARLY FUTILE TREATMENT IS NOT MORALLY
 Treatment is needed to alleviate physical REQUIRED
pain or discomfort  If medical care is clearly beneficial, the infant
 Time is important; when there has been no should always be treated; but if treatment will
opportunity to assess the infant and resuscitation be clearly futile or will only prolong dying, it is
will sustain life, TREAT justified to withhold it
 Without the time that you can buy, then there is no  Treatment is futile in terms of the infant’s survival
opportunity for you to assess the patient. In any  The medical condition of the infant should be
situation where there is uncertainty regarding the the sole criterion for with-holding treatment
diagnosis and prognosis, treat the patient.  Treatment is also futile if the infant has some
 In general, NICU policy is posited on a physical impairment incompatible with life,
presumption in favor of treating infants. which is uncorrectable
 When you are in the NICU as a junior intern, you
are part of the team. When you are not sure of the
prognosis of a particular infant, especially if the
patient is premature, then the goal is to
resuscitate. Just because the baby is already
unconscious and with no signs of heartbeat and
respiration, you don’t stop there. When confronted
with such a patient, you resuscitate.

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IF TREATMENT IS NOT MEDICALLY INDICATED  A surrogate may decide to forego
THERE IS NO MORAL OBLIGATION TO TREAT disproportionate means of preserving life.
 Treatment is not medically indicated if the  In children, life support measures may be
pediatrician/physician, according to reasonable necessary to permit full evaluation of the
medical judgment, determines that any of these patient’s condition; these interventions should
conditions exists: not be withheld during evaluation.
1. The infant is chronically and irreversibly  The free and informed consent made by a
comatose surrogate/family concerning the use or
 You may need the help of a neurologist withdrawal of life sustaining procedures should
at this point. always be respected and complied with unless
2. Treatment would merely prolong dying contrary to the child’s best interest and/or
 In this case, if the patient is proven to be Catholic moral teaching.
brain dead, at this point he is already  No patient should be discharged against
dead. There may be heart and lung medical advice without the initiation of
function but the brain is not functioning. discussions with the surrogate/family and
3. Treatment would not be effective in appropriate review by the medical team.
correcting all of the life threatening
conditions. 3. ISSUES
 You may have multiple congenital
anomalies in a particular infant MAY TREATMENT BE WITHHELD IF PARENTS
4. Treatment would be futile in terms of REQUEST IT?
physical survival  NO, if it clearly benefits the infant/child and there
5. Treatment would be virtually futile and is no clear indication of futility.
inhumane  YES, if it is clearly futile.
 In general, there is no obligation to treat on the
remote chance of success, especially when the SHOULD TREATMENT BE CONTINUED WHEN
treatment would produce severe and prolonged PARENTS REQUEST IT, EVEN IF THE MEDICAL
suffering. STAFF CONSIDER IT FUTILE?
 NO, when it causes more significant suffering to
MEDICALLY INDICATED TREATMENT MAY NOT BE the infant/child and it is already futile.
WITHHELD.  YES, if it is for the sake of the parents.
 Medically indicated treatment:  YES, if it is for organ donation.
 Whatever is likely to be effective in
ameliorating or correcting all life MAY FUTILE TREATMENT BE CONTINUED FOR THE
threatening conditions PURPOSE OF FUTURE KNOWLEDGE?
 If it is uncertain that medical care will be  For better care for premature & impaired infants
beneficial, treatment is not necessarily required  Boundaries between treatment and research
 If treatment is withheld, the infant’s disability become blurred
should not be the basis of withholding  Non-therapeutic research on infants and children
treatment is never morally required

*In cases of disagreements or uncertainty about whether or IS FOOD, WATER, AND PALLIATIVE CARE ALWAYS
not treatment is required, a bioethics committee should be REQUIRED?
consulted.  Depending on the clinical circumstances,
nutrition and hydration may be considered
WITHHOLDING/WITHDRAWING LIFE SUSTAINING medical treatment.
TREATMENT  The child should not be made to suffer needlessly.
 The attending physician (AP) should assume the  Nutrition and hydration should be provided to
primary responsibility for coordinating all patients; as long as this is of sufficient benefit
communication among those involved in to outweigh the burdens involved to the
considering to limit or withdraw therapy. patient/family, medically assisted nutrition and
 The AP or family may initiate the discussion and hydration should also be given.
decide concerning withholding or withdrawing life
support measures in the presence of the ARE COSTS AND USE OF RESOURCES RELEVANT
following: FACTORS IN NON-TREATMENT DECISIONS?
1. Patient’s condition is terminal and death is  There is no set value on life or an upper limit on
imminent expenditures for life-sustaining treatment.
2. Patient is irreversibly comatose or in  If treatment is virtually futile and prognosis for a
persistent vegetative state and there is no minimally good quality of life is very poor, one
hope for improvement may end/withdraw treatment.
3. The burden of treatment far outweighs the
benefit WHEN NON-TREATMENT IS GENERALLY ACCEPTED
 Every surrogate/family is obliged to use  There is brain death.
proportionate means to preserve the child’s  The child is in a persistent vegetative state and
health there is virtually no hope of recovery
 Treatment is clearly futile.

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4. PHILIPPINE ETHICAL GUIDELINES IN THE  When the concerned parties fail to reach a
IMMEDIATE CARE OF EXTREMELY PREMATURE consensus, the matter can be referred to the
AND EXTREMELY LOW BIRTH WEIGHT Hospital Ethics Committee.
NEONATES
 Good medical practice favors initiation of life- GUIDELINES IN AGGRESSIVE CARE
sustaining medical treatment until the clinical  Full resuscitative measures should be made
situation is confirmed and ethical concerns, if available to all live newly born; non-initiation of
any, are clarified. resuscitation may be considered, however, when
 If postnatal assessment differs from antenatal such is deemed futile, as in:
assessment, recommendations to parents 1. Presence of lethal anomalies or
may be changed accordingly. 2. Birth weight less than or equal to 400
 Factors to consider in decision-making are fetal grams and postnatal gestational assessment
and immediate neonatal conditions, including less than 24 completed weeks.
available resources  Resuscitation of newly born infants
 In cases of extremely premature and other than (1) and (2) may be stopped
extremely low birth weight, especially in after 15 minutes, when cardio-
hospital with scarce resources. respiratory function has not been
 All decisions should be based on both parents’ and restored.
the attending physician’s assessment of what is in
the best interest of the neonate GUIDELINES IN PALLIATIVE CARE
 Parents’ involvement in decision-making is  When the decision not to continue aggressive care
mandatory is reached, every effort must be made to offer
 In cases of conflict between the parents and the comfort care such as human contact, providing
attending physician, the decision must be for the warmth, oxygen, hygiene, fluids and nutrition;
good of the newly-born infant, beginning with the adequate support for the grieving process should
respect of his right to life. be made available and coordinated accordingly.

B. BIOETHICAL GUIDELINES AND ISSUES IN QUALITY OF LIFE


1. DEFINITION C. TREATMENT IS CLEARLY FUTILE:
 The experience of life as viewed by the patient  It will be easier to justify non-treatment when
 i.e. how the patient, not the parents or health survival is unlikely than when treatment is futile
care providers, perceives or evaluates his or relative to improved status.
her existence
 In pediatrics, it is difficult to determine the LIFE-SUSTAINING MEDICAL TREATMENT (LSMT)
quality of life, so we must get as much as we can  LSMT encompasses all interventions that may
from the patient’s parents or primary guardian. prolong the life of patients
 Ventilators or respirators, organ
2. GUIDELINES transplantation, dialysis
 Antibiotics, insulin, chemotherapy, nutrition
THREE SITUATIONS WHERE ONE CAN FOREGO LIFE- and hydration provided IV/by tube
SUSTAINING MEDICAL TREATMENT
“FOREGO”
A. THERE IS BRAIN DEATH:  Refers to both stopping a treatment already
 Even though heart-lung function can be sustained begun as well as not starting a treatment
artificially, where there is no brain function,  It is futile
there is no life and that is the end of treatment.  You may say forego if you do not want to initiate
 Clinical Criteria for Brain Death the treatment or if you want to withdraw the
 Fixated pupils treatment.
 Absent oculo-vestibular response
 Absent corneal reflex 3. ISSUES
 Apnea with PCO2 >60mmHg
 Isoelectric EEG and ECG ARGUMENTS AGAINST QUALITY OF LIFE
 No behavioral or reflex response stimuli that  Human life is of unqualified value
imply function above the level of the  Life is better than death, but in some
foramen magnum patients, death is better than life.
 For example: generalized paralyze
B. THE CHILD IS IN A PERSISTENT VEGETATIVE patient but very conscious.
STATE AND THERE IS VIRTUALLY NO HOPE OF  To one life worth living and another not is to
RECOVERY: deny the essential equality of all people, to
 There is little, if any, controversy that it is not discriminate against some, and to devalue what is
required, legally and morally, to sustain life sacred
functions for such a child.  Judging QOL implies valuing some lives more
 For example, a child with SSPE stage 4 than others and this is morally wrong because all
 There’s no more hope anymore, but human life is equally valuable
parents still wants to continue  Implication: The difference between the
treatment. value of life and the value of human life

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 “The value of life” vs. “The value of human life” ARGUMENTS FOR QUALITY OF LIFE
– Biological life vs. Biographical life  Some lives are so unbearable that to continue
 Some say biographical life is more important them is wrong in itself
than biological.  Some recommend consideration of quality of life,
 For those against quality of life, they will the best interest of the infant, the interests of
choose biological life the family members, and issues of futility
 Medical staff, family and relatives are  Human life is sacred, but not an absolute good
included in decision-making.  Utilitarian argument
 Parents usually choose biological life, because  Cure-oriented medical treatment may be
the life of their child is always important. withdrawn if and when the patient and
 Judging QOL in the context of refusing treatment family determine that the burdens of
implies that not all life is good and that treatment outweigh the possible benefits
sometimes death may be better than life  The “best interests” standard is based on quality
 But this is not true; life is always good and of life considerations and the child’s potential
death is always bad by comparison for human relationships
 A rational person would always choose life  For infants, a patient-centered quality of
over death. life approach based on the potential for
 The Slippery Slope Argument human relationship associated with the
 If we allow refusal of treatment for those infant’s medical condition.
just above a vegetative state, it will be
easier to begin to allow less severe stages CONFLICTS AND ISSUES
 Refer to the Hospital Bioethics Committee

-END-

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MORAL ASPECTS OF SURGERY 1-2
Renato Cirilo A. Ocampo, MD, FPCS, FACS
January 12, 2015; 8:00 AM – 10:00 AM / 10:00 AM – 12:00 NN
Bioethics III

OUTLINE SURGERY AND RESIDENCY TRAINING


 Ghost Surgery  In recent years, a great deal of controversy has
 Sexual Reassignment centered on the role of residents in the
 Organ Transplantation operating room
 Types of Transplantation  Allowing residents in teaching hospitals to
 Criteria for Transplantation
perform surgical procedures under the
 Determination of Death
supervision of attending surgeons
 This is a “disguised” form of ghost surgery
GHOST SURGERY  Conversely, how will we train them if they do
 Surgery in which the patient is not informed of, not perform the procedure?
or is misled, as to the identity of the operation  Hospital training programs with residents
surgeon performing for consultants is the most common
 Someone does the surgery in behalf of the form of ghost surgery
other surgeon (an “appointed" surgeon)  The number one suspicion for ghost surgeons
 Someone who has not examined the are the residents
patient  If the guidelines are not properly
 Someone the patient has not yet met implemented, the residency training program
 Originally, the term “ghost surgery” referred to a is a disguise, like a form of ghost surgery
practice whereby an unqualified physician would, particularly involving private patients (if the
often with the consent of the hospital, call a consultant does not want to do the operation
qualified surgeon to the operating room to especially at night when they are sleeping,
perform a procedure he would give it to the residents)
 The ghost surgeon is likely to be excluded in the
GUIDELINES
pre- and post op-care period of a patient
1. An operating surgeon is the performing surgeon
 For example, a pregnant woman’s cervix is
 As such, his duties and responsibilities go
9-10 cm dilated but her OB is not around
 This is NOT ghost surgery because this case beyond mere direction, supervision,
is an emergency guidance, or minor participation.
 The patient should not have to pay the same 2. The operating surgeon may be assisted by
operation fee since it is not her primary OB residents or other surgeons
3. With the consent of the patient, the operating
BASES OF THE IMMORALITY OF GHOST SURGERY surgeon may delegate the performance of
1. The patient has the right to know and select the certain aspects of the operation to his assistants
surgeon to whom he is to entrust his life. provided this is done under participatory
 It is against the BASIC RIGHT OF supervision
AUTONOMY  Therefore, HE MUST SCRUB!
 Example: Gusto ko si Doc Gellido ang  Importantly, dapat alam ng pasyente na may
mag-oopera sakin kasi I TRUST HIM <3 assistance; nakalagay sa informed consent
2. The moral evil is the attendant justice which is yung mga pangalan ng assistant/s
likely to befall the patient. 4. Full disclosure to the patient is necessary if the
 The moral evil in ghost surgery lies in resident or other physician is to perform the
ATTENDANT INJUSTICE operation under non-participatory supervision
 Justice is giving the patient what he  In cases when the attending doctor cannot
deserves, what is due to him make the operation
 What the patient paid for should be  Primary doctor should be informed of
given to them the details in the OR
3. Professional fees  For example, the resident calls you up
 The referring surgeon has no right to it habang nasa event kang malayo. OB ka
because he/she did not perform it! kunyari, tapos fully dilated na yung
pasyente! Crowning na! Sure na hindi ka
 The ghost surgeon has no total right to it
aabot! Explain to patient that this is an
because he is an accomplice! emergency and somebody must fill in
 This is for medical service! because the doctor is not yet there.
4. The ghost surgeon is likely to be excluded from DISCLOSURE IS IMPORTANT. If the patient
the pre-operative examination and the post- requests for another doctor instead, respect
operative care, and this is likely to be the request.
detrimental to the patient
5. It seriously militates against the common good
 You’re more likely to be liable legally
 Because this is injustice, deceitful, etc.

Transcriber: Nicxz Icaro


Formatting: Craig Angelo Reyes D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 1 of 4
Editor: Sarah Livelo
THE SURGEON’S OBLIGATION TO THE PATIENT  It violates the principle of non-maleficence
REQUIRES HIM TO PERFORM THE OPERATION (“primum non nocere” or “first do no harm”),
1. Within the scope of authority granted by the as it mutilates a non-diseased body
consent of the operation.  Being “trapped in the bodies of the wrong
 For example: If the appendix was taken out in a CS sex” is an irrational belief (a delusion or a
operation, the surgeon may be liable and should disordered perception of self)
not ask for additional fee  It does not accomplish what it claims;
2. In accordance with the terms of the contractual it does not change a person’s sex and
relationship does not provide benefits
3. With complete disclosure of facts relevant to the
need and performance of the operation. IT IS MORALLY UNACCEPTABLE BECAUSE:
4. Utilizing his best skill 1. Since it is not definitely established that the
5. If a resident is to operate upon and take care of problem is biological, the procedure is not a cure
the patient, under the general supervision of an  Is there a pathologic lesion that tells you that the
attending surgeon who will not participate person is gay? None. So there is no biological basis.
actively, the patient should be so informed and They are perfectly male, so it’s very psychological.
consent thereto 2. The procedure is an attempted palliation which is
6. It is unethical to mislead a patient as to the drastic, destructive and irreversible
identity of the doctor who performs the 3. Surgical sex change does not solve the person’s
operation. existential problem; it is primarily a case of
psychotherapy
SEXUAL REASSIGNMENT  There is no evidence that gender identity confusion
that is contrary to the anatomical structures is
inborn; any attempt to change this through by
HERMAPHRODISM surgical means, forever dooms the individual’s
1. Medical and scientific tests should be done to chances in overcoming sexual and psychological
determine which is the more predominantly difficulties, and it does not cure the problem.
determined sex 4. Such mutilation involves a total lack of due
 Considerations: stewardship of human life and integrity of the
 External genital morphology human person
 Internal genital morphology 5. There is no solid agreement that such procedure
 Chromosomal sex does much good and help to the individual
 Gender role 6. There can be ambiguity about really wanting it
2. In cases where there is a total equivocal sex
identification ORGAN TRANSPLANTATION
 The approach may be either towards
either sex TYPES OF TRANSPLANTATION
 Choice of sex depends on the individual 1. Living donors (usually related to the recipient)
 In the case of infants or minors (to a certain 2. Dead/cadaver Donors (declared brain-dead or
age), the parents determine after clinically dead)
consultation with specialists
1. LIVING DONORS
SEXUAL REASSIGNMENT SURGERY  Requires:
 Is it ethical to perform a surgery whose purpose  Consent from donor
is to make a male look like a female or a female  Functional integrity of the body is
to appear male? Is it medically appropriate? maintained
 Sexual reassignment surgery (SRS)  Absence of immediate adverse effect
violates basic medical and ethical (proportionate risk)
principles and is therefore not ethically or  Charity as the motive for organ donation
medically appropriate justifies the risk and the loss of anatomical integrity
 The term “sexual reassignment surgery” is in itself  Organ donation is not an obligation
problematic  Usually has good prognosis
 Implies that the sexual identity is assigned at
birth and can actually be surgically 2. DEAD/CADAVER DONORS
reassigned, in which the DNA already says
 Respect and reverence are due to the remains of
otherwise
a human being
 “I’m a woman locked up in man’s body, I
want to be a woman.”  They should be
 Sacredness of human life
evaluated by a psychiatrist if they meet the  Respect for the dead body signifies respect
criteria for sexual reassignment; siyempre, for human life
kailangan baguhin boses mo, kailangang  Respect for the author of life
tanggalin ung testicles and penis, then form  Respect for the dead person’s relative
it as an artificial vagina/clitoris, they have to  Culture and tradition should also be respected
take estrogen meds.  Consent from the deceased before death or
 Argh, it’s complicated.
consent from the family if there is no will is needed
 Sex is written on every cell of the body and
 Make sure that the donor is truly dead
can be determined through DNA testing; it
 If he is not and you declare him to be, it is
cannot be changed
considered murder

Transcriber: Nicxz Icaro


Formatting: Craig Angelo Reyes D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 2 of 4
Editor: Sarah Livelo
CRITERIA FOR TRANSPLANTATION CRITERIA FOR CESSATION OF BRAIN FUNCTION
1. There is a serious need on the part of the recipient 1. Irreversible coma
that cannot be fulfilled in any other way. 2. No spontaneous respiration and response to apnea test
 Needs and concerns for 6 minutes
 Worth of the transplant expenses and personnel 3. Absence of the following brainstem reflexes
involved  Papillary, corneal, gag, and caloric tests
 Establishing the death of the donor
 Can be a criminal offense if the patient donor is not EXCLUSIONS TO THE ABOVE CRITERIA
yet dead 1. Drug and metabolic intoxication
 The transplant surgeon is usually not part of the 2. Hypothermia
team that declares a patient “clinically dead” 3. Children (18 years old and below)
2. The functional integrity of the donor as a human 4. Shock
person will not be impaired even though anatomical
integrity may suffer PHILIPPINE CRITERIA FOR BRAIN DEATH
 Anatomical integrity  Irreversibility is recognized when the evaluation
 Material or physical integrity of the human body
discloses that:
 Functional integrity
a) The cause of coma is established and is
 The systematic efficiency of the human body
3. The risk taken by the donor as an act of charity is sufficient to account for the loss of brain function.
proportionate to the good resulting for the recipient. b) The possibility of recovery of any brain function is
 The motive for donating is charity excluded.
 Only limited harm to the donor c) The cessation of brain function persists for at
4. The donor’s consent is free and informed least 24 hours of observation and therapy.
 The donor comes over, not driven by poverty or
ignorance to donate his organ, and sometimes, this ORGAN DONORS POLICY
is like coercion due to certain circumstances (no A. Living Donors
money for living) that provoked them just to  Registration in donor centers (should be fully
sustain their living conditions; therefore, this is not competent adults)
really free  Screening of all donors
 Living Donor  Education; free and informed consent
 Has been informed of the benefits for him  Identification
 Has been informed of the risks he takes as a B. Cadaver Donors
donor  Free and informed consent of relatives, advance
 Has signed the free and informed consent directives
form  Brain death criteria
5. The recipients for the scarce organs are selected C. Recipients (when deciding who gets the organ)
justly  Utilitarian Principle
 Need for a policy  The one who needs it more gets the organ
 Need to determine “just selection”  Egalitarian Principle
 Wealth is not a basis or a determinant with who  First come, first served (first one to lose
receives an organ their organ function is the one given)
 Transplant surgeon should never be involved in  Social Work or Merit
the transaction of procuring/obtaining the organ;  This is decided by value of judgment
it becomes immoral D. No monetary compensation except for burial
expenses or attendant surgery
DETERMINATION OF DEATH  No negotiations are allowed in exchange for an
organ
 Transplantation requires organs that are well-
E. Confidentiality
nourished by oxygenated blood
 The team must remove them as soon as possible after  Organ donation is not an obligation, not to offer
death an organ even if needed is not against charity.
 Determining the moment of death is a crucial issue  Great care should be taken in weighing the
 Taking the heart out of a person not yet dead is not an merely potential benefits against the actual risk,
act of organ retrieval but an act of killing someone to that is, a brief prolongation of life against a
get his organs lifelong risk to the donor.
 Obey the ‘‘dead donor rule’’  People should not know who gets the kidney.

*The "dead-donor rule" refers to two widely accepted ethical norms SALE OF ORGANS
that govern practices of organ procurement for transplantation:  Selling of human organs is unethical because it is
1) Vital organs should be taken only from dead patients contrary to the dignity of the human being and because
2) Living patients should not be killed for or by organ procurement. need, rather than wealth, should determine who
receives an organ
 The most rigid moral argument not allowing the sale of
1) FIRST CRITERIA (TRADITIONAL)
donated organs
 Irreversible cessation of CARDIOPULMONARY
 Reduces the human person to a commodity
FUNCTIONS
 However, when you rely on this criteria, what
viable organ will you get? Wala na, anoxic na.
2) SECOND CRITERIA (MORE POPULAR) -END-
 Irreversible cessation of ALL BRAIN FUNCTIONS,
including those of the brain stem

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Transcriber: Nicxz Icaro


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Editor: Sarah Livelo