Bioethics I, II, III

TRANSCRIPTIONS
BATCH 2016

AY 2012 – 2013
COMPILED BY MARIE MAE PANTOLLA BATCH 2016
SUBJECT: BIOETHICS
COPY PASTE BY: MARIE MAE PANTOLLA
BATCH 2016
BIOETHICS 1
The course involves the study of the fundamental concepts
of general ethics and the foundations of Bioethics. Here,
students are made aware of their moral responsibilities as
Christians as they exercise their profession. It is
emphasized that as medical students, they should know
where decisions are based in order to be ethical and
Christian-oriented physicians. The course also includes
related values and virtues that are necessary for the
enhancement of morality in the practice of medicine.
ELGA
The expected lasallian graduate’s attributes (ELGA) are:
• Ethically competent
• Ethically efficient
• Imbued with the spirit of faith
• Virtuous
• Reveres life: promotes and defends life
• Respectful towards the human person
• Compassionate and safe physician
• Ethically responsive
• Just
• Responsible for oneself and responsible to
others/patients
• Respectful to human rights
• Effective communicator
INTRO TO BIOETHICS
OBJECTIVES
1. To define the different ethical sciences
2. To identify the similarities of the ethical sciences
3. To differentiate the ethical sciences from one
another
4. To determine the scope of Bioethics
ETHICS
That branch of philosophy that studies and draws
conclusions of the degree of goodness and badness of
human actions and conduct in relation to the purposes of
human living.
CHRISTIAN ETHICS
That branch of theology which studies, in the light of
human reason and of Christian Faith, the guidelines man
must follow to attain his final goal.
BIOETHICS
Is the systematic study of human conduct in the areas of
life sciences and of health care, insofar as that conduct is
examined from the view point of moral values and
principles
Bioethics goes beyond ethical issues in medicine to
include ethical issues in:
• Public health
• Population concerns
• Genetics
• Environmental health
• Reproductive practice and technologies
• Animal health and welfare and the like
ISSUE AREAS IN BIOETHICS
1. The rights and duties of patients and health
professionals.
2. The rights and duties of research subjects and
researchers;
3. The formulation of public policy, guidelines for clinical
care and biomedical research.
WHY IS THERE A NEED TO STUDY BIOETHICS?
1. there is a physician-patient relationship
2. the physician is a healer of another’s body
3. the physician does not have a total right and/or
obligation over the patient
4. the physician must be guided by principles
5. the physician must be able to decide on certain
actions/procedures without prejudice to the patient
HUMAN ACTS
OBJECTIVES:
1. To define human act
2. To differentiate human act from act of man
3. To analyze the nature of the human act
4. Describe the kinds of voluntary acts
5. To describe the effects of voluntary acts
6. Indentify the impairments of human acts or to
voluntariness
7. To judge the imputability of a human act
HUMAN ACTS
Actions that proceed from insight into the purpose of
one’s doing and from consent of free will
VOLUNTARY ACT
• perfect – an act performed with full knowledge and
full consent of the will
• imperfect – knowledge and/or consent are not full or
lacking
• actual – the act that proceeds from the present
deliberation of the will
• virtual – the act is placed by a previous deliberation
that still persists in its effect
EFFECT OF THE VOLUNTARY ACT
• Positive – the effect comes from an action that is
done (committed)
• Negative – the effect comes from an action that is not
done (omitted)
• 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
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IGNORANCE
• Invincible Ignorance – one is not able to
dispel/remove the ignorance by a reasonable
diligence
• Vincible Ignorance – the ignorance can be removed
by reasonable diligence but it is not removed due to
negligence or bad will
Principles:
1. Invincible Ignorance takes away or prevents the
human act from being voluntary in regard to that
which is not known. So, a human act coming from
invincible ignorance is not voluntary in its cause.
2. Vincible Ignorance does not take away the
voluntariness but diminishes voluntariness
INATTENTION
• an actual, momentary privation of knowledge
Principles:
1. if a person does not attend at all to what he is doing,
he does not accomplish a human act.
2. if a person is only half-attending to what he is doing,
he performs an imperfect human act.
ERROR
1. the origin of error may be traced from:
– deficient education
– influence of bad company
– misleading mass media
2. man is challenged to overcome the errors and search
for the truth.
3. man must be able to reach views based on sound
reasons.
4. man, as an individual, must fight against errors, and
the community must help one another to resist error.
PASSION OR CONCUPISCENCE
• a movement of the sensitive appetite which is
produced by good or evil apprehended by the
imagination
Concept:
• there is no connotation of evil
• God has endowed man with these appetites which
pervade his whole sensitive life
• they are instruments for the self-preservation of the
individual and the whole human race
• passions become evil only if their force is not
controlled by reason
• man has the urgent duty to check his sensitive
appetites
Division:
• antecedent – precedes the action of the will and at
the same time induces the will to consent
• consequent - follows the free determination of the
will and is either freely admitted and consented to or
deliberately aroused
Principles:
1. antecedent passions always lessen voluntariness and
sometimes preclude it completely because it hinders
the reflection of reason and weakens its attention, at
the same time, it strongly entices one to action and
entices the will to consent. The more intensive
concupiscence is, the weaker the intellect and will
become.
2. consequent passions are either good or bad because
they are either freely admitted and consented to or
deliberately aroused. They are voluntary in
themselves.
FEAR
• the shrinking back of the mind on account of an
impending evil
Concept:
• this kind of fear is intellectual fear as distinguished
from the fear arising from the senses which is one of
the passions
• intellectual fear does not generally escape the control
of the mind and will
• generally it leaves the person free
• the evil that causes the fear may threaten the
affected person or those associated with him
Principles:
1. fear does not destroy the voluntary character of an
action but it usually lessens the merit or guilt
2. even though an action done out of fear has an
involuntary aspect, it holds that a person does so by a
decision of his will and therefore performs a human
act.
3. grave fear – caused by a grave evil which one cannot
easily escape from – usually excuses from the
obligations of divine or human laws. The reason for
this is that moral impossibility excuses from the
compliance with such laws.
VIOLENCE
• a compulsive influence brought to bear upon one
against his will by some extrinsic agent
Concept:
• violence is not caused by moral force but only by the
compulsive force of some physical or psychic agent
• while internal resistance of the will is essential for
violence, external resistance is not always called for
Division:
• absolute – if the will dissents totally and resists as
best it can and is meaningful
• relative – if the will dissents only partially or weakly
and is perhaps deficient in its external resistance, too
Principles:
• absolute violence excludes any voluntariness.
• relative violence does not impair voluntariness
completely but lessens it
DISPOSITIONS AND HABITS
1. Disposition – an inclination that one has to certain
ways of action and conduct which have their roots in
one’s character an inherited propensities
2. Habit –the facility or easiness and readiness of acting
in a certain manner acquired by repeated acts
Principles:
1. a deliberately admitted habit does not lessen
voluntariness, and actions resulting there from are
voluntary at least in their cause; person is responsible
if he consents by free decision to the habit.
2. an opposed habit lessens voluntariness and
sometimes precludes it completely.
NORMS OF MORALITY
Objective Norm – Moral Law
Subjective Norm – Conscience
MORAL LAW
OBJECTIVES:
 To identify the objective norm of morality
 To define the different laws
 To differentiate the different laws from one another
 To explain the nature of moral law
 To explain the nature of natural law
 To explain the nature of human law
 To determine and justify the obligations towards the
laws
 To judge a human action according to the moral law
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LAW
- ANY DIRECTIVE OR RULE OF ACTIVITY
MORAL LAW
- A DIRECTIVE RULE OF OBLIGATORY, GENERAL,
AND STABLE CHARACTER, ORDERING MAN’S
ACTIVITY TOWARD THE ULTIMATE END.
DIVISION OF MORAL LAW
(hierarchical order):
Divine Law
Natural Law
Human Law
Moral Law Includes:
– obligatory demands
– recommendations
– common laws which concern all men or groups of
men
– personal commands which result from an individual
call addressed to an appointed person
– counsels
– permission
CHARACTERISTICS OF A GENUINE MORAL LAW: GOOD
and HOLY
A genuine moral law must be good and holy because the
moral law MUST GUIDE human activity to contribute to
the REALIZATION OF THE FINAL GOAL of human history
and of creation and that it should prevent man from
obstructing the attainment of this end.
CHARACTERISTICS OF A GENUINE MORAL LAW: GOOD
and HOLY
PRINCIPLES:
• a norm which does not contribute to the final end has
no moral force binding the will.
• a norm which results in the frustration of the ultimate
good is morally evil and its observance unlawful.
The Moral Law is based on the ORDER OF BEING
• Action follows being
1. a thing acts according to its nature.
2. the nature of a thing is the cause, while the
action is the effect.
The Moral Law is based on the ORDER OF BEING
• Application of this axiom to man’s activity
1. man’s moral obligation must be derived
from and measured by the nature of his
being.
2. God is the ultimate norm of moral law since
He created everything.
3. the laws emerging from man’s nature have
their origin in the Creator’s designs.
4. the task of Christian Ethics is to recognize
man as he really is in his true nature and
with all his essential relations and to derive
therefrom the moral laws which are to
direct his activity.
NATURAL MORAL LAW
- IS THAT MORAL ORDER WHICH ARISES FROM
THE FULL REALITY OF HUMAN NATURE AND
WHICH CAN BE RECOGNIZED BY MAN’S REASON,
INDEPENDENT OF POSITIVE DIVINE REVELATION.
- “full reality of human nature”
- spiritual – the effects of Christ’s saving work
- comprises all the ends designed in the physical,
psychical and spiritual inclinations and
aspirations of human nature inclusive of the
ultimate end
“full reality of human nature”
The ends here refer to existential ends, and these
are/include:
1. self-preservation which includes bodily integrity and
social respect
2. self-perfection physically and spiritually which
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
necessary property or income
3. broadening of experience and knowledge
4. procreation and education of children
5. interest in the spiritual and material welfare of one’s
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
the opportunity for all to attain full human existence
by sharing proportionately in the welfare of society
7. promotion of cultural progress and creative evolution
of the world
8. the knowledge and worship of God and the ultimate
fulfillment of man’s destiny through union with Him
“recognized by man’s reason”
- the medium is reason alone but this does not
exclude the influence of grace.
PROPERTIES OF THE NATURAL LAW
1. Universality
2. Immutability
3. indispensability
UNIVERSALITY
– the natural law binds all people at all times in all
places
– no one is superior to the guidelines which show man
the way
– no one is beyond good and evil
– no one is free from the obligation of fulfilling the duty
to obey and abide with this law
– the most universal principle of the natural law is:
GOOD MUST BE DONE AND EVIL MUST BE AVOIDED.
What is good and worthy of man’s desire?
The following are guidelines:
1. the golden rule
2. maintain and promote your bodily and mental life.
3. maintain and promote social coexistence
4. give to everyone what is his due
IMMUTABILITY
INDISPENSABILITY
– no one is dispensed from the natural law from the
side of human authority
– there may be a suspension of the natural law but
such suspension always demands an expressed
positive divine revelation
HUMAN LAW
- IS AN ORDINANCE OF REASON FOR THE
COMMON GOOD, PROMULGATED BY HIM WHO
HAS THE CARE OF THE COMMUNITY.
Reasons for the necessity of human law
1. to make clear the requirements of the natural law
and the divine positive law for everybody
2. to enforce obedience at least to those demands of
the moral law which are of greater value for the
common good.
3. to determine the moral law more precisely when
several possibilities of fulfilling it are open to men.
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OBJECT OF THE HUMAN LEGISLATION
 The direct object of human law is the common
welfare/good
 Human legislation is supposed to create favorable
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
equally and according to the capacities of the
subjects
– new penal laws cannot be extended to past
actions
3. the law must be physically and morally possible.
– the law must be within the forces and means of
a person
– the command of the law can be done with no
great difficulty
4. the law must be useful and of benefit for the
common good
MORAL OBLIGATION TOWARDS THE LAW:
PRINCIPLES:
1. on the nature and gravity of the moral obligation
– just laws bind in conscience by reason of their
intrinsic necessity and justice
– anyone who violates a just law is in conscience
bound to submit to a just punishment
– a punishment is just if it measures up to the
importance of the law for the common welfare
2. on the extent of the moral obligation
– the subject has the moral obligation to acquire
by sufficient means a knowledge of the law
– the subject is obliged to use the ordinary means
which are absolutely necessary for the
observance of the law
– the subject is bound to remove or anticipate
obstacles which make the observance of the law
proximately impossible, if this can be done
without great inconvenience
CESSATION
1. of the obligation towards the law:
– when one ceases to be subject of the law
– when one is invincibly ignorant of the law
– when there is a physical impossibility
– when there is a moral impossibility
– a dispensation
– a privilege
2. of the law:
– through the act of a legislator or through
contrary customs
– a new law abrogates a former law if it expressly
states it, or if it is directly contrary to the old law
– the purpose of the law ceases to exist
CONSCIENCE
Conscience judges on the morality of a concrete action
commanding to do what is good and to avoid what is evil
OBJECTIVES:
 To identify the subjective norm of morality
 To describe what is conscience
 To distinguish the division of conscience
 To identify the kinds of conscience
 To demonstrate the obligation towards
conscience
 To judge a human action according to the dictate
of conscience
The Concept of Conscience:
 It is not a theoretical or scientific knowledge of moral
values and of good and evil, but
 It shows to man what his nature is and what the
divine Spirit requires of him as his personal obligation
and then leads him to perceive the binding force of
these requirements.
 In most cases, the judgment of conscience is not
reflexive but spontaneous. The judgment of
conscience is expressly reflected upon especially in
instances of doubt, or of resistance and disobedience
to the dictates of conscience.
 It concerns a person’s concrete action in a concrete
situation.
 It formulates general moral principles concerning the
morality of human actions in the abstract without
relation to the concrete activity of a person here and
now.
The Dictate of conscience Contains 2 Elements:
 the judgment on the morality of a concrete action
which a person intends to perform or has performed,
and
 the command and obligation that what is recognized
as good must be done and what is recognized as evil
must be avoided. The obligation is categorical. It is
not only right to follow it, it is obligatory to do so.
Antecedent Conscience
- the judgment on the morality of an action and
the obligation to perform it or omit it is passed
before the action is done. This conscience
commands, exhorts, permits or forbids.
Consequent Conscience
- evaluates a deed already done or omitted. This
conscience approves, excuses, reproves or
accuses.
Right Conscience
- the moral judgment agrees with the objective
norm of morality
Erroneous Conscience
- the moral judgment disagrees with the objective
norm of morality. This can be:
a. vincibly erroneous – it dawns on man that his
moral outlook might not be entirely sound or he
is aware of being careless and irresponsible in his
decision
b. invincibly erroneous – the person has no
awareness of the possibility of error
Other Kinds of Erroneous Conscience:
1. Perplexed
2. Lax
3. Scrupulous
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Perplexed
- when confronted with two alternative precepts,
it fears sin in whatever choice it makes. This is a
disturbed conscience. There is a disturbance of
the capacity to form a judgment
Lax
- judges a thing to be lawful when it is actually
unlawful, moral when actually immoral, light or
venial sin when actually serious or mortal sin.
Scrupulous
- judges something to be sinful when actually it is
not, or something to be grievous or moral when
actually light or venial
Certain Conscience
- passes judgment without fear or error
Doubtful Conscience
- uncertain concerning the morality of an action
WE MUST HAVE A RIGHT AND DELICATE (SENSITIVE)
CONSCIENCE PRESERVING OURSELVES INTACT WITH
CLEAR AND VIGILANT DISCERNMENT OF THE GOOD AND
EVIL.
The VINCIBLY ERRONEOUS CONSCIENCE
Before a person with this kind of conscience may act:
1. he must remove his erroneous state by
searching the truth; if this is not possible
because he is unable to do so,
2. He must postpone the action; if the action
cannot be postponed,
3. He must follow the safer line of action.
THE PERPLEXED CONSCIENCE
The line of actions to be taken is:
1. if the decision can be delayed, postpone the action to
obtain information and deliberate; if the decision
cannot be postponed,
2. One must choose what appears to be the lesser evil; if
still this is impossible to settle/do,
3. Either of the alternatives may be done
Principles:
1. If this line of action is observed, there is no formal sin
because it is impossible for the person to escape both
alternatives of the perplexing situation;
2. If this line of action is not observed, the person may
be guilty of formal sin because nothing was done to
correct the error.
The DOUBTFUL CONSCIENCE
the line of actions to be done:
1. the action must be postponed until certainty is
reached; If the doubt cannot be solved directly,
2. one may make a presumption
PRESUMPTION - a conjecture where the GREATER RIGHT
COMMONLY LIES and the lesser injustice is to be feared
REFLEX PRINCIPLES WHERE PRESUMPTION STANDS
1. In doubt, presumption stands on the side of the
superior.
2. In doubt, stand for the validity of the act.
3. In doubt, amplify the favorable and restrict the
unfavorable.
4. In doubt, presumption stands for the usual and the
ordinary.
BINDING FORCE OF CONSCIENCE
1. MUST BE OBEYED:
 Certain
 Invicibly Erroneous
 Right
 Unaware Lax
2. MUST NOT BE OBEYED:
 Aware Lax
3. MUST NOT BE OBEYED UNTIL SOME CLARIFICATION IS
OBTAINED, BUT ONE MAY ACT IF CLARIFICATION
CANNOT BE OBTAINED AND THE DECISION HAS TO BE
MAKE IMMEDIATELY:
 Vincibly Erroneous
 Perplexed
 Doubtful
FREEDOM OF CONSCIENCE
- There is a strict obligation to follow one’s certain
conscience; correspondingly, one has the right to
act according to one’s conscience.
- The restrictions of the freedom of conscience is
when it happens that the dictate of conscience
runs in conflict with the demands of the
common welfare.
SOURCES OF MORALITY
OBJECTIVES:
1. To explain the meaning of “sources of morality”
2. To enumerate the sources of morality
3. To explain each of the sources of morality
4. To determine how the elements affect the morality of
a human act
5. To judge a human act according to the sources of
morality
SOURCES OF MORALITY
Sources defining the morality of human acts
- these are the elements in the human act which
determine its morality. These elements are
called sources of the morality of human acts
because the human act derives its morality from
their agreement or disagreement with the moral
norm.
These sources are:
OBJECT
CIRCUMSTANCES
INTENTION
OBJECT
- Object of the human act is the effect which an
action primarily and directly causes. It is always
and necessarily the result of the act,
independent of the circumstances or of the
intention. It is generally regarded as the primary
source for the judgment on the morality of an
act.
Effect of the Human Act is:
1. the physical, biological changes which an act brings
about;
2. The impact of the act on rights and claims of persons,
whether of other persons or of the agent himself, and
the changes the act brings about in this sphere.
To determine the OBJECT of a specific action:
1. look into the matter the act is concerned with and the
existing rights and claims of persons to this matter;
2. Define the changes which are to be brought about
primarily and directly.
CIRCUMSTANCES
- These are the particulars of the concrete human
act which are not necessarily connected with its
object,
These CIRCUMSTANCES are:
WHO
WHAT
WHERE
WITH WHAT MEANS
WHY
HOW
WHEN
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The CIRCUMSTANCES can alter the morality of human acts
for better or for worse. They can influence the morality of
a human act.
INTENTION / END
- This is the reason for which the agent
undertakes an act. The agent performs the
action for the sake of this end/intention which
he expects to achieve.
- The INTENTION/END can modify the morality of
an act in similar ways as circumstances do.
VIRTUE
- A habit that gives both the inclination and the
power to do readily what is morally good.
OBJECTIVES:
1. To define virtue
2. To explain the concept of virtue
3. To specify the fundamental requirements for virtue
4. To define, enumerate and explain the meaning of the
requirements of the theological virtues
5. To define, enumerate and explain the meaning and
requirements of the cardinal virtues
6. To apply the concept of virtue in medical practice
7. To enumerate and explain the meaning of the virtues
of a physician
Fundamental Requirements for Virtue
1. moral knowledge
– some insight and knowledge of the value it
endeavors to realize
– education, instructions, formation
2. prudence
– cautious deliberation
– to look carefully into the concrete circumstances
3. love of moral value
– the beauty and goodness of the moral value
must be deeply sensed and truly loved
– deepening and faithful pursuance of the right
fundamental option
4. dominion over the passions
– moderating restraint
Theological Virtues:
• Faith
• Hope
• Charity
Theological Virtue - God is the
 immediate object
LOVE / CHARITY
- is the most exalted, the most fundamental and
universal of all virtues
 can co-exist with:
o failures that result from weaknesses:
wrong attitudes which result from
deficient insight into the real demands
of the moral value
 cannot co-exist with:
o bad habit;
o fully deliberate adherence to a serious
vice
CARDINAL VIRTUES:
- considered as “hinges” on which the whole
moral life turns
PRUDENCE
- disposes a man to discern correctly what
measures he must take to realize the exigencies
of a virtue in concrete circumstances
JUSTICE
- to give what is due
FORTITUDE
- courage to stand/defend what one believes
TEMPERANCE
- gentleness; benevolence; moderation
VIRTUE IN MEDICAL ETHICS
Virtue as lived morality or a lived dimension of morality,
refers to a gathering of personal motives, feelings and
dispositions for a consistent lived expression of a virtue.
“Becoming A Good Doctor”
by James F. Drane
p. 157
Virtue is the personal appropriation of values made with
the help of reason
Ibid., p. 164
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
Connected with medical communication
- it is the disposition to tell the truth, not only
once but several times over;
- The habit of telling the truth even when it is not
convenient or does not serve a personal
convenience;
- It disposes the doctor to prepare patients for full
participation in decision-making regarding their
own lives
VIRTUE OF RESPECT
Connected with decision-making
- it is the trained attitude or disposition to
reverence those free acts by which patients carry
out their best interests
- It disposes the doctor to handle differences with
the patient with sensitivity, avoiding deceit or
manipulation
VIRTUE OF FRIENDLINESS
Connected with inevitability of feelings; affective
dimension
- there is pleasure in one another’s company,
confidences are shared, and there is an
exchange of benefits;
- Feelings are shared and intimacies revealed
appropriate only within this relationship
Affectionate relationship - controlling personal hostility
Understanding - looking beyond the patient’s acts, words
and behavior and seeing the interior world of thoughts
and feelings
Forgiving
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VIRTUE OF RELIGION
Connected with the idea that doctors are priests
- Reflection on the awesome dimensions of his
work
- Recognition of what is “transcendent” in the
patient (the mystery of life)
- Commitment to serving patients struggling with
life’s meaning
- Treating the patient as Christ would
- “Other” - directed; the “other” is the patient
- It keeps doctors from confusing themselves with
God, and from falling into the temptation of
moral self-righteousness
- It is the reality of God that keeps creatures
aware of “their place”.
FUNDAMENTAL BIOETHICAL PRINCIPLES
1. Sanctity and Inviolability of Life
2. Human Dignity
3. Autonomy
4. Stewardship and Accountability
5. Totality
SANCTITY AND INVIOLABILITY OF HUMAN LIFE
OBJECTIVES:
1. To explain the meaning of the principle of
sanctity and inviolability of human life
2. To evaluate the bases for this principle
3. To formulate the general rule system bearing on
the sanctity and inviolability of human life
4. To apply the principle in given cases or situations
5. To judge violation or non-violation of the
principle in given cases.
SANCTITY OF LIFE
- Interpreted as to mean that each individual,
regardless of the state of health, is not to be
used as means, and is to be treated with dignity
because he is valuable.
 Life is holy because God is the origin of life and
the ultimate guarantor of the sanctity of human
life;
 Because man’s life comes from God he belongs
directly and exclusively to Him;
 One must respect one’s own life and the life of
others not only because of this;
 Because of man’s eternal destiny
HUMAN LIFE
- the fundamental ethical value
MORAL INTEGRITY
- the absolute ethical value
General Rule System Bearing on the Sanctity of Life
1. Survival and integrity of the human species –
man ought to work towards his own survival
2. Survival and integrity of family lineage
3. Integrity of bodily life – the basic right to life
4. Integrity of personal, mental and emotional
individuality – the right to be oneself
5. Integrity of personal bodily individuality –
integrity of the human body
CONCLUSION: Man’s life is holy because it comes
from God and has an eternal
destiny.
INVIOLABILITY OF LIFE
Because life is holy it cannot be violated
HUMAN DIGNITY
OBJECTIVES:
1. To explain the meaning of the principle of human
dignity
2. To evaluate the bases for this principle
3. Co-relate this principle with sanctity and inviolability
of life
4. To determine the scope of reference of human
dignity
5. To explain respect for human dignity in the
dimensions of personhood
6. To apply the principle in given cases/situations
7. To judge the violation or non-violation of the principle
in given cases.
HUMAN DIGNITY
The dignity of the human person is the STRUCTURAL
NUCLEUS OF ETHICS
 In the sense that moral life is basically the
actualization of what it means to be a person in
relation to other persons and sentient beings.
 RESPECT for the dignity of all persons and each
person is the necessary condition for all morally good
attitudes and acts.
BASES OF THE DIGNITY OF THE HUMAN PERSON
1. Every human person is crated in His image and
likeness.
2. Every human person is endowed with intelligence to
know and a free will to decide/choose.
3. The creation of the human soul is a direct action of
God.
4. Every human person is called into existence in
relation to God.
5. Each human person is unique and irreplaceable.
6. Each human person is called to maturity and eternal
life.
SCOPE OF REFERENCE OF HUMAN DIGNITY
Respect for the dignity of the human person should be:
1. Concrete
2. Universal
3. Egalitarian
4. Absolute
5. Partisan in favor of those who suffer from
dehumanizing situations
Respect for the dignity of the human person should be:
CONCRETE
 In the sense that it refers not to abstract
human nature, but to concrete and actual
human beings immersed in complexed and
conflictive historical realities
UNIVERSAL
 that it applies to all persons, going beyond
geographical and political boundaries
EGALITARIAN
 In that it affirms the equality of all human
persons in dignity, rejecting all
discrimination, whether this be based on
race, religion, sex, ideology, generation,
social class or any other arbitrary criterion
ABSOLUTE
 Because it is inherent in human persons
precisely as persons, and not for what they
possess, nor for what they can give, nor for their
physical, intellectual and social capabilities, but
for what they are --- persons
 The human person is valuable most of all
because he is a person; he is an end in himself
and should never be used or manipulated as a
mere means for another end
PARTISAN IN FAVOR OF THOSE WHO
SUFFER FROM DEHUMANIZING SITUATIONS
 in the sense that it has a preferential option in
practice in favor of the liberation of those
human beings whose humanity has been
disfigured by dehumanizing situations – the
oppressed, the destitute and other marginalized
persons
7

Human dignity
 entails respecting the human person in all the
concrete dimensions of his personhood:
1. his / her corporeity
2. his / her social nature
3. his / her reason and liberty
CORPOREITY
- Human beings exist corporeally. The biological
bodies and the bases for their human
consciousness, and thus for their personhood,
and so participate in the dignity of the human
person
Social Nature
- Human persons are by nature social; they live
together and interact with other persons in
society.
- Within society, the rights and responsibilities of
persons should be recognized, and as persons
they should be active participants in social and
cultural life in a relation of equality with other
persons.
REASON AND LIBERTY
- Human persons are characterized by reason and
liberty, and are thus called to realize themselves
responsibly as persons.
- They should be active and responsible subjects
of their own lives.
- Consequently, they have a right to access to
information that affects them.
- Liberty of human persons must be respected as
long as its exercise does not violate/injure the
rights of other persons.
AUTONOMY
One has the moral right to choose and follow one’s own
plan of life
OBJECTIVES:
1. To explain the meaning of the principle of autonomy
2. To describe the assets of autonomy
3. To identify the role of the health professional in
helping the patient make an autonomous choice
4. To co-relate this principle with the principle of
stewardship
5. To apply the principle in given cases/situations
6. To judge the violations and no-violation of the
principle in given cases.
IMPLICATIONS OF AUTONOMY
1. This does not mean absolute freedom to do anything
as one wishes;
2. To act morally, man still has to follow the guidelines
of moral law and conscience;
3. One has a right to determine what will be done to
him;
4. One has a duty not to constrain another’s
autonomous choices and actions;
5. Human beings should be treated with dignity;
6. Human beings should be allowed to make decisions
for themselves.
POSITIVE ASSETS OF AUTONOMY
1. Autonomy enhances a person’s worth and self-image
2. It protects a person from being used or abused by
others
3. In health care it develops a mature therapeutic
alliance between health care professional and
patient.
VIOLATIONS OF THE PRINCIPLE OF AUTONOMY
 Actions performed that constrain a person’s
capacity to make a decision;
 Actions performed that constrain a person’s
capacity to act according to his decision
NON-VIOLATIONS OF THE PRINCIPLE OF AUTONOMY
 When a person expresses his autonomous wish
to waive consent or delegate authority to others.
The physician’s delegated prerogative refers to
the authority of a physician over his patient as
an authority delegated to him by the patient
 When respecting a person’s autonomy competes
with other moral principles
THE ROLE OF THE HEALTH PROFESSIONAL
The health professional should help the patient make
his/her autonomous choice and act on it by:
 providing him/her with the information
necessary to weigh the reason for his/her
opinion;
 stating his/her own convictions and clearly
explaining the reason for this opinion;
 not exercising coercion, manipulation, undue
influence, or irrational persuasions;
 respecting the patient’s autonomous choice;
 withdrawing from the case and helping the
patient find another health professional who
might be more successful in these particular
situations when the health professional thinks it
is impossible to help the patient.
STEWARDSHIP/ACCOUNTABILITY
Man is not the independent lord of his life but only a
steward subject to the sovereignty of God, and he is
responsible for it because he is accountable to God. Man’s
bodily life is entrusted to his freedom
STEWARDHIP AND ACCOUNTABILITY
OBJECTIVES:
1. To explain the meaning the principle of
stewardship and accountability
2. To analyze man’s responsibility
3. To detect dangers and risks
4. To distinguish different kinds of prerogatives
5. To determine the moral obligations in
prerogatives
6. To co-relate this principle with human dignity
7. To apply the principle in given cases/situations
8. To judge the violation and non-violation of the
principle in a given case
STEWARDSHIP
 Man is accountable in the way he uses his
autonomy/freedom and in the way he respects
and maintains his own (and that of others’)
dignity.
 (Prudent) stewardship means seeing that the
powers entrusted to people are gifts and that
the true meaning of these powers is to be found
in respecting the dignity of everyone and
everything.
 Man must use his freedom responsibly, in
conformity with the ends which are set forth by
the inclination of his own nature as a rational
being.
DANGERS AND RISKS
 Earthly life lies constantly exposed to many
dangers. But human life is altogether impossible
without a free risk of bodily loss in the quest for
life’s meaning. Excessive concern about bodily
risks is not acceptable.
 It is a matter of weighing values or ideals, and a
question of prudence;
 The expected benefit must be proportionate to
the risk. The greater the love with which man
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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BENEFICENCE
 One has the obligation to help others further
their important and legitimate interests.
 The term beneficence refers to actions that
promote the wellbeing of others. In the medical
context, this means taking actions that serve the
best interests of patients.
 One of the obligations of the physician and other
health care professionals is TO DO GOOD and to
do everything to benefit the patient
 Not absolutely good, there are some risks in
every procedure that are unavoidable
 Always do good as a physician
Implications of Beneficence
1. There is an obligation to confer benefits that is,
doing or promoting good, and actively to prevent
and remove harm or evil.
 The physician should be able to identify
both the benefits and harm that could be
brought about by the
procedure/treatment
 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
discern in the future what is good and
what is harmful.
2. There is an obligation to weigh and balance the
possible good against the possible harm.
 There is always a certain degree of harm in
every procedure you perform in your
patient.
 Make sure that the benefits outweighs the
harm
 Recommend something that is better or
more beneficent
The impossibility of doing all good - this arises from
limitations of:
1. The nature of time and space
 Doctors hold many clinics and manages
many patients in different places and
SPECIFICATION OF BENEFICIENCE
hospitals
 Distance limitation – the physician will not
be able to attend a patient may be if he is at
home or at different place
2. One’s own limitations.
 Limitations of a physician depends on the
physician's expertise or specialization.
SY 2011-2012
Subject: Bioethics
Topic: Beneficience
Lecturer: Dr. Melchor Vrias
Date of Lecture: 29 July 2011
Transcriptionist: Gluttinoids
Pages: 3
 You would need other to ask help from
other physicians.
 Referral is also an obligation of the
physician
3. The state of the art in a given area as well as the
availability of state of the art tools.
 Limited by equipment and facilities
 If assigned in a barrio, there are limitations
in terms of diagnostic test a physician can
request as well as th availability of
medications
4. One’s obligation to avoid evil
 Sometimes we cannot avoid evil in the
course of the treatment
o Ex: Adverse effects of drugs are
inevitable, but the drug is necessary
and will do more good than harm
 The physician must inform the patient or
the significant other about the risks (both
known and unknown risk)
 Doing good and avoiding evil is NOT simply a
question of principles but of practical wisdom of
knowledge, skills, and common sense weighing
the relevant aspects of the factual and social
situation as well as the concrete meaning of
human dignity in a particular time and space
 You have to weight certain aspects, such as the
patients social situations, how the treatment
affects the relatives, the patient per se and the
meaning of his dignity in a particular time and
place
 In doing good, consider the dignity of the
patient.
 Always treat patient as a Human Being
o E.g: In a brain dead patient, the relatives
may say to continue treatment.. But the
doctor must explain that continuing with
the treatment can be harmful.
 The things necessary for the person to remain
human and maintain dignity are the top of the
list of goods to be done.
 It would be more important for the patient
to die with dignity especially in terminal
cases. For instance, they would rather die at
home than stay in the hospital.
1

Limits of Specification
1. Talent
 It is a matter of situations in which the effort
to do good/better or to preserve the good
may conflict with the good of other human
beings
o As physicians, sometimes you really want
to do good, but keep in mind that the
patient and his relatives have the right to
choose, this includes their choice to
refuse the treatment.
o So no matter how much you want to do
good, the obligation to do good is over
ridden when the patient or the relatives
doesn’t want to continue with the
treatment.
o Betterment of Patient < Betterment of
the Family
- Ex. when treatment is expensive &
would bankrupt the patient’s family
– patient forgoes treatment)
 There is tension between respecting freedom
and securing what a health care professional
may consider the best interests of the patient.
o Medical benificence can come in conflict
with the autonomy of the patient.
o You may know what is best for the
patient, but the patient's autonomy
dictates that he doesn't want to continue
with the treatment.
o Autonomy of the patient shall prevail,
given that the patient is competent.
2. Most goods that we have to do are specified by:
a. Law
 Law: patient’s right
 Law of child’s abuse – Doctors are
required to report child abuse.
b. Custom
 Some customs and principles limit your
obligation to do good
o Custom includes tawas, can't take a
bath during menstrual periods.
o Religion – Cannot do blood
transfusion on Jehova’s witnesses;
one religion forbid medical
intervention
c. Relationship and Roles
 doctor-patient relationship, patient-
relative relationship, patient-spouse
relationship can be limiting
d. Agreements
 Agreements like contracts.
 Example, company physicians are limited
by the fact that they should disclose
certain information regarding his
patients, in this case the employees, as
indicated by the company
PATIENT’S GOOD
 Take the following into consideraration because
patients use one or combination of these goods
in making a decision:
1. The Ultimate Good
 The meaning and destiny of human existence;
 The positions taken with reference to
relationships with other human beings, the
world and God;
 The “ultimate concern” – the one to which we
turn for final justification of our acts if all
secondary or intermediate reasons fail
 If the other good fail this would be our last
resort, to turn to our Creator.
 This value supersedes the biomedical good and
the patient’s view of his own good
2. The Biomedical Good
 The good that can be achieved by medical
intervention into a particular disease state;
 The statement of what can be achieved based on
strictly scientific and technical assessment
 Ultimate good supercedes the medical good
 The good that is usually used by health care
professionals
o The biomedical good is the basis of the
physicians on why a patient should follow
the decisions of the physician
3. The Patient’s View of his Own Good: His Best
Interest
 The patient’s subjective assessment of the
quality of life the intervention might produce;
 Whether of not this quality of life is consistent
with the patient’s life plan and goals;
 The patient’s life plan is highly personal
 The choices that are to be made according to his
life plan may run counter to biomedical good or
what the physician thinks is a good life for the
patient.
 The initial good the patient use
 If an information is disclosed, this good is used
when the patient is making a decision.
 If the probable result of the treatment is in
conflict with the patient's life plan and goals, the
patient may not adhere with the treatment.
4. The Good of the Patient as a Human Person
 The good that is grounded in his capacity as a
human person to reason, to choose and to
express those choices in speech with other
humans;
 Freedom to choose
 This value supersedes the biomedical good and
the patient’s view of his own good
2
PATERNALISM
 Involves acting without consent. Or even over-
riding the patient’s wishes, wants or actions, in
order to benefit the patient or at least to prevent
harm to the patient
 Physicians used this principle before
 Physicians can overlook the autonomy and rights
of the patient.
Two (2) Elements of Paternalis
1. The absence of consent or over-riding of consent
2. The beneficent motive
 The welfare of the patient
Types of Paternalism
1. Strong Paternalism
 Also called extended paternalism
 The health care provider attempts to
override the wishes of a competent person
2. Weak Paternalism
 Also called limited or restricted paternalism
 Consent is missing or the health care
provider overrules or overrides the wishes of
an incompetent or a doubtfully competent
patient.
 Doubtfully competent patient: alcohol/ drug
intoxicated patient, in sedatives, effect of
illness ( high-grade fever, depression)
 Sometimes called cooperative paternalism
when one of its purposes is to restore the
person’s competence so that the patient
may give informed consent.
 Example: Over-ride by giving IV fluid and IV
antipyretic to lower the fever making the
patient competent again and making them
capable to make competent decisions
Strong paternalism is ethically rejected if:
 The competence of an individual to make
decisions for another competent individual
would require both knowledge of the other
person’s values and of all the factors influencing
their lives.
 Health care professionals do not have the right
to enforce value and judgments to the patients
on the grounds that the “doctor knows best”
 It would be a rare health care professional who
knew all the factors influencing the life of the
patient.
- Unless the patient tells you “bahala ka na
Doktor”. However, you still need to inform the
patient.
It is NOT Paternalism
1. When the health care provider acts to prevent
the patient from causing serious injury to others.
 Ex: psych patients, though incompetent
(especially waning patients,who are
sometimes competent, sometimes not) you
may constrain them by giving sedative to
calm them and make them competent
2. If the Health care professional overrules the
patient for the convenience or profit of the
provider
 Example: Like nurses in a hurry in shifting
and give a drug immediately, some drugs
are painful when administered in fast rate,
it's not paternalism because the provider
has other obligation to do and not to give
care and compassion to the patient, this is
inhumane at times.
3. If the health care professionals refuses to go
along with the patient’s wishes because these
wishes are against the conscience or professional
standard of the provider, and vice versa.
 If the patient has the right to refuse
treatment, the physician also has right to
refuse a patient.
 This occurs when the patient is non-
compliant because he/she doubts the
physician as a competent professional.
 This doesn't apply in emergency cases
though, a physician can't refuse a patient in
an emergency case
Paternalism is justified:
1. If the harm is prevented from occurring or the
benefits provided to the patient outweigh the
loss of independence and the sense of invasion
caused by the interference.
2. If the person's condition seriously limits his/her
ability to choose autonomously.
3. If the interference is universally justified under
relevantly similar circumstances.
 Example: sedatives can be given to violent
patients, restraining restless patient (tied to
railings), this is universally justified and may
do without the consent of the patient
Rule of thumb involving Paternalism:
 Decisions about health, life and death are not
merely medical decisions but involve the good of
the society and the good of third parties, as well
as the values of the patient.
 Consider that it is not only the physician who
decides, also consider the value and situation of
the patient (socially, emotionally...)
End of Transcription
"Your life is the manifestation of your dream; it is an art. And you
can change your life anytime if you aren't enjoying the dream.
Dream masters create a masterpiece of life; they control the dream
by making choices.”
3

Cooperation
• Any physical or moral concurrence with a
principal agent in a sinful deed. (principal agent:
attending physician)
* In Medicine, unlike in other circumstances, cooperation
means a negative thing.
• The participation of more than one person in
the same immoral or criminal action.
• Circumstances may arise in which a man is
associated, to a greater or lesser degree, with
someone else in a situation which is contrary to
right order.
• Depends on the degree of participation in the
medical practice
Types of Cooperation
1. Formal Cooperation
• When one externally concurs in the sinful deed
of another and at the same time internally
consents to it.
• When one takes part in the immoral action of
another while at the same time adopting the
evil intention of his associate.
• If the intention of the anesthetist is the same as
that of the surgeon in an illicit operation (e.g.
contraceptive sterilization), the cooperation of
the anesthetist is called formal cooperation.
* one internally consents to and physically agrees to
do the action
• Always wrong, sinful or immoral
• The cooperator is equally guilty with the
principal agent.
2. Material Cooperation
• When one externally concurs in the sinful deed
of another without internally consenting to it.
• Generally illicit, since the evil of sin should not
be supported by any means, but on the
contrary, opposed and suppressed
* Participation in a situation such as when one is forced
to do the action or one didn’t actually know what was
being done (ergo, without intention). However, if you
know that an act is wrong, you should refuse to do it
because even if you refuse, your practice should not be
threatened.
2 types of Material Cooperation
2.1 Immediate Material Cooperation
• When one concurs in the sinful deed or evil act
itself.
• When one person actually performs the
immoral action in cooperation with another
SY 2011-2012
Subject: Bioethics
Topic: Cooperation
Lecturer: Dr. Melchor V. G. Frias
Date of Lecture: September 9, 2011
Transcriptionist: Polkadots
Pages: 2
person.
• Almost always sinful or immoral.
• If the surgeon and the assistant are both
engaged in actually aborting the fetus, the
cooperation of the assistant is said to be
immediate material cooperation.
• Usually translates into formal cooperation.
* exception: when one is being threatened, such as when
the action is done at gun point or in resident training,
when threatened of training termination (in this case you
can refuse and report about the threatening to the
administration)
2.2 Mediate Material Cooperation
• When one provides means and other help for
the sinful deed or evil act without joining the
evil act itself.
• Concurrence in the sinful action of another not,
however, in such a way that one actually does
the act with the other or concurs in the evil
intention of the other but, while merely doing
something which is good or indifferent in itself,
the action also supplies an occasion of sin to
another, i.e. supplies some assistance, means,
or preparation for the sinful action of another.
*Example: a circulating nurse who prepares the
equipment and facilities for surgery--she is just doing
her job, which is good/indifferent in itself. I this case,
the gravity of her participation is less than the people
actually involved, eg, the2nd assistant (junior intern)
who did the retraction, but greater than for example,
the institutional worker who just wheeled in the
patient to the OR.
• The morality of mediate material cooperation is
to be sought using the principle of double
effect:
1. Good effect-- one’s own freedom of action, plus
the value of doing this or that action not wrong in itself.
2. Evil effect -- usually has a double aspect: (1) one’s
action constitutes an occasion of sin for someone else;
(2) there may be some evil coming upon a third party
(patient) as a result of the action.
Norms for Material Cooperation
• Permissible if 2 conditions are verified:
1. The act by which cooperation is rendered may
not be sinful in itself.
2. There should be a sufficient cause for granting
an assistance which is to serve an evil purpose.
*For the circulating nurse, she is just doing his/her job
and doing her job is not wrong in itself. Also, she may not
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:)!
I.)ETHICS)IN)RESEARCH)!
! General!Ethical!Guidelines!!
! General!Bioethical!Principles!!
! Basic!Elements!of!Research!Ethics!!
! Ensuring!Quality!Ethical!Research!!
! Ethical!Considerations!in!a!Research/Study!
Protocol!!
! Authorship!!
II.)ETHICAL)BREACHES)IN)SCIENTIFIC)RESEARCH)!
! Scientific/Research!Misconduct!!
! Dealing!with!Misconduct!
! " Waiver!of!informed!consent!is!to!
ETHICS'IN'RESEARCH'
! exception,!and!must!in!all!cases!be!
GENERAL)ETHICAL)GUIDELINES)FOR)HEALTH)
RESEARCH!
! Health!research!involving!human!subjects!
includes!research!on!identifiable!human!
material!or!identifiable!data![Principle!1!–!
Declaration!of!Helsinki,!2004]!!
! Considerations!related!to!the!wellKbeing!of!
the!human!subject!should!take!precedence!
over!the!interests!of!science!and!society!
[Principle!1!–!Declaration!of!Helsinki,!2004]!
! It!is!the!duty!of!the!researcher!to!protect!the!
life,!health,!privacy!and!dignity!of!the!human!
subjects!and!to!safeguard!scientific!integrity!!
! !
GENERAL)BIOETHICAL)PRINCIPLES)!
! All!research!involving!human!participants!
should!be!conducted!in!accordance!to!four!
basic!ethical!principles:!!
" Respect)for)persons)!
# Autonomy,!which!requires!that!
those!who!are!capable!of!
deliberations!about!their!
personal!goals!should!be!treated!
with!respect!for!their!capacity!
for!selfKdetermination!!
# Protection)of)persons)with)
impaired)or)diminished)
autonomy,!which!requires!that!
those!who!are!dependent!or!
vulnerable!be!afforded!security!
against!harm!or!abuse!!
! " The!findings!are!scientifically!
" Beneficence)!
# Ethical!obligation!to!maximize!
possible!benefits!and!to!
minimize!possible!harm!and!
wrongs!!
! ameliorate!or!treat!these!
" NonPMaleficence)!
# [do!no!harm]!holds!a!central!
position!in!the!tradition!of!
medical!ethics!and!guards!
against!avoidable!harm!to!
research!participants!!
!
!
!
!
" Justice)!
# Requires!that!cases!considered!
to!be!alike!be!treated!alike,!and!
that!cases!considered!to!be!
different!be!treated!in!ways!that!
acknowledge!the!difference!!
!!
ELEMENTS)OF)RESEARCH)ETHICS)!
! Informed)Consent)!
" For!all!biomedical!research!
involving!humans,!there!must!be!a!
voluntary!informed!consent!of!the!
prospective!subject!!
be!regarded!as!uncommon!and!
approved!by!an!ethics!review!
committee![Guideline!4!–!Council!
for!International!Organizations!of!
Medical!Science!(CIOMS),!2002]!!
!
! Risk,)Benefits)and)Safety)!
" Health!research!is!only!justified!if!
there!is!a!reasonable!likelihood!
that!the!populations!in!which!the!
research!is!carried!out!to!stand!to!
benefit!from!the!research!results!
[Principle!19!–!Declaration!of!
Helsinki,!2004]!!
! Community)!
" Conclusion!or!termination!of!the!
research!care!activity!should!not!
preclude!the!possibility!of!
administering!extended!
community!care![Bhutta,!2000]!!
!
! Privacy)and)Confidentiality)!
" Every!precaution!should!taken!
to!respect!the!privacy!of!the!
participant!and!the!
confidentiality!of!the!
participant’s!information!!
!
! Disclosure)of)Research)Results)!
o Must)occur)when)ALL)of)the)ff)
apply:!
valid!and!confirmed!!
" The!findings!have!significant!
implications!for!the!subject’s!
health!concerns!!
" The!course!of!action!to!
concerns!is!readily!available!
when!research!results!are!
disclosed!to!its!subjects!!
!
!
!
 ! !
! Standard)of)Care)!
" Particular!needs!of!the!community!
and!medically!disadvantaged!must!be!
recognized!in!determining!the!
standard!of!care!that!must!be!
provided!them!as!research!subjects!!
! " Special)Ethical)
! Compensation)of)Research)Subjects)!
" Compensation!given!to!subjects!for!
costs/expenses!incurred!in!taking!part!
in!a!study;!free!medical!services!and!
compensation!for!the!inconvenience!
and!time!spent!should!not!be!so!large!
as!to!induce!the!prospective!subjects!
to!consent!to!participate![Guidelines!7!
–!CIOMS,!2002]!!
! populations!!
! Subjects)groups)that)require)special)
considerations)!
" Some!populations!require!special!
protections!because!of!characteristics!
or!situations!that!render!them!
vulnerable!!
!
! Absence)of)Direct)Benefit)!
" Risk!from!research!interventions!that!
do!not!hold!out!the!prospect!of!direct!
benefit!for!the!individual!subject!
should!be!no!more!likely!and!no!
greater!than!the!risk!attached!to!
routine!medical!or!psychological!
examination!of!such!persons!!
! " The!International!Conference!on!
ENSURING)QUALITY)RESEARCH)!
! Role)of)the)Ethics)Review)Committee)!
" Review!the!scientific!merit!and!ethical!
acceptability!of!any!research!involving!
human!participants!!
! reactions/effects!!
! Research)Protocol)!
" Should!adequately!address!the!four!
ethical!principles!and!should!be!
sufficiently!detailed!to!serve!as!
documentation!of!the!study!
! ! Indemnification))
! Qualifications)of)Investigators)!
" Persons!engaged!in!health!research!
involving!human!subjects!should!be!
scientifically!qualified!!
!
! Protections)of)the)Environment)and)
BioSafety)!
" In!conduct!of!biomedical!or!behavioral!
research,!appropriate!caution!shall!be!
exercised!to!avoid!harm!or!damage!to!
the!environment![Principle!12!–!
Declaration!of!Helsinki,!2004]!!
!
! Welfare)of)Animals)!
" In!regards!to!the!use!of!animals!for!
research,!animal!investigators!shall!
abide!by!RA!No.!8485K!Animal!Welfare!!
! !
!
Act!of!1998!and!its!
implementing!rules!and!
regulations!!
!
! National)Ethical)Guidelines)for)
Health)Research)2006:)!
Guidelines:))
# Clinical!trials!on!drugs,!devices!
and!diagnostics!!
# Herbal!medicine!research!!
# Complementary!and!alternative!
medicine!research!!
# Epidemiological!research!!
# Social!and!behavioral!research!!
# Research!involving!traumatized!
# HIV/AIDS!research!!
# Research!on!assisted!
reproductive!technology!!
# Genetic!research!including!
stem!cell!research!!
!
! International)Guidelines)!
" World!Medical!Association’s!
Helsinki!Declaration!of!1964!
(revised!and!amended!in!1975,!
1983,!1989,!1996,!and!2000)!!
" The!WHO!Council!of!
International!Organizations!of!
Medical!Sciences!(CIOMS)!2002!!
Harmonization!Good!Clinical!
Practice!Guidelines!(1996)!!
!
ETHICAL)CONSIDERATIONS)IN)A)
RESEARCH/STUDY)PROTOCOL)!
! Provision!for!management!of!adverse!
! Stopping!of!the!study!in!case!harmful!
effects!are!demonstrated!!
! Potential!benefits!outweigh!potential!
harm![literature!review,!previous!trials,!
records]!!
" Amount!and!methods!of!
reimbursement!of!trialKrelated!
expenses!of!study!participants!!
" Guarantee!of!medical!
care/financial!indemnification!of!
study!participants!in!case!of!
trialKrelated!injuries!!
! Informed)Consent)!
" English!or!Tagalog;!dependent!of!
location!!
" Who!may!solicit!consent?!Who!
may!give!consent?!!
" Statement!that!the!study!is!
investigative!in!nature!!
" Specify!number!of!participants!in!
the!study!!
 " Express!the!purpose/objective!of!the!
study!!
" Disclose!probability!of!random!
assignment!to!treatment!and!trial!
treatments!!
" Explain!the!procedure!of!the!study!
including!all!invasive!procedures!!
" Expected!duration!of!subject’s!
participation!including!followKup!
visits!!
" Benefits!to!the!subject!!
" Alternative!procedure/course!
treatment!that!may!be!available!!
" Disclose!risk,!discomforts!and!
inconveniences!associated!with!the!
study!!
" Responsibilities!of!the!subject!!
" Statement!of!voluntary!participation!!
" Study!participants!have!the!option!to!
withdraw!from!the!study!anytime!!
" Guarantee!of!confidentiality!!
" Circumstances/reasons!for!the!
termination!of!the!subject’s!
participation!!
" Statement!regarding!indemnification!!
" Contact!person!!
! INTEGRITY'AND'ETHICAL'BREACHES'IN'
AUTHORSHIP)!
! There!is!no!universally!agreed!definition!of!
authorship.!As!a!minimum,!Authors!should!
take!responsibility!for!a!particular!section!of!
the!study!!
! All!persons!designated!as!“authors”!should!
QUALIFY!for!authorship!!
! Should!have!participated!sufficiently!in!the!
work!to!take!PUBLIC!RESPONSIBILITY!for!
the!content!!
! dealing!with!breaches!in!the!
! Who)Qualifies?!
)(Substantial!contribution!to):)!
" Conception!and!design;!or!analysis!
and!interpretation!of!the!data!!
" Drafting!the!article!or!revising!it!
critically!for!important!intellectual!
content!!
" Final!approved!of!the!version!to!be!
published!!
! ! Intellectual!honesty!ought!to!be!actively!
! Who)does)Not)Qualify?!
" Participation!solely!in!acquisition!of!
funds!
" Just!collection!of!data!
" General!supervision!!
" Performing!statistical!tests!
" No!‘laundry!list’!
" No!‘gift’!authorship!
!
! Group)or)corporate)author)
" Multicentre!trials/research!
" Should!fully!meet!the!criteria!for!
authorship!
) 2003]!
!
" NonKqualified!can!be!listed!in!!!!!!!!!
acknowledgement!or!in!
appendix!!!(with!permission))
" Order!of!authorship!to!be!
decided!jointly!(first!24!+!last!
one!if!>25!listed!in!Medline)!
" Watch!out!for!“personality”!
influence!
!
! Who)and)what)comes)under)
‘Acknowledgement’?)
" Those!that!do!not!qualify!for!
authorship!like!general!support!
by!departmental!chair!
" Those!rendering!technical!help,!
or!financial!and!material!support!
" Relationships!that!may!pose!a!
conflict!of!interest!e.g.,!financial!
relationships!with!the!industry!
" Others!like!scientific!adviser,!
critical!review!of!study!proposal,!
data!collection!or!participation!
in!clinical!trial!
!
****************************************!
)
SCIENTIFIC'RESEARCH'
'
OBJECTIVES:!
! Identify!specific!situations!of!
breaches!in!integrity!and!ethics!
in!scientific!research.!
! Define!specific!situations!of!
breaches!in!integrity!and!ethics!
in!scientific!research.!
! Discuss!appropriate!actions!in!
integrity!and!ethics!of!scientific!
research.!
!
Introduction:)
! It!is!essential!to!define!and!develop!best!
practice!in!the!integrity!and!ethics!of!
scientific!research.!
! The!crucial!aim!is!to!find!practical!ways!
of!dealing!with!the!issues.!
encouraged!and!used!to!inform!
publication!ethics!and!avoid!
misconduct.!
! Guidelines!should!be!developed!–!
advisory!rather!than!prescriptive!!!!!!!!!!!!!!!!!!!!!!!!!!!!
[The!COPE!Report,!2003])
! Serious!ethical!breaches!occur!in!at!
least!1.0%!of!all!clinical!researches.!
! Issues!are!identified!and!reported!by:!
" Anonymous)callers:!33.0%!
" Whistle)blowers)at)study)site:!
33.0%!
" Ethics)committee)and/or)
sponsor:)20.0%![Gitanjali,!
 ! !
! Behaviour!by!a!researcher!that!falls!short!of!
good!ethical!and!scientific!standards.!
! Significant)misbehaviour)that:!!
" Improperly!appropriates!the!
intellectual!property!of!others,!
" Impedes!the!progress!of!research,!!
" Risks!corrupting!the!scientific!record!
" Risks!compromising!the!integrity!of!
scientific!practices.!
! Misrepresentation)
" Fraud!
" Omission!of!facts!
! Misappropriation)
" Plagiarism!
" Use!of!confidential!information!from!
review!of!manuscript!or!grant!
application!
! Interference)
" Obstruct!research!of!another!by!
damaging!/!taking!away!research!
related!property!of!another!–!
apparatus,!reagents,!writings,!data!etc.!
! outcome!are!statistically!
FRAUD)
! Descriptive/Analytic)Study)or)
Experimentation)
" Planning!K!stealing!idea!
" Conduct!K!fabrication!
" Statistics!K!manipulation!of!data!
" Reporting!K!suppression!of!negative!
findings![Gitanjali!B,!2003]!
! ! It!may!occur!at!any!stage!research.!
! Publication)
" Gift!authorship!
" Duplicate!or!repetitive!publications!
" Failure!to!publish!
! ! Paraphrasing!
! Study)Design)and)Ethical)Approval!!
" Good!Research!should!be!well!justified,!
well!planned,!appropriately!designed,!
and!ethically!approved.!To!conduct!
research!to!a!lower!standard!may!
constitute!misconduct.!
" !
! Data)Analysis)
" Data!should!be!appropriately!analyzed,!
but!inappropriate!analysis!does!not!
necessarily!amount!to!misconduct.!
Fabrication!and!falsification!of!data!do!
constitute!misconduct.!
! the!individual.!
! Authorship)
" As!a!minimum,!authors!should!take!
responsibility!for!a!particular!section!of!
the!study.!
! !
! Redundant)or)Duplicate)Publication)
" Publication!of!a!paper!that!overlaps!
substantially!with!one!already!published!
in!print!or!electronic!media.!
" When!2!or!more!papers,!without!full!
cross!reference,!share!the!same!
hypothesis,!data,!discussion!points,!or!
conclusions![The!cope!report,!2003]!!
!
" When)is)a)Secondary)
Publication)acceptable?)
# Articles!that!need!to!reach!the!
widest!possible!audience!or!are!
intended!for!a!different!group!
of!readers!
# Competing!manuscripts!based!
on!the!same!study!
$ Differences!in!analysis!or!
interpretation!
$ Differences!in!reported!
methods!or!results!
# Competing!manuscripts!based!
on!the!same!database!
[IMCJE,2008]!
!
! Failure)to)Publish)
" Failure!to!report!findings!of!any!
carefully!done!study!of!an!
important!question,!relevant!to!
readers,!whether!the!results!for!
the!primary!or!any!additional!
significant.!
!
PLAGIARISM)
! Unreferenced!use!of!others’!published!
and!unpublished!ideas,!including!
grant!applications,!and!submission!
under!“new”!authorship!of!a!complete!
paper.!
! It!applies!to!print!and!electronic!
versions.![Gitanjali!B,!2003];!
[The!COPE!Report,!2003]!
! Copying!word!for!word!
! Quoting!based!on!secondary!sources!
! Taking!ideas!without!citation!
! Putting!one’s!name!to!work!written!by!
another!
!
DEALING)WITH)SCIENTIFIC)MISCOUNDUCT)
PRINCIPLE)
! The!general!principle!confirming!
misconduct!is!intention!to!cause!others!
to!regard!as!true!that!which!is!not!true!
! The!examination!of!misconduct!must!
focus,!not!only!on!the!particular!act!or!
omission,!but!also!on!the!intention!of!
! Deception!may!be!by!intention,!by!
reckless!disregard!of!possible!
consequences,!or!by!negligence.!
! Codes!of!practice!may!raise!awareness.!
DEALING)WITH)SCIENTIFIC)MISCOUNDUCT)
INVESTIGATING)MISCONDUCT)
! Editors!are!ethically!obligated!to!
pursue!the!case.!
! It!is!for!the!editor!to!decide!what!action!
to!take.![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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NMMAIKBATCH!2016! !
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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.!
)
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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-

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 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
 Procreation
 Two principles of procreation
 Conjugal act
 Perspectives of conjugal act
 Unitive
 Procreative
PART 1
PROCREATION
 The process by which an organism produces
others of its biological kind
 The sexual activity of conceiving and bearing
biological offspring
TWO PRINCIPLES OF PROCREATION
1. It requires the part of the spouse responsible
collaboration with the fruitful love of God.
 Responsibilities of the spouses:
1) Know and understand their sexuality
 The man or husband is aware that he is
a man and the wife is aware that she is
a woman.
2) Know and understand the unity of
marriage
 When a man and a woman enter
marriage, they become one.
3) Know and understand their personality
 You cannot enter a marriage without
knowing yourself or your spouse’s
personality.
4) Know and understand their duties with
their children
 It does not mean that just because a
man and a woman enters marriage
they may keep on procreating without
knowing that they have duties towards
their children such as education or
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
PART 2
 Prenatal Diagnosis
 Legitimacy and criteria of therapeutic procedures of
human embryo
 Principles in pregnancy
2. The gift of human life must be actualized in
marriage through the specific and exclusive
acts of husband and wife in accordance with
the laws inscribed in their persons and in their
union.
 Actualization of marriage is where the concept of
procreation or sexual intercourse comes in. This is
a requirement in marriage.
 It is not gratifying if a woman refuses to have
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
annulment.
 When we say specific and exclusive, there must be
no one else but the husband and wife. (No extras!)
 It has to be in accordance with the natural
laws and nature of marriage.
 Within marriage, the child has to be born
inside a “legitimate union”.
 A child has to be born in the context of marriage
to be considered legitimate.
 Being legitimate is the right of the child.
 A child born from live-in partners is still
considered illegitimate, but if they marry the child
may be considered legitimate.
 Legitimacy is important even in laws of
society, for the dignity of the human person.
 A child born in the context of marriage has more
dignity that a child born out of the context of
marriage.
CONJUGAL ACT
 The act of sexual intercourse between two
opposite sexes
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”
 Husband and wife render mutual help and
service to each other through an intimate
union of their persons and their actions
 It will not end after sexual intercourse
and must go beyond that
 Husband and wife see their “self-worth” by
being loved
 Husband and wife share intimacy
 Intimacy does not only refer to physical
closeness, it is when one becomes
willing to be vulnerable to each other
 PROCREATIVE = “life giving”
 This is why the church is against
contraception because in contraception, the
procreative power of conjugal act in
marriage is abolished
 The natural ordination of the conjugal act
towards the creation of human life
(“matrimonial right”)
 The result is another human life.
 By principle, human life will start when
the sperm of the father will meet the
ovum of the mother. Any insult or
attack to that human life is unethical
and immoral.
 In abortion, we destroy human life
which is the product of the conjugal
act. Hence abortion is immoral and
unethical.
CASE 1
R.M., a 21 year old female, sought consult at the out-
patient department for amenorrhea. Pregnancy test
was done revealing a positive result. So the patient was
requested for vaginal ultrasonography and revealed a
left ovarian pregnancy approximately 7 weeks AOG.
She was immediately brought to the operating room
and underwent direct oophorectomy.
 Was the decision of the physician acceptable?
 Technically, the obstetrician should not have
immediately proceeded with the
oophorectomy; the ectopic pregnancy at
this point has no risk or danger to the
mother.
monitor the progress of the pregnancy until
the pregnancy reaches the age of viability,
and then oophorectomy may be performed.
If the fetus does not survive upon reaching
the age of viability, let the fetus die the
natural way.
 If the at some point the mother experiences
bleeding or rupture, then you may perform
oophorectomy even if the fetus is not viable.
CASE 2
X.M., 16 year old G1P0, 16 weeks AOG, was
diagnosed with endometrial cancer stage 4. As the
patient’s attending obstetrician, you informed her on
the risk of harmful effects of chemotherapeutic drugs
to the fetus. However, if chemotherapy will not be
given, there is a greater chance that the mother will
die.
 If you’re the obstetrician, who will you choose?
Will you proceed with chemotherapy and let the
baby die? Or delay the management and let the
mother die eventually?
 Both the life of the mother and fetus is of
equal reverence/value.
 There is no direct answer. You are not
supposed to choose whether the life of the
mother or the life of the fetus. You may
delay the treatment; wait for the age of
viability. Once the fetus is at the age of
viability, deliver the baby, institute the
chemotherapeutic treatment to the mother;
if the baby will not survive outside the
mother, let the baby die the natural way. In
that way, you are not choosing between the
mom and the baby.
 If the management is very urgent and must
be given immediately, use the Principle of
Double effect. You may institute the
chemotherapeutic agents in this case
provided that your intention is to cure and
not to terminate the pregnancy. But if the
intention is to institute therapy and
eventually terminate the therapy, that is
bad.

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
 Prenatal diagnosis must respect the life and
integrity of the embryo and the human fetus and
must be directed towards its safeguarding or
healing as an individual.
 If the prenatal diagnosis will destroy the
integrity of the embryo, then the
management is not justified, unacceptable
or immoral.
 Prenatal diagnosis is opposed to the moral law
when it is done with the thought of possibly
inducing an abortion due to malformation or
congenital anomalies or hereditary illness.
 For example, during the prenatal diagnosis,
you were able to diagnose the fetus would
have anencephaly; do not terminate the
pregnancy. Proceed with the pregnancy,
deliver the baby and let the baby die the
natural way. But do nothing to terminate the
pregnancy.
LEGITIMACY AND CRITERIA OF THERAPEUTIC
PROCEDURES OF HUMAN EMBRYO
 Strictly therapeutic
 If the therapeutic efficacy of the
management is questionable, do not
institute that therapy to the mother.
 Explicit objective is healing of maladies
(chromosomal defects)
 If a therapeutic management would be able
to solve the chromosomal defect, then carry
on as long as it is strictly therapeutic and
would not destroy the integrity of the
embryo.
 Directed to the true promotion of the personal
well-being of an individual
 Does not harm the integrity of the embryo.
 Does not worsen the embryo’s condition of life
 Delicate and particular precaution in embryonic
life are called for
-END-
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PRINCIPLES IN PREGNANCY
 PRINCIPLES OF INVIOLABILITY OF LIFE
 No one has the right to end someone’s life
 Physicians cannot terminate the life of a
patient because they have no right.
 When in doubt, always side with life.
 Always apply this principle in obstetrics.
 PRINCIPLES OF DOUBLE EFFECT
 Criteria for evaluating the permissibility of
acting when one’s otherwise legitimate act
will also cause an effect one would normally
be obliged to avoid
 Always applicable in obstetrics especially
when the life of the mother and the life of
the fetus is at risk.
 BOTH LIVES ARE EQUAL IN VALUE
 The mother’s life and the fetus’s life are of
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.
 NATURE OF DISORDER OR TRAUMA
 If you were able to assess that one will really
not survive, then that is the only time that
you may choose.
CASE
A 16 week pregnant mother went to the emergency
room because of massive bleeding or spotting.
Ultrasound showed that there is a separation of the
placenta and the implantation site (placenta previa).
The mother is already hypotensive upon reaching the
ER. Will you terminate the pregnancy?
 The first step is to manage the hypotension. The
fetus cannot be delivered because it is not yet at
the age of viability (20 weeks).
 Improve the condition of the mother.
 Assess the condition of the fetus. If there is only
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
this good of the whole is the fundamental reason
of, and reason for, the existence of the parts,
 There is no violation of right order in the
destruction of the parts, when this is necessary for
the whole
 All parts of the human body 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.
 Therefore, when some part or function becomes
detrimental to the good of the whole body, it is
morally acceptable to remove such part or to
suppress its function.
PRINCIPLE OF DOUBLE EFFECT
 Often invoked to explain the permissibility of an
action that causes a serious harm, such as the
death of a human being, as a side effect of
promoting some good end
 Example #1
 A pregnant woman with uterine cancer has to
undergo surgery to remove the uterus. The good
effect is that the mother may be cured with the
removal of the uterus but the bad effect is the
termination of the baby.
 The act itself is good which was the removal
of the cancerous uterus, the good effect and
not the evil effect is the one intended by the
agent

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Editor/s: Craig Angelo Reyes
 Example #2
 A patient terminally ill from cancer has metastasis
to the bones which is causing extreme
excruciating pain. Usual doses of analgesics is no
longer effective. Morphine, which is an opioid
used to relieve intense or chronic severe pain, was
given to relieve the patient from suffering
regardless of the incremental dosage.
 Example #3
 A patient bleeding from gastric ulcer, vomiting
blood, and in hypotensive shock. He had
myocardial infarction a few weeks before. If
operated, chances of dying is 90%. The bleeding
has to be stopped immediately by doing surgery
FOUR CONDITIONS:
 The act itself is good or indifferent
 The good effect and not the evil effect is the one
directly intended by the agent
 The good effect is not produced by the evil
effect. The good effect must follow from the
action at least as immediately as the harmful
effect
 There is proportionate reason for permitting the
foreseen evil to occur
 Example #1
 Performing a surgery to remove a life-threatening
uterine cancer from a pregnant woman may be
permitted, since the action is not evil in itself,
even though it may cause death of the fetus.
 Example #2
 Giving increasingly high doses of morphine in
terminally ill patients to relieve suffering, even
though this might bring about end of life.
PRINCIPLE OF NON-MALEFICENCE
 “Primum non nocere” –“first do no harm”
 One ought not to inflict evil or harm
 Related to the following human rights:
 Right not to be killed
 Right not to have bodily injury or pain
inflicted
 Right not to have one’s confidence revealed
AUTONOMY/INFORMED CONSENT
AUTONOMY
 The moral right to choose and follow one’s own
plan of life
 Freewill, Free to choose anything you want
to do
INFORMED CONSENT
 The willing and uncoerced acceptance of a
medical intervention by a patient after adequate
disclosure by the health professional of the nature
of the intervention, its expected risks, benefits
and alternatives available
 Signing of consent form is just signing and
NOT securing. The act of securing a consent
from the patient is the actual
communication between the doctor and the
patient. The signing is just an evidence that
the patient really consented.
Transcriber/s: Nicxz Icaro
Formatting: Nicxz Icaro
Editor/s: Craig Angelo Reyes
ELEMENTS OF INFORMED CONSENT:
1. Disclosure of information
2. Comprehension of information
 Explain all the details of the nature of
disease, urgency of the treatment,
treatment options, recent publications,
benefits, costs
3. Voluntariness
 Patient is not coerced (scared by the
surgeon)
 Do not force the patient to agree on the
procedure if he/she is not willingly
consenting
4. Competence
 Consent given voluntarily by the patient
himself
 If patient is incompetent, legal guardian or
immediate family member is the one to be
asked for consent.
NOTE: ALL SURGERIES NEED INFORMED CONSENT
ELECTIVE SURGERY
 Not urgent surgery or Scheduled at own
convenience or leisure
 Cosmetic surgery
1. May be done:
 if the risk is low
 if the functional integrity is maintained
 even if the other organs that are affected by
the removal are rendered functionless
secondary to a more important surgery
2. May not be done:
 if the risk is high
 if it does benefit the patient
 if there is no medical usefulness
THERAPEUTIC SURGERY
1. Since it is a necessary surgery, because it is
curative, then it should be done.
2. Informed consent is necessary
 Examples:
 Colon cancer: colectomy
 Appendicitis: appendectomy
 Breast cancer: mastectomy
PALLIATIVE SURGERY
 Relieve symptoms
1. Since it is not designed to prolong life but
make the patient more comfortable (the
condition cannot be cured), it is an optional
surgery.
2. Informed Consent is necessary
3. If proper disclosure of information has been
made and the patient still requests it, it may
be done but always weigh the benefits and
the risks.
 Example #1
 Bleeding gastric cancer with gastric outlet
obstruction, the cancer obstructed the pylorus
and food cannot proceed to the duodenum.
Surgery is done for the patient to enjoy the
pleasure of eating food normally and not by tube.
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
UNNECESSARY SURGERY
1. It is unethical to perform surgery with no real
medical indication but which might be
undertaken for some unworthy motive such as
financial gain or face-saving.
2. A surgeon is culpable when, because of inability or
lack of knowledge to preserve or repair an injury,
performs an amputation/mutilation rather than
ask for assistance or make a referral.
3. Although it would be easier to amputate, the
surgeon is bound to conserve as much as possible
a part, or all of the part of the body that is injured.
 Example #2
 Cholecystectomy (surgical removal of gallbladder). If
a patient with gall stones is asymptomatic, 90% does
not progress to cholecystitis so usually the
gallbladder is not removed. A doctor should not
scare or force the patient to have a surgery if it’s not
medically necessary.
INCIDENTAL SURGERY
1. The removal of the part of the body does not
pose a serious threat to the patient’s life.
2. It is done during the course of a main surgery.
3. The part removed has no integral function in the
body.
4. The part removed enhances physical
appearance.
 Example #3
 Gynecologist will remove mucinous tumor of
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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 Example #4
 Colectomy, removal of the right side, patient also
has asymptomatic gall stones, since the part is
already opened might as well remove the
gallbladder but still ask for an informed consent
from a family member if the patient is
incompetent or if not anticipated.
SUPPRESSION OR EXCISION OF A HEALTHY ORGAN
 Justifiable if the normal organ exercises an
influence on another diseased organ
 Example #5
 Hormonal treatments are usually used in breast
cancer which works by blocking the effects of
estrogen on breast cancer tumor cells. Since
ovaries produce estrogen, removal of the ovaries
may be an option. However, it is only effective or
advised for pre-menopausal women
CLINICAL CASES
1. Incidental Appendectomy
2. Strictly Elective Appendectomy
 No symptoms involve but insisted on having
it remove
3. Elective Tonsillectomy
4. Circumcision of the Newborn
 Not unnecessary nor incidental
5. Oophorectomy in breast cancer
 There are Pro’s and Con’s since hormonal
medications may also be taken
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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
SOME ETHICAL CRITERIA TO TAKE INTO ACCOUNT
FOR THE ACTUAL MORAL DISCERNMENT
REGARDING BIRTHREGULATION:
1. The exercise of responsible parenthood should be
such as to respect human life.
 This does not mean you have to be PRO-life but
RESPECT LIFE because it’s coming from God
 The fundemental bioethical principle is
SANCTITY and INVIOLABILITY to life
(Reverence or respect for human life)
2. The moral evaluation of the various methods of
contraception should be made not from an
excessively biological point of view of human
sexuality, but from a complete vision of
marriage and human love.
 Regulating birth is not just physical or biological
but also spiritual or moral
 We cannot separate sexual love from human
love because it’s a part of it. When we look at a
person, when he/she acts according to that love.
It is the whole thing of himself including his own
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
with God.
 When we talk about Human love were talking
about a responsible human love, real sexual love,
mature love, complete love not just love that see
in the streets or hear in songs
 Marriage is not just having a child; it’s only a part
of it. Marriage is when two people in complete
mature love come together and decide to be
together for life because they decide that the
other would be the parent of his/her children
coming from a real love and as part of sexuality. It
starts with sex, starts with attraction but ends up
with something.
 Sexual intercourse may have its end, what
remains is the real love.
 Marriage is not a sacrifice; marriage is a gift of
oneself because of a supplying love in which you
want that person to be the parent of your child
and to live with him/her for the rest of your life.
3. From the technical point of view, none of the
available methods of contraception satisfies all
the criteria for an ideal method.
 There would be no ideal method
 One method may be effective for one couple but
not for the other
 There should be openness between husband and
wife
Transcriber/s: Eliza Marie Hererra
Formatting: Nicxz Icaro
Editor/s: Nicxz Icaro, Craig Angelo Reyes
4. The morally acceptable use of contraceptive
methods should be the result of the free and
responsible discernment of the spouses
 When the spouses discern: they talk, they
dialogue about their fertility, they talk about their
sexual love together, and they talk about
themselves.
 What if after discerning the couple agreed to use
the pills? it still depends on the circumstances
they are in or situation, their health, social status
and many things.
The spouses should keep in mind that their mutual
self-giving and the resulting procreation should be an
expression of authentic personal love
 It’s not only biological, not only ligation, pills or
family planning. It should be coming expression
of authentic personal love, from that authentic
personal love, they discuss, and they discern and
talk.
 Their mutual self-giving, specially the physical,
should be intimate and sacred. And from that
sacredness and intimacy, the resulting pro-
creation should be there for an expression of
authentic personal love. Children are expression
of authentic personal love.
RESPONSIBLE PARENTHOOD
 The right and duty of increasingly humanized
population ethically entails the principle of
responsible parenthood, with the corresponding
need for family planning. Children should be the
product of the mature and responsible love of
married couples.
 Right and duty cannot be separated
 Responsible parenthood is a principle and not a
means for contraception.
 When we talk of responsible parenthood it might
imply the number of children or spacing of birth
 The term responsibility should echo the
fundamental bioethical principle of
STEWARDSHIP and ACCOUNTABILITY
 Responsible parenthood is not family planning;
family planning is a part of responsible
parenthood.
 Family planning is NOT a necessity.
 Society has the obligation to create adequate
conditions for the exercise of responsible
parenthood by the spouses.
 Society must create adequate conditions. Society
including government should not fight but should
give proper respect on how other people look at
these things.
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 2
  The actions of the community should respect the
dignity of the human person and the value of
personal decisions.
 If a particular couple has a particular decision, we
don’t condemn them.
 Includes both the dignity of the spouses and of
the unborn
 Personal decisions are valuable which include the
decisions of the spouses after proper discussion
and are therefore respected
 “The product of human reproduction is not a
potential person but a person with potentials”
CONTRACEPTION
 The deliberate prevention of conception.
 The essential action of contraceptive methods is
to prevent fertilization by precluding the meeting
of ovum and spermatozoa.
-END-
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 The spouses have the obligation to make the
ultimate ethical discernment regarding the
exercise of their fecundity, taking into
consideration
 The orientation of conjugal love toward
fecundity
 The various values which are involved
 Religious, cultural, social, family &
moral values
 The circumstances of their situation.
 Don't plan on having 6 children if you
can't provide them food adequately
 Why have only one child when you can
raise 3? This plan may arise from
personal selfish reasons
 Spouses should consider monetary and
social situation
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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 2
 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
 The human person is so deeply influenced by his
sexuality that this latter must be regarded as one
of the basic factors shaping human life
 The person’s sex is the source of the biological,
psychological and spiritual characteristics which
make a person male or female, and thus are
extremely important in the maturation and
socialization of the individual
 Moral corruption is on the increase
 Boundless exaltation of sex
 Teachings, moral norms and habits faithfully
preserved have been called into doubt
 The Sources of Moral Knowledge
 Conscience
SEXUAL MORALITY
CONVENTIONAL SEXUAL MORALITY
 Sex is morally legitimate only within the bounds
of marriage Defense:
 Social utility
 A stable family life is absolutely
essential for the proper raising of
children and the consequent welfare of
society as a whole
 Natural law theory
 Actions are morally appropriate insofar
as they accord with our nature and end
as human beings and morally
inappropriate insofar as they fail to
accord with our nature and end as
human beings
 Procreation is the natural purpose or
end of sexual activity
THE LIBERAL VIEW
 Reject as unfounded the conventionalist claim
that non-marital sex is immoral
 Reject the related claim that sex is immoral if it
cuts off the possibility of procreation
 Nor are willing to accept the claim that sex
without love is immoral
 There are important moral restrictions on sexual
activity
 It is morally objectionable to the extent that it is
incompatible with a justified moral rule or
principle
 Infliction of personal harm
SEX
 Two common designations:
1. The biological aspect of one’s personhood,
the individual’s biological makeup based on
the appearance of genitals
2. Genital behavior, i.e. What we think, feel
and do sexually
SEXUALITY
 It encompasses both sex, i.e. who we are and
what we think, feel and do sexually, as well as the
meanings given to sex.
 “What our body means to us, how we understand
ourselves as a woman or as a man, the way we
feel comfortable in expressing affection – those
are part of our sexuality… Un this broadest sense,
sexuality is how we make sex significant”
(Whitehead and Whitehead 1989:45)
 It does not necessarily include genital intercourse
or related sexual practices.
SEXUAL ORIENTATION
 Sexual orientation refers to the emotional and
erotic preference for the category of people –
heterosexual, homosexual, or bisexual – how an
individual prefers to relate sexually or intimately.
SEXUAL IDENTITY
 Sexual identity refers to the individual, gay,
lesbian, or bisexual. “Self-identification” is the
operative word which is indicative of whether the
individual considers him-/herself as male or
female.
 Sexual identity is related to but different from
gender identity

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
Editor/s: Craig Angelo Reyes
GENDER
 A socially constructed designation.
GENDER IDENTITY
 This refers to the individual’s subjective sense of
being a man or woman. It is the individuals inner
sense of self as a man or woman
SEXUAL LOVE IS:
 Exalted as a human value
 Willed by the Creator
 Wholly good
LIMITATION OF SEXUAL LOVE:
 An easy, unpreoccupied enjoyment of sexual love
and its spontaneous regulation by the instincts of
human nature.
 The fallen state of man cannot be ignored
REALITY OF HUMAN SEXUALITY:
 Its creative powers of enriching love
 Its eroding forces of dehumanizing abuse
CHRISTIAN VIEW OF SEXUALITY:
 God created man male and female (principle of
differentiation)
 The woman is a human person like Adam
(principle of equality)
 The original goodness of sexuality (principle of
value)
MEANING OF HUMAN SEXUALITY
BIBLICAL VIEW – OLD TESTAMENT
 Gen 1:27 “God created man… created them.”
 Man is God’s image
 Differentiated in two sexes
 The entire man is created good. Sexuality, as a
gift of God, is wholly acceptable.
 Man’s nature must primarily be understood from
the nature of God, and not from the nature of the
animal.
BIBLICAL VIEW – NEW TESTAMENT
 Jesus Christ treated women equally with men
 The early church was concerned with self-control
and discipline in sexual life
 Fornication and adultery are listed as vices and are
condemned (I Thes.4:4-8; I Cor. 6:9 ff.)
 Christians must sanctify their bodies and sexuality
because they are the temples of the Holy Spirit (I
Cor. 6:13-20)
 Married people are to maintain mutual love for
each other (I Peter 3:1-7). And there is parallelism
between the bond that unites Christ with the
Church and the bond of marriage (Eph. 5:21-33).
 There is a recommendation of virginity.
Transcriber/s: Eliza Marie Hererra, Nicxz Icaro
Formatting: Nicxz Icaro
Editor/s: Craig Angelo Reyes
THE PURPOSE OF SEXUALITY:
 Procreation (Gen. 1:28)
 Mutual companionship (Gen. 2:18) and to
complete (completion) each other (the sexes)
(Gen. 2:21 ff.) The completion of each other is
both biological and spiritual.
 This completion and mutual companionship
culminates in the mutual self-giving by which they
form so intimate a union that they can be called
“one flesh”. (Gen. 2:24)
BECAUSE OF SIN:
 State of integrity is lost
 The entire order of creation is disturbed
 The relationship of the sexes is disturbed
 The carefree naturalness of the sexes in their
mutual relationship is lost.
 Sexuality is experienced as a vulnerable
possession which man must protect against abuse
by others and also by himself
MAN’S SEXUAL CONSTITUTION IN GENERAL
 Man and woman complement each other. Any
contempt of the other sex is unfounded conceit
and ultimately an offense of the Creator
 The erotic is a marvellous and creative power in
man. But its force can be terrifying. When sexual
desires and genital satisfaction are detached from
the totality of eros and human love, evil can be
revealed.
 Only when integrated in the totality of man’s
being is sexuality good, amiable and constructive.
NATURE OF SEXUAL LOVE
 The attraction and love of the sexes finds its
expression in the act of sexual love.
 Sexual love aims at a partner of the other sex.
Every other form of sexual actuation is:
 Incomplete
 Directed to the beloved
 Immature
 To be able to have sexual desire or
fulfillment with another sex and to be
able to love the opposite sex with one’s
whole being
 Perverse
 Outside of what is natural
 Pleasure is not the purpose/aim of sexual function.
Pleasure is the divinely instituted allurement of
human beings to use their sexual powers and
thereby to maintain and to propagate life.
 J. Grundel: “Sexuality cannot and may not
become purely the means to private satisfaction
of instinct nor a sort of easily available drug. It
gives man a goal beyond himself.”
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
PURPOSE OF SEXUAL LOVE
1. Propagation of mankind through procreation of
children.
 This is the innate, ultimate purpose of man’s
sexual faculties
 This is the nature-ordained end of sexuality
 It includes education of children
2. A means to express mutual love
 Expresses mutual love and esteem
 Deepens the intimate unity of husband and wife
 Truly a human action that signifies and promotes
the mutual self-giving
 If a person accepts this act in its whole
significance and value as suited and intended for
the procreation of children he/she will be ready
for such intimate love only with a partner whom
he/she would like to be the father/mother of
his/her possible child
3. Creates a community
4. Mutual love is enhanced and more perfectly
achieved when man and woman are bound
together by a permanent union of common life.
SOCIAL ASPECT OF SEXUAL LOVE
1. Since sexuality orders a man toward other human
beings and since its complete actualization
involves a partner, in necessarily affects the social
life of a community scholar
2. Nobody can arbitrarily use another for the
satisfaction of one’s own sexual desires. He/She
has to respect the rights of the partner:
 To his/her body
 To the free disposition of him-/herself
 To a treatment worthy of a person
 To responsible care
3. Sexual relations give life to children who are the
future of the community. A sound family life is an
essential condition for the guarantee of a healthy
youth.
4. Human sexuality possesses specific qualities
which demand a control of its energies for social
living
Transcriber/s: Eliza Marie Hererra, Nicxz Icaro
Formatting: Nicxz Icaro
Editor/s: Craig Angelo Reyes
CHRISTIAN ATTITUDE TOWARDS SEX AND
SEXUALITY
 The Christian attitude towards sex and sexuality is
RESPECT AND REVERENCE.
 The nature of SHAME in the realm of sexuality is
fundamentally that of a protective instinct, built in
by nature between a person and his fellow
 The moral virtue which disposes a man to meet
the demands of shame in the realm of sexuality is
MODESTY.
 Modesty is a readiness to keep away from all
dangers rising against a person’s sexual integrity.
Modesty is the protection and custodian for
chastity.
 FIELDS OF MODESTY
 Conversation
 Literature/reading
 Media (TV, radio, movie theatre)
 Looks touches
 Fashion (dress)
 Chastity is the moral force which keeps order in
the sphere of sexual activity.
 Chastity is not only continence but is an attitude
of reverence for the mystery of life and for the
personal dignity of the partner.
 Chastity shapes and orders the sexual powers in
such a way that they are truly able to serve the
human relation of conjugal partnership and the
social need of the propagation of the community
PRINCIPLE OF PERSONALIZED SEXUALITY
 The gift of sexuality must be used in keeping with
its intrinsic, indivisible, specifically human
teleology.
 It must be a loving, bodily, pleasurable expression
of the complementary, permanent self-giving of a
man and a woman to each other which is open to
fruition in the perpetuation and expansion of this
personal communion through the family they
responsibly beget and educate
 Sex is a search for sensual pleasure and
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
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 4

PRINCIPLE OF PERSONALIZED SEXUALITY
 The gift of sexuality must be used in keeping with
its intrinsic, indivisible, specifically human
teleology
 It must be a loving, bodily, pleasurable expression
of the complementary, permanent self-giving of a
man and a woman to each other which is open to
fruition in the perpetuation and expansion of this
personal communion through the family they
responsibly beget and educate.
PRINCIPAL VALUES OF HUMAN SEXUALITY
 Sex is a search for sensual pleasure and
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
SEX OUTSIDE MARRIAGE IS ETHICALLY WRONG
 Selfish pursuit of pleasure apart from love
 Casual or promiscuous relations
 May express love but not a committed love
involving true self-giving
 Adultery or premarital sex may be committed,
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
BASIS Pdf file, PPT RECORDINGS
REMARKS Content is lifted from the latest PPT, 2012 PDF file and recordings of the latest lecture; “What you see is what you get”-Dr. Ballesteros
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PART 2
ENCYCLICAL LETTERS, PAPAL LECTURES
 Humanae vitae
 Encyclical Letter of His Holiness Pope Paul VI on
the Regulation of Birth
 Evangelium vitae
 Encyclical Letter of the Supreme Pontiff John
Paul II on the Value and Inviolability of Human
Life
 Theology of the human body
 Pope John Paul II
HOW HEALTH CARE PROFESSIONALS CAN HELP
 Provide for an understanding of the unitive-
procreative meaning of sexuality in marriage
 Provide information on essential biological facts
on sexual differences and equality, pregnancy and
birth
 Provide information on why people have a need
for children and on problems of sterility and the
limits on the right to have children
 Provide information on the problems of
responsible parenthood in present-day society,
natural family planning methods and alternative
methods and ethical evaluation of all birth
regulation methods
 Explain the rights of the unborn child
 Discuss the problems of genetic defects and the
supportive attitude toward defective persons and
consider problems in psychosocial development
-END-
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D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 4
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
 Brain States
 Brain Death
 Artificial Nutrition/Hydration (ANH)
 Brain Death and Organ Donations
 Case 2
 Medical Futility
 Case 3
 Withdrawing/Withholding Life-Prolonging
Treatments
 Euthanasia and Assisted Suicide
 Allowing to Die
 Case 4
 Terminally Ill
 Case 5
 Challenging Autonomy
 Advanced Directives
CASE 1
A 45 year old man had a motorcycle accident last
year and is presently in a permanent vegetative state. He
is dependent on a feeding tube where he is being fed and
hydrated. He has been in this state for more than 12
months and the family is experiencing “caregiver fatigue”.
The family members know that there is really no chance of
the patient returning to previous functionality and
productivity and they made a court appeal if they can
already remove the feeding tube.
a) What is the condition known as the “permanent
vegetative state”?
b) What will be your opinion with regards to the
withdrawal of the feeding tube? Please defend
your answer.
c) Is ARTIFICIAL NUTRITION AND HYDRATION
(ANH) comprise proportionate (ordinary) or
disproportionate (extraordinary) treatment?
 There is no wrong answer as it is still a subject
of debate
BRAIN STATES
 MCS: Minimally Conscious State
 State of wakefulness
 Fluctuating awareness of self and
environment
 Potential for re-activation or “emergence”
being able to do or be able to respond to
stimuli
 Unable to interact with the environment,
“eyes-open” state (vs. COMA which is a
“closed-eyes” state)
 Cannot be classified as conscious
 COMA NA DILAT
 Permanent if > 3months after an anoxic
injury or >12months following traumatic
injury
 Anoxic – no oxygen to the brain for
30minutes or more
 Patients with cardiorespiratory
arrest
 Brain Death
 Irreversible cessation of all brain function
(cortical and brain stem)
 EEG – flat line
 Legally dead
 Cardiac Death
 Cessation of cardiac physical and electrical
activities
 In the advent of advanced life support
systems, it is difficult to base the actual
occurrence of death with cardiac death
 Brain death = actual death
BRAIN DEATH
 Clinical determination
 Absence of cortical function:
 Unresponsive and unarousable
 Absence of brain stem function:
 Absent reflexes (gag, papillary,
corneal), no spontaneous breathing
 EEG: No brain activity
 In the clinics, usually doctors rely on
clinical like the PE findings and the like
ARTIFICIAL NUTRITION/HYDRATION (ANH)
 As per the Catholic Church
 Is an ORDINARY treatment and IS
MANDATORY
 Life prolonging measures should not be given
IF THEY ARE INEFFECTIVE
 In CASE 1 – ANH can prolong the life of
the patient as per doc; family should
also be considered in decision making
 For some dying patients, ANH may increase the
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

Formatting: Ro-Janna Jamiri 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
Editor: Craig Angelo Reyes
  TERRI SCHIAVO Case
 Ruled to be in permanently vegetative state
after anoxic brain injury
 Long legal battle in the US which eventually
resulted in a decision to remove the feeding
tube in 2005
 Husband wants tube removed but the family
(parents and siblings) countered
 Florida court agreed to remove feeding tube
March 18, 2005
 George Bush signed an emergency law on
March 21, 2005 allowing the parents of Terri
to appeal the court’s decision
 Schiavo died March 31, 2005
BRAIN DEATH AND ORGAN DONATIONS
 Importance of knowing the time of brain death
is for organ donation
 Those who are brain dead but whose circulation is
supported by artificial means, can be approached
for the possibility of organ donation
 Obtaining consent from relatives should be done
in a humane and empathic manner
 May be present in some living wills
SUMMARY
 FOR ANH
 Should not be removed since it is an ordinary
treatment that can provide nourishment to
the patient.
 But still depend on the morality of the
individuals involved and the legality of the
process in the country
CASE 2
An 85 year old male with stage IV lung cancer
went to the emergency room for difficulty breathing. His X-
ray showed multiple lung masses and nodules occupying
aggregately about 70% of his lungs. He also developed
severe sepsis from a concomitant pneumonia and his
kidneys are failing due to the infection. At this time, the
patient will require intubation with mechanical ventilation,
and hemodialysis from a strictly medical point of view. The
relatives of the patient said “do everything” despite the
doctors stating the incurable state of the cancer.
a) As a relative, what further information would you
require from the doctor to help you in making
decisions?
 Pros and cons of the treatment
 Cost of treatment
 Survival and success rates
b) As a doctor, what treatment goals would you set
for the patient?
 Palliative – support or minimize the
discomfort, treatment of other symptoms
c) Would you strongly recommend mechanical
ventilation and hemodialysis? Why or why not?
 YES – since the family stated to do
everything, and as long as the family can
sustain the treatment financially
Transcriber: Nicxz Icaro
Formatting: Ro-Janna Jamiri
Editor: Craig Angelo Reyes
MEDICAL FUTILITY
 Hippocrates: “Refuse to treat those who are
overmastered by their disease, realizing that in
such cases, medicine is powerless”
 Clinical action serving no useful purpose in
attaining a specified GOAL for a given patient
 GOALS should be established:
 Cure or palliation?
 Keep alive or return to full functionality
 Goals to be discussed with patient and
relatives
 Important to SPECIFY THE GOAL to the
RELATIVE
 Example: Goal for intubation is to provide
oxygenation
 If for palliation, specify to the relative that it
will not make the patient well and go back to
work
CASE 3
A 70 year old male has multi-drug resistant
staphylococcal pneumonia and has stayed at the intensive
care unit for 2 weeks. He is on mechanical ventilator and
inotropic drugs to maintain his blood pressure. All possible
antibiotics were already used and the patient is not
responding to treatment. The blood pressure is declining
despite maximum inotropic support, and his level of
oxygenation is dropping despite full oxygen support. He is
mostly unconscious but can be awaken for short periods.
His family is contemplating on stopping inotropic support
and mechanical ventilation.
a) Will stopping mechanical ventilation and inotropic
support constitute euthanasia?
b) Are these measures (inotropic, mechanical
ventilation) considered extraordinary measures to
prolong life?
 Inotropic – disproportionate
c) c. Would you agree in discontinuing these
treatments?
WITHDRAWING/WITHHOLDING LIFE PROLONGING
TREATMENTS
 Withdrawing
 An act of commission
 Decide and commit to discontinue an
ongoing treatment
 Withholding
 An act of omission
 Treatment is not given in the first place
 Legally, there’s no legal difference (BMA 1999)
 Ordinary (proportionate) means vs. extra-ordinary
(disproportionate) means of sustaining life
 No obligation for doctors to provide
disproportionate, ineffective or even experimental
treatment
 Withdrawing disproportionate treatment –
NOT CONSIDERED EUTHANASIA since the
disease will take the natural course
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
EUTHANASIA AND ASSISTED SUICIDE
 Taking deliberate action to end a life of another
person on compassionate grounds
 The primary objective is to achieve the death of
the person and not merely allowing death to
occur
 Illegal in most countries
 Legal: NETHERLANDS, BELGIUM,
SWITZERLAND
 Church: euthanasia is a homicide act which no
end can justify
 Maximize pain management, hospice care and
psychological counseling
 DIGNITAS CLINIC, SWITZERLAND
 Sir Edward Downes and wife Joan
 Conductor – BBC Philharmonic Orchestra
 Died July 10, 2009 via assisted suicide at the
Dignitas Clinic in Switzerland
 Suffered from progressive deafness and blindness
 Lady Downes had Stage IV pancreatic cancer
ALLOWING TO DIE
 It is the condition or the disease that causes the
death of the person, not the deliberate acts of
the doctor
 Discussed in the context of medical futility and
withholding of extra-ordinary means of
prolonging life
CASE 4
A 45 year old male lawyer is diagnosed with
Stage IV pancreatic cancer. You told him that though the
disease is incurable by modern medicine, treatment can
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
whatsoever and just let the disease take its course.
a) As his physician, are you obliged to convince him
to undergo treatment?
 Obliged to give information not to convince
b) He was admitted several months later due to lung
and liver failure due to spreading cancer. This time
he asks you to “do everything” and invokes his
right to self-determination and autonomy. What
will you do?
 Can do in the context of the situation
 Give goals, treatment options and outcomes
TERMINALLY ILL
 When the state of one’s health deteriorates to
an irreversible and fatal condition
 Right to life… right to death with dignity
-END-
TRANSCRIPTION DETAILS
BASIS Latest PPT + IDK 2014 RECORDINGS
REMARKS Editor’s note: Wala.
-BATCH 2016 Transcribers’ Guild Transcriptions. Version 2.0.0.0.0 Build 3202-
Transcriber: Nicxz Icaro
Formatting: Ro-Janna Jamiri
Editor: Craig Angelo Reyes
 BIOETHICAL PRINCIPLES
 Beneficence: acting in the best interest of
the patient
 Non-Maleficence: first do no harm
 Autonomy: patient’s right to choose or
refuse treatment
 Justice: decision of who gets what
treatment
CASE 5
A 75 year old man who was a chronic smoker has
been living with emphysema for the past 7 years. The past
6months, he has been dependent on oxygen at home, but
would still have difficulty breathing even on light
movements. The past week, he called his lawyer to write
down his will and advanced directives. His will states that if
ever his breathing becomes severely labored, he would not
want intubation and mechanical ventilation to be done.
And if ever his heart and circulation stops, he would not
want CPR to be done. One day, he slipped while inside the
bathroom and went unconscious after hitting his head on
the floor. His wife brought him to the emergency room.
The doctors advised intubation and mechanical ventilation
to control the swelling of the brain due to the trauma.
Intubation has a good chance of saving the patient’s life.
The patient’s wife brought up the will that no intubation
should take place.
a) What will you do in this situation? Defend your
answer.
 Respect the will
 Proceed with the intubation since the
circumstance is different from what is stated
in the will
CHALLENGING AUTONOMY
 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
known values and beliefs
 Patient’s decision should not be overturned just
because it does not conform with societal norms
(autonomy will be meaningless)
ADVANCED DIRECTIVES
 Advanced decision are legally binding
 Must be made by an adult who is well informed
 Validity of long standing advanced refusals may be
questioned if treatment options are substantially
different
 Consider if circumstances are different from what is
stated in the will
 If there is no written will and the patient becomes
incapacitated to decide, then the “presumed wishes” of
the patient have to be implemented (doctrine of
substituted judgment)
+ NOTES + DEVIATIONS 8-10% CREDITS -
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 3
 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
 Disclosure
 Termination of Pregnancy
 Is Termination of Pregnancy Morally Acceptable?
 Abortion
 Erroneous Justifications
DISCLOSURE
 Any facility identified as Catholic assumes with
this identification the responsibility to reflect in
its policies and practices the moral teachings of
the Church
 NOT A MATTER OF OPINION
 The medical profession is always at the SERVICE
OF LIFE
 Many moral problems of relevance today
stems from conflicts arising from the life of
the mother and the fetus
In telenovelas, characters are always given the option to
choose between the mother and the baby, but in real life,
this is not really an option. So yung mga nasa drama na
nagsasabing wala tayong magagawa at kailangan mamili
kay mommy at kay baby is wrong because the rights of the
baby is totally and completely the same as the rights of the
mother, the same rights each and every one of us has.
TERMINATION OF PREGNANCY
There is always a bad connotation when you say
“termination of pregnancy” but it is actually only a
terminology that says to put an end to pregnancy. There is no
moral responsibility. It only means to stop the pregnancy
from progressing, regardless of the age of gestation. It can be
medical (use of drugs), operative or surgical.
 Putting an end to the progression of pregnancy
 To stop the pregnancy from progressing
 Regardless of the age of gestation
 Covers different methods
 Medical, operative or surgical
procedures
IS TERMINATION OF PREGNANCY MORALLY
ACCEPTABLE?
 IT DEPENDS ON THE SITUATION
WHEN DOES IT BECOME ACCEPTABLE?
 When you say acceptable, it is RIGHT
 It is not acceptable if you’re not at peace with your
conscience or if it’s only considered acceptable
because it is what the majority does
Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas
Formatting: Craig Angelo Reyes
Editor: Craig Angelo Reyes
WHEN DOES IT BECOME ILLICIT?
 LICIT is morally acceptable; if it is ILLICIT, it
becomes erroneous or illegal
 When you say when it becomes morally illicit?
 It is asking the question “Kailan hindi
nagiging tama?” or “When does it become
morally bad?”
 It becomes acceptable (acceptable means you
are free of moral responsibilities and it is the
right thing to do) if:
 INTRAUTERINE CONDITIONS become
unfavorable for the developing fetus to
continue specially if the fetus has reached
the period of viability.
 If the conditions inside the mother’s
womb make it dangerous for the fetus to
stay longer and the fetus is already
viable, then there is no sense to prolong
the pregnancy, so terminate the
pregnancy. The decision becomes easier
when the fetus is already viable.
 In cases of:
 Pre-eclampsia
 Since the intrauterine conditions are
not good for the fetus, you terminate
and prepare the fetus. Give antenatal
steroids, antihypertensive
medications, so on and so forth.
 Oligohydramnios
 Terminate the pregnancy. No need
for resuscitation, such as intra-
amnionic infusion or any other heroic
methods because the baby is already
viable.
 Premature rupture of membranes
 The danger in dealing with PROM are
the intrauterine infections or
chorioamnionitis
The late Dra. Ferrolina once told Dra. Nadal, “Carrie,
mabuti ng ilabas mo ng buhay kesa mamatayan ka sa loob
ng tiyan. Pagnilabas mo yang premature, problema ng pedia.
Pero pag namatay yan sa loob ng nanay, ikaw ang may
kasalanan niyan.” [HAHAHA. WHAT AN ADVICE :))]
MATERNAL INDICATIONS
 Hemorrhagic conditions in pregnancy
 i.e. Placenta previa –
You cannot do anything with placenta
previa. You are faced with a placenta totally
covering the internal os. You cannot predict
when the mother will contract or when she
will have internal hemorrhage. If the baby is
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.
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 7
  Medical conditions
 i.e. Eclampsia
 Tonic-clonic seizure is an indication for
termination of pregnancy because the
intrauterine conditions are no longer
favorable.
 Termination of pregnancy becomes morally
illicit when it is willed as the principal end or as a
means to an end as in direct induced abortion.
WHEN DOES LIFE BEGIN?
 FERTILIZATION
 At the level of the fallopian tube pa lang,
life na yan.
 Biological and genetic truth
 Genetic code of the fertilized ovum is
DISTINCT from that of the father and of the
mother (totally different human being)
ARE YOU CONVINCED OF THIS FACT? ARE YOU
CONVINCED ENOUGH THAT YOU CAN MAKE A
STAND FOR IT?
(If you answer yes, it should not only come from the mouth but
from the heart. Naks naman!)
 A FUTURE DOCTOR WHO IS COMMITTED
WITH THE CONVICTION TO PROTECT AND
DEFEND LIFE (conception to natural death)
 You have to realize from the depths of your
heart that fertilization and life is
synonymous because you will be giving
advice to people about the implications. Are
you a doctor who will prescribe
contraceptives? Because that is the
implication of contraceptives, they prevent
ovulation. But if you will look at the
prescribing information, it is not 100%
anovulation. What becomes of the 2-3%?
There is fertilization.
“Human life must be respected and protected
absolutely from the moment of conception. From
the first moment of his existence, a human being
must be recognized as having the rights of a
person – among which are inviolable right of every
innocent being to life.” ~Congregation for the
Doctrine of the Faith, DONUM VITAE
 “You have to guide your family, friends, loved ones
and every soul around you on what is the right
thing to do because you want to be morally upright
doctors, di ba? Being a doctor is a gift and you have
to use it wisely, correctly, giving glory to God, who
is the source of our life. It is God’s love who is giving
us this wonderful experience, this wonderful life.”
~Dra. Nadal
ABORTION
 Termination of a pregnancy at any time after
fertilization and before viability of the fetus
 Abortion is until 20 weeks; beyond 20 weeks,
it is not termed as abortion anymore
 An aborted embryo should be respected as
deceased human person and should be blessed if
requested or permitted by the family.
Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas
Formatting: Craig Angelo Reyes
Editor: Craig Angelo Reyes
CLASSIFICATION OF ABORTION
a) Spontaneous
b) Induced / Direct / Provoked / Intentional / Artificial
/ Voluntary
c) Indirect Abortion
d) Threatened Abortion
e) Inevitable Abortion
f) Therapeutic Abortion
A. SPONTANEOUS ABORTION
 Accidental / involuntary / ovular / causal
 Occurs as a result of natural causes:
 Involuntary
 No moral value
 Free from any human responsibility
 “Nakunan”
 There is no dilemma with regard to
spontaneous abortion
B. INDUCED / DIRECT / PROVOKED / INTENTIONAL /
ARTIFICIAL / VOLUNTARY ABORTION
 Results from voluntary human intervention
purpose is to terminate pregnancy
 You become accessory to the crime even if you only
give an advice or if, for example, the patient asks
you to buy “pampalaglag” at Quiapo and you don’t
refuse, then you are already an accessory. If a
patient comes to you for advice, that is the golden
opportunity to advice the patient on what to do.
Not to condemn them for their acts, but to
understand and help them.
 Directly willed as the principal end, or as a
means to an end, regardless of whatever
means.
 The intention is there, para malaglag.
That is morally unacceptable.
 ALWAYS IMMORAL
 An excommunication is attached to those
directly responsible for creating the decision
and implementing the decision to induce
abortion
 Life threatening conditions, resulting from
this type of abortion, will be treated in the
hospital but said treatment shall not be
deemed as approval of such abortions.
 If treated, it is because the mother is
also a patient, a human being in need
of treatment
 The mother will be referred for
counseling.
DIRECT / INDUCED ABORTION
 Can be LEGAL or ILLEGAL and CRIMINAL
 LEGAL
 Is what civil law permits in certain
cases, not punishing those who
perform it (Singapore, USA, Japan,
China)
 This is NOT SYNONYMOUS WITH
LICIT (which is not being punishable by
the law)
 Coincides with the so called
THERAPEUTIC ABORTION
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 7
 Legality is not the same with being morally upright. There
will be no repercussions from the law but it will not save you
from being responsible for your actions. These legal abortions
at times coincide with what is so called the therapeutic
abortion. It may sound good because that means you’re
treating the mother, but it is actually a form of induced
abortion.
 ILLEGAL
 Prescribed and prohibited by civil law
 CRIMINAL
 Punishable by law
 In our country, it is illegal and is
punishable by law.
PURPOSE OF CLEARING CONFUSION
 At the level of public opinion, to identify [and
differentiate] the LICIT with the LEGAL
 DIRECT ABORTION IS ALWAYS ILLICIT
and NO HUMAN LAW can make it good or
legitimate to justify it, because the right to
life comes directly from God and not from
the parents, nor from society, nor from any
other authority
 No matter how much you look at it, to
kill the life of another being, especially
one without defenses, is always
irrevocably and undeniably wrong.
Minsan, kung sino pang tama, siya pa yung nahihiya.
Kahit ikaw na lang ang nagiisa, kapag tama ka, wagi ka pa
din, because at the end of our life, we will be judged
according to what we’ve decided and what we’ve done with
your life. At the end of the day, you can face God and you
can say. “Lord, I have loved you and I have defended you.”
Because it is God working in us that should prevail.
“Life must, from its conception, be safeguarded
with the greatest care; abortion and infanticide are
abominable crimes.” ~Gaudium et spec, no. 51 cf. no
27
 Total respect for human life and condemnation
of direct/induced abortion is NOT confined to
Christians
 It is conviction and a rule of conduct shared by
non-Christians, founded on what a PERSON is
and should be
 The right of life comes from God, not from
parents or from society.
Dra. Nadal once had a patient, currently pregnant at the
time, who was a G9008 who wanted to have the baby
aborted. Dra. Nadal advised her patient that had her
parents not been generous with her, then she would not be
here at all. Having a baby may be expensive but the
happiness they give parents is priceless.
Some say, “dugo pa lang naman yan doc eh, walang laman.”
Knowing that life begins with fertilization, you know that life
is already there.
Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas
Formatting: Craig Angelo Reyes
Editor: Craig Angelo Reyes
C. INDIRECT ABORTION
 Foreseen but merely permitted, side effect of a
procedure which is directed toward some good
end and legitimate purpose
 Is not wanted nor sought directly
 It lacks voluntariness, the essential characteristic
by which a man becomes responsible for his acts.
 It is rather the consequence of an unavoidable
circumstantial accident
 In cases of ectopic pregnancy, the dangerously
pathologic part of the mother may be removed
and the loss of the embryo is indirect or incidental
to the surgery
 Remove the dangerously pathologic part of
the mother, which is the fallopian tubes,
regardless of which part. It may be removed
and the loss of the life of embryo is indirect
and incidental to the surgery.
Dra. Nadal once had a case wherein the patient came in
because of right lower quadrant pains. There was an
adnexal mass with cardiac activity, but because of the
Principle of Double Effect, knowing that the patient will not
survive knowing that the fallopian tube cannot facilitate the
growing embryo, will you subject the patient to emergency
laparotomy right away, knowing that the cardiac activity of
the baby is still there? Yes, because if you don’t, it will rupture
and cause hemorrhage on the mother. Transfusion would
have to be done, which would endanger the mother’s life
more. You are not trying to abort the baby directly, but
because it would eventually abort and the fallopian would
rupture, you can already proceed to do laparotomy. The evil
effect there is the removal of the growing embryo, but the
good effect is that you saved the life of the mother from
extensive hemorrhage. The intention is good because ectopic
pregnancy is aborted even if nothing is done.
 Another example is the removal of bleeding
cancerous uterus because you cannot do
anything. The mother is tremendously
bleeding, the fetus will eventually abort so
remove it.
 Human life is beset with conflicts of values
because there are actions which aside from
producing a good effect, cause an unwanted evil
effect which are inseparable.
 “Principle of double effect”
 Intention of the agent is morally good, the
evil effect is foreseen and permitted but not
wanted, is avoided in so far as possible
 Removal of a bleeding, cancerous uterus in a
pregnant woman
D. THREATENED ABORTION
 Signs and symptoms of premature expulsion of
a non-viable fetus (bleeding, cramps)
 No moral problem, but by how long must a mother
go in terms of bed rest? General inactivity?
 Principle of Charity
 Mother is obliged to undergo this sacrifice to
try to preserve the pregnancy as long as there
is real hope of saving the infant
 Mothers and fathers can be very
heroic!
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 7
 Dra. Nadal once had a patient with incompetent
cervix. Cerclage was done and the patient has to be in
complete bed rest because if the uterus will contract, it will
dilate the cervix and can tear up the cervix, leading to
bleeding. Dra. Nadal did the cerclage 12 weeks AOG after
ultrasound with viable fetus. The husband asked her how
long the patient has to be in bed rest, to which she answered
until the patient gives birth. The husband was concerned who
will do the household chores. During one of the check-up (sa
house ng patient kasi complete bed rest), she saw the
husband heating water for him to bathe his wife. So you see,
if you marry the right person, it is heaven made. So the
principle of charity here is that the mother is obliged to
undergo this sacrifice to try to preserve the pregnancy as long
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
premarital sex. The bottom line is when you love the person
you have to love them as a person with dignity. Don’t allow
the relationship to be at the level of sex. You have to control
your sexual appetites, because if not, that will result to
unwanted pregnancy that will destroy your innate self
because that is abuse of yourself, just like taking drugs. Sex is
not supposed to be left and right. It has to be controlled
because you have this innate dignity. Do you agree?
Sabi nila, if you cannot do the act in front of
your parents, then don’t do it. Set limitations so that the
standard is set and you avoid temptations. No matter how
strong you are, if you put yourself in that situation, sabi nga
nila, “I am but human.”
E. INEVITABLE ABORTION
 Abortion cannot be prevented anymore
 Membranes are ruptured, minimal to profuse
vaginal bleeding (depending on the placental
separation or attachment)
 Moral difficulty:
 It is not morally acceptable if the fetus is
not dead.
 It is also not morally acceptable to hasten
the inevitable abortion
 Ensure minimal bleeding, vital signs of the mother
are stable, conservative management – letting
nature take its place
 In cases wherein the obstetrician rightfully judges
separation of the placenta so irrevocably
progressed, to empty the uterus in an attempt to
save maternal life, fetal death is neither sought
nor intended for
F. THERAPEUTIC ABORTION
 The current permissive legislature considers as
an indication for abortion any pregnancy which
endangers the life of the mother
 Risks to life of the mother is anything that
affects the physical or even psychological health
of the mother
 Aside from the physical, they may also say
that they are not yet ready to become a
mother.
 Undoubtedly pregnancy can occasionally
aggravate maternal health to such a degree as to
endanger her life but INTENSIVE OBSTETRIC
CARE has allowed may pregnancies to continue
in spite of complications
“To save the life of the mother is a lofty goal, but to
directly kill her baby as means to achieve this is not
permissible.” ~Pope Pius XII, Address, Oct 29, 1951
Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas
Formatting: Craig Angelo Reyes
Editor: Craig Angelo Reyes
ERRONEOUS JUSTIFICATIONS
PSYCHOLOGICAL WELL-BEING
 Little basis
 Psychiatrists know well that modern therapy can
solve any psychiatric problem precipitated by
pregnancy
 Abortion has caused a lot of mental
disturbances
 “The women for whom abortion is justified
are the very same ones who carry the
highest risk of mental disorders once
abortion is performed” ~WHO
Dra. Nadal had a patient who wanted to have induced
abortion and no matter how much she tried to persuade her,
she went ahead with it. After that she had some sort of
postpartum psychosis because every night she would hear a
baby crying. Psychological trauma would affect them more.
FREEDOM TO DECIDE FOR ONE’S BODY
 Feminists’ outcry:
 “My body belongs to me”
 They believe that the fetus as a mere
appendage of the mother’s body which
can be removed according to her free
decision
 The new human being in her womb
possesses its own genetic apparatus
distinct from that of the mother.
 She may have the right to her body but
not over the unborn who is another
human being and not just a part of her
own
RAPE OR INCEST
 Reason why some hospitals justify giving
morning-after pills
 Abortion does not necessarily remove nor
reduce the trauma; on the contrary it
increases it
 To kill the innocent to atone for the fault of
the father is always illicit
*Who among you thinks or agrees that the rapist should be
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.
EUGENICS (Greek, “EUGENESIA”, “to engender
well”)
 To procreate healthy offspring (positive) and
avoid the birth of defective offspring (negative)
 Prenatal diagnostic tests:
 Amniocentesis
 Chorionic villi sampling
 Ultrasound
 It becomes illicit, when selective induced abortion
is intended
 A diagnosis of malformation or hereditary disease
must not be equated with a death sentence
 Life is valued not for its normality nor future
productivity but for its intrinsic dignity
-END-
But wait… There’s more.
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 7
 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
 Ectopic Pregnancy
 Bioethical Considerations in Specific Conditions:
 Chorioamnionitis
 Eclampsia
 Hemorrhages of Pregnancy
 Hydatidiform Mole
 Cancer
PRINCIPLES OF INVIOLABILITY OF HUMAN LIFE
 Destruction of one life CANNOT become a mere
means to saving the life of the other
 Each life is equally important with its own
dignity
PRINCIPLES OF DOUBLE EFFECT
 Choosing a decision that produces a good effect
(intention is morally good) but there is an
inseparable unwanted evil effect which is
foreseen and permitted but NOT wanted and is
avoided as much as possible
 So the thing here is that the evil effect is unwanted
but you allow it because it will eventually happen
but you do not intend – you are not the cause, you
are not the reason why it is happening it’s just the
effect
WHICH LIFE IS TO BE PREFERRED? WHICH LIFE IS TO
BE SAVED?
 Maternal and fetal life are treated with equal
reverence and the inviolability of each is equally
respected
 Example: Mother with uterine cancer, not
bleeding, needing chemotherapy 12 weeks AOG.
What will you do? The life of the mother at this
point in time is not at stake, thus giving
chemotherapy which is fetotoxic is already giving
preference to the mother so there is violation of the
rights and the life of the baby. In 14 weeks AOG
with uterine cancer, do you think the baby can
survive?
 Answer: Yes, it can progress and can turn out
to be a mature human being- it is very easy
for us to decide in preferring the mother
especially if the pregnancy would still need a
very long time but if you are guided with the
principle that each life is valuable then you
would consider otherwise.
Ang common na iniisip ng tao ay kapag baby yan pwede na,
kasi ang preferred ay nanay, total ang intention ay mabuti –
MALI!!!
 Unless the life of the mother is threatened
like in placenta previa, especially if the baby
is premature, so you don’t have any choice.
As long as you prefer the baby you are not
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
SPECIFIC CONDITIONS
ECTOPIC PREGNANCY
 Any gestation developing outside the uterus
 Implantation of the ovum in the fallopian tube
presents a SERIOUS pathological situation 
RUPTURE  SHOCK  DEATH
 Utilizing the PRINCIPLE OF DOUBLE EFFECT
 Dangerous maternal tissue may be surgically
removed, the loss of the fetus is indirect
incidental to the surgery
 It is a SECONDARY ABDOMINAL PREGNANCY
 Moral aspect – it must be permitted to
advance if possible to viability
 Actual crisis of DANGEROUS
HEMORRHAGE
 Surgical intervention to control the
bleeding is permissible provided NO
DIRECT ATTACK is made on the fetus
 If there is bleeding then do blood
transfusion and try to be conservative
as much as possible
 If there is minimal bleeding and the
vital signs are stable, then you allow
the pregnancy to continue
 If there is tremendous hemorrhage
threatening the life of the mother,
then you can intervene right away; but
in ectopic pregnancy, since there is no
possibility that the life of the baby reach
viability, so you could already
intervene
 The same principles apply to other types of ectopic
pregnancy of ovarian and cervical pregnancies.
CHORIOAMNIONITIS
 PROM occurring before viability of the unborn
child is accompanied by the threat of
INTRAUTERINE INFECTION
 No moral issue – if viable fetus  DELIVER
 MORAL DILEMMA
 Fetus is not viable
 Serious infection
 Maternal and Fetal
 It is ideal to continue the pregnancy until
viability
 Antibiotics to control infection
 Medical intervention to hasten fetal lung
maturity
 Diagnostics:
 Blood tests, fetal surveillance studies
(ultrasound)

Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas

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 | 5 of 7
Editor: Craig Angelo Reyes
 EXAMPLE: 22 weeks AOG, ruptured bag of water what
will you do?
Answer: Don’t deliver right away. You have to do your
diagnostics – do CBC. Try as much as possible to control
infections by giving antibiotics and try to give
dexamethasone or steroids for fetal lung maturity. Also, do
your fetal surveillance studies. Prepare an Intensive Neonatal
Care / environment that would offer a better chance of
survival than the baby be left alone to survive in the infected
uterus. Or in some cases, transfer to a perinatology hospital
Advice that Dra. Nadal gave to her Colleague: If the
parents really want to deliver the patient in 29 weeks old,
then they should transfer into higher perinatal center who
has a better success rate than our hospital. If they don’t want
to continue with the pregnancy then okay but refer so that
the fetus has bigger chance of survival. It’s not a matter of
losing money because you refer but a matter of exhausting all
possible help to the parents and to the baby. Even if you end
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
Philippines.
“If the available intensive neonatal care is judged
to be incapable of prolonging the extra-uterine life
of the baby for any considerable length of time, it
is clear that the emptying of the uterus, even to
avert serious danger for the mother, would simply
be a direct abortion which the fact that the infant
is going to die anyhow would neither justify nor
change.” ~Thomas J. O’Donnel, SJ
-No matter how young the baby is, we give life to the unborn.-
ECLAMPSIA
 Begins with uncontrolled hypertensive
condition of the mother
 Growing increase in number of elderly
gravida
 Poor prenatal care
 Poor compliance in medicines (superstitions,
poverty)
When is the best time to have baby? In Doc’s opinion, it is
after residency so that we can graduate on time and
concentrate daw.  BUT FIRST GET MARRIED WITH THE
RIGHT PERSON!!! 
 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)
Transcriber: Reichell Brebonia, Nicxz Icaro, Gladys Hulipas
Formatting: Craig Angelo Reyes
Editor: Craig Angelo Reyes
 Some obstetrical texts advise immediate
termination of pregnancy even when there is no
hope that the fetus can survive outside the uterus.
 Such procedure is viewed as DIRECT
ABORTION and in violation of the uniquely
divine prerogative of absolute dominion
over human life
 Like the mere presence of convulsion in
22 weeks AOG, you cannot terminate
the pregnancy because such
intervention is tantamount in doing
direct abortion because we could still
control convulsion.
 The PRINCIPLE OF DOUBLE EFFECT CANNOT
BE USED HERE because the evil effect (removal
of the fetus) is directly willed since it is envisioned
as a necessary means to produce the good effect
(control of eclampsia).
HEMORRHAGES OF PREGNANCY
 Conservative and expectant management when
possible to achieve both maternal safety and
fetal salvage
 With the use of ultrasound, we can already
diagnose early the presence of placenta previa
, so at early age we could already advise to go
on bed rest, to be closely monitored by an
obstetrician and she will be prepared early
enough that she needs to be delivered in the
hospital.
 Use the PRINCIPLE OF DOUBLE EFFECT
 What is Important is the moral distinction
between DIRECT AND INDIRECT
ABORTION
 To DIRECTLY kill the fetus or to uproot it
from its site of implantation is never
morally acceptable
EXAMPLE: 15 weeks AOG with fear of hemorrhage, not
bleeding, and was diagnosed with placenta previa.
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
blood. Do you think it is justifiable to be conservative? No. It
is justifiable to deliver the baby right away.
Looking for a stress reliever? No problem.
Last push. Go get ‘em. 
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 6 of 7
ABRUPTIO PLACENTA
 Degree of separation of placenta varies from
slight (harmless) to complete (fetal distress to
fetal death) to maternal death
 MORAL ASPECT
 If maternal hemorrhage is mild, not
endangering the mother’s life and fetus is
not viable  expectant management
 No steps can be taken which would
indirectly expose the life of the fetus to any
considerable danger
Using ultrasound with color Doppler studies, we can know if
the baby needs immediate delivery or not. If in the initial
ultrasound is already severe and the baby is in danger, deliver
the baby right away.
 ELEMENT OF PROPORTION in the PRINCIPLE
OF DOUBLE EFFECT
 There should be a due proportion between
the good that is intended and the evil that is
permitted.
 To avert a slight danger from the mother
(hemorrhage) by a procedure which would
expose the fetus to considerable danger
would violate this proportion
 The ideal thing here is that the
proportion is not balance
 There should be more good than evil
PLACENTA PREVIA
 After viability, uterus may be emptied
 Preparation
 Give steroids
 Prepare NICU
 PRAY
 Prepare the intensivist
HYDATIDIFORM MOLE
 Expectant management when diagnosed with
the presence of a living fetus (Incomplete H-
mole)
 For complete H-mole, you evacuate right away
using your suction curettage
 Evacuation, by dilatation and suction
curettage, hysterectomy or hysterotomy are
morally acceptable and indicated with a fetal
death in utero, regardless of the stage of
pregnancy
CANCER
 Extirpation of a cancerous uterus in a pregnant
woman as in indirect abortion
 For example, the mother needs chemotherapy
and the baby is very far from viability and you
allow chemotherapeutic agents knowing
that it is fetotoxic, so it is indirect abortion
and the principle of double effect cannot be
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
MODERN MEDICAL TECHNOLOGY:
 May be life saving
 May present ethical dilemmas
 Most of these medical technologies may be scarce,
therefore the principle of justice comes in, which
discerns the benefit of these medical technologies
given to premature babies
 May be risky and costly
 Risks are involved due to some procedures that are
invasive and mostly expensive
 Generates issues that cause agony and
disagreements among:
 Physicians/pediatricians/neonatologists
 Medical staff
 Parents
 Ethicists
IN EMERGENCY SITUATIONS, TREAT
 Emergency situation:
 Unanticipated and life threatening
 A sudden referral in the emergency room or
in a delivery room with a premature baby
 Lack of immediate treatment will increase
risk to health
 Treatment is needed to alleviate physical
pain or discomfort
 Time is important; when there has been no
opportunity to assess the infant and resuscitation
will sustain life, TREAT
 Without the time that you can buy, then there is no
opportunity for you to assess the patient. In any
situation where there is uncertainty regarding the
diagnosis and prognosis, treat the patient.
 In general, NICU policy is posited on a
presumption in favor of treating infants.
 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.
 The burden of proof is on the proponent of not
treating
 An advantage of viewing the immediate
treatment of newborns as emergency is that
emergency treatment is always acceptable,
even without parental consent.
 Once you satisfy all the criteria for emergency,
you won’t need to consult for parental
consent.
 Immediate treatment can buy time to clarify
diagnosis and prognosis, and to inform and
consult with parents.
2. GUIDELINES ON INITIATING VERSUS
WITHDRAWING TREATMENT
INITIATING VERSUS WITHDRAWING TREATMENT
 It used to be thought that initiating treatment
meant a commitment to continued treatment.
 Physicians were too cautious in using artificial
life support
 Psychological difference
 Moral difference
CLEARLY FUTILE TREATMENT IS NOT MORALLY
REQUIRED
 If medical care is clearly beneficial, the infant
should always be treated; but if treatment will
be clearly futile or will only prolong dying, it is
justified to withhold it
 Treatment is futile in terms of the infant’s survival
 The medical condition of the infant should be
the sole criterion for with-holding treatment
 Treatment is also futile if the infant has some
physical impairment incompatible with life,
which is uncorrectable

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
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IF TREATMENT IS NOT MEDICALLY INDICATED
THERE IS NO MORAL OBLIGATION TO TREAT
 Treatment is not medically indicated if the
pediatrician/physician, according to reasonable
medical judgment, determines that any of these
conditions exists:
1. The infant is chronically and irreversibly
comatose
 You may need the help of a neurologist
at this point.
2. Treatment would merely prolong dying
 In this case, if the patient is proven to be
brain dead, at this point he is already
dead. There may be heart and lung
function but the brain is not functioning.
3. Treatment would not be effective in
correcting all of the life threatening
conditions.
 You may have multiple congenital
anomalies in a particular infant
4. Treatment would be futile in terms of
physical survival
5. Treatment would be virtually futile and
inhumane
 In general, there is no obligation to treat on the
remote chance of success, especially when the
treatment would produce severe and prolonged
suffering.
MEDICALLY INDICATED TREATMENT MAY NOT BE
WITHHELD.
 Medically indicated treatment:
 Whatever is likely to be effective in
ameliorating or correcting all life
threatening conditions
 If it is uncertain that medical care will be
beneficial, treatment is not necessarily required
 If treatment is withheld, the infant’s disability
should not be the basis of withholding
treatment
*In cases of disagreements or uncertainty about whether or
not treatment is required, a bioethics committee should be
consulted.
WITHHOLDING/WITHDRAWING LIFE SUSTAINING
TREATMENT
 The attending physician (AP) should assume the
primary responsibility for coordinating
communication among those involved in
considering to limit or withdraw therapy.
 The AP or family may initiate the discussion and
decide concerning withholding or withdrawing life
support measures in the presence of the
following:
1. Patient’s condition is terminal and death is
imminent
2. Patient is irreversibly comatose or in
persistent vegetative state and there is no
hope for improvement
3. The burden of treatment far outweighs the
benefit
 Every surrogate/family is obliged to use
proportionate means to preserve the child’s
health
Transcriber: Nicxz Icaro
Formatting: Craig Angelo Reyes
Editor: Sarah Livelo
 A surrogate may decide to forego
disproportionate means of preserving life.
 In children, life support measures may be
necessary to permit full evaluation of the
patient’s condition; these interventions should
not be withheld during evaluation.
 The free and informed consent made by a
surrogate/family concerning the use or
withdrawal of life sustaining procedures should
always be respected and complied with unless
contrary to the child’s best interest and/or
Catholic moral teaching.
 No patient should be discharged against
medical advice without the initiation of
discussions with the surrogate/family and
appropriate review by the medical team.
3. ISSUES
MAY TREATMENT BE WITHHELD IF PARENTS
REQUEST IT?
 NO, if it clearly benefits the infant/child and there
is no clear indication of futility.
 YES, if it is clearly futile.
SHOULD TREATMENT BE CONTINUED WHEN
PARENTS REQUEST IT, EVEN IF THE MEDICAL
STAFF CONSIDER IT FUTILE?
 NO, when it causes more significant suffering to
the infant/child and it is already futile.
 YES, if it is for the sake of the parents.
 YES, if it is for organ donation.
MAY FUTILE TREATMENT BE CONTINUED FOR THE
PURPOSE OF FUTURE KNOWLEDGE?
 For better care for premature & impaired infants
 Boundaries between treatment and research
become blurred
 Non-therapeutic research on infants and children
is never morally required
IS FOOD, WATER, AND PALLIATIVE CARE ALWAYS
REQUIRED?
 Depending on the clinical circumstances,
nutrition and hydration may be considered
medical treatment.
 The child should not be made to suffer needlessly.
 Nutrition and hydration should be provided to
all patients; as long as this is of sufficient benefit
to outweigh the burdens involved to the
patient/family, medically assisted nutrition and
hydration should also be given.
ARE COSTS AND USE OF RESOURCES RELEVANT
FACTORS IN NON-TREATMENT DECISIONS?
 There is no set value on life or an upper limit on
expenditures for life-sustaining treatment.
 If treatment is virtually futile and prognosis for a
minimally good quality of life is very poor, one
may end/withdraw treatment.
WHEN NON-TREATMENT IS GENERALLY ACCEPTED
 There is brain death.
 The child is in a persistent vegetative state and
there is virtually no hope of recovery
 Treatment is clearly futile.
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
4. PHILIPPINE ETHICAL GUIDELINES IN THE
IMMEDIATE CARE OF EXTREMELY PREMATURE
AND EXTREMELY LOW BIRTH WEIGHT
NEONATES
 Good medical practice favors initiation of life-
sustaining medical treatment until the clinical
situation is confirmed and ethical concerns, if
any, are clarified.
 If postnatal assessment differs from antenatal
assessment, recommendations to parents
may be changed accordingly.
 Factors to consider in decision-making are fetal
and immediate neonatal conditions, including
available resources
 In cases of extremely premature and
extremely low birth weight, especially in
hospital with scarce resources.
 All decisions should be based on both parents’ and
the attending physician’s assessment of what is in
the best interest of the neonate
 Parents’ involvement in decision-making is
mandatory
 In cases of conflict between the parents and the
attending physician, the decision must be for the
good of the newly-born infant, beginning with the
respect of his right to life.
B. BIOETHICAL GUIDELINES AND ISSUES IN QUALITY OF LIFE
1. DEFINITION
 The experience of life as viewed by the patient
 i.e. how the patient, not the parents or health
care providers, perceives or evaluates his or
her existence
 In pediatrics, it is difficult to determine the
quality of life, so we must get as much as we can
from the patient’s parents or primary guardian.
2. GUIDELINES
THREE SITUATIONS WHERE ONE CAN FOREGO LIFE-
SUSTAINING MEDICAL TREATMENT
A. THERE IS BRAIN DEATH:
 Even though heart-lung function can be sustained
artificially, where there is no brain function,
there is no life and that is the end of treatment.
 Clinical Criteria for Brain Death
 Fixated pupils
 Absent oculo-vestibular response
 Absent corneal reflex
 Apnea with PCO2 >60mmHg
 Isoelectric EEG and ECG
 No behavioral or reflex response stimuli that
imply function above the level of the
foramen magnum
B. THE CHILD IS IN A PERSISTENT VEGETATIVE
STATE AND THERE IS VIRTUALLY NO HOPE OF
RECOVERY:
 There is little, if any, controversy that it is not
required, legally and morally, to sustain life
functions for such a child.
 For example, a child with SSPE stage 4
 There’s no more hope anymore, but
parents still wants to continue
treatment.
Transcriber: Nicxz Icaro
Formatting: Craig Angelo Reyes
Editor: Sarah Livelo
 When the concerned parties fail to reach a
consensus, the matter can be referred to the
Hospital Ethics Committee.
GUIDELINES IN AGGRESSIVE CARE
 Full resuscitative measures should be made
available to all live newly born; non-initiation of
resuscitation may be considered, however, when
such is deemed futile, as in:
1. Presence of lethal anomalies or
2. Birth weight less than or equal to 400
grams and postnatal gestational assessment
less than 24 completed weeks.
 Resuscitation of newly born infants
other than (1) and (2) may be stopped
after 15 minutes, when cardio-
respiratory function has not been
restored.
GUIDELINES IN PALLIATIVE CARE
 When the decision not to continue aggressive care
is reached, every effort must be made to offer
comfort care such as human contact, providing
warmth, oxygen, hygiene, fluids and nutrition;
adequate support for the grieving process should
be made available and coordinated accordingly.
C. TREATMENT IS CLEARLY FUTILE:
 It will be easier to justify non-treatment when
survival is unlikely than when treatment is futile
relative to improved status.
LIFE-SUSTAINING MEDICAL TREATMENT (LSMT)
 LSMT encompasses all interventions that may
prolong the life of patients
 Ventilators or respirators, organ
transplantation, dialysis
 Antibiotics, insulin, chemotherapy, nutrition
and hydration provided IV/by tube
“FOREGO”
 Refers to both stopping a treatment already
begun as well as not starting a treatment
 It is futile
 You may say forego if you do not want to initiate
the treatment or if you want to withdraw the
treatment.
3. ISSUES
ARGUMENTS AGAINST QUALITY OF LIFE
 Human life is of unqualified value
 Life is better than death, but in some
patients, death is better than life.
 For example: generalized paralyze
patient but very conscious.
 To one life worth living and another not is to
deny the essential equality of all people, to
discriminate against some, and to devalue what is
sacred
 Judging QOL implies valuing some lives more
than others and this is morally wrong because all
human life is equally valuable
 Implication: The difference between the
value of life and the value of human life
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 4
  “The value of life” vs. “The value of human life”
– Biological life vs. Biographical life
 Some say biographical life is more important
than biological.
 For those against quality of life, they will
choose biological life
 Medical staff, family and relatives are
included in decision-making.
 Parents usually choose biological life, because
the life of their child is always important.
 Judging QOL in the context of refusing treatment
implies that not all life is good and that
sometimes death may be better than life
 But this is not true; life is always good and
death is always bad by comparison
 A rational person would always choose life
over death.
 The Slippery Slope Argument
 If we allow refusal of treatment for those
just above a vegetative state, it will be
easier to begin to allow less severe stages
-END-
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ARGUMENTS FOR QUALITY OF LIFE
 Some lives are so unbearable that to continue
them is wrong in itself
 Some recommend consideration of quality of life,
the best interest of the infant, the interests of
the family members, and issues of futility
 Human life is sacred, but not an absolute good
 Utilitarian argument
 Cure-oriented medical treatment may be
withdrawn if and when the patient and
family determine that the burdens of
treatment outweigh the possible benefits
 The “best interests” standard is based on quality
of life considerations and the child’s potential
for human relationships
 For infants, a patient-centered quality of
life approach based on the potential for
human relationship associated with the
infant’s medical condition.
CONFLICTS AND ISSUES
 Refer to the Hospital Bioethics Committee
- DEVIATIONS 0-5% CREDITS -
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 4
 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
 Ghost Surgery
 Sexual Reassignment
 Organ Transplantation
 Types of Transplantation
 Criteria for Transplantation
 Determination of Death
GHOST SURGERY
 Surgery in which the patient is not informed of,
or is misled, as to the identity of the operation
surgeon
 Someone does the surgery in behalf of the
other surgeon (an “appointed" surgeon)
 Someone who has not examined the
patient
 Someone the patient has not yet met
 Originally, the term “ghost surgery” referred to a
practice whereby an unqualified physician would,
often with the consent of the hospital, call a
qualified surgeon to the operating room to
perform a procedure
 The ghost surgeon is likely to be excluded in the
pre- and post op-care period of a patient
 For example, a pregnant woman’s cervix is
9-10 cm dilated but her OB is not around
 This is NOT ghost surgery because this case
is an emergency
 The patient should not have to pay the same
operation fee since it is not her primary OB
BASES OF THE IMMORALITY OF GHOST SURGERY
1. The patient has the right to know and select the
surgeon to whom he is to entrust his life.
 It is against the BASIC RIGHT OF
AUTONOMY
 Example: Gusto ko si Doc Gellido ang
mag-oopera sakin kasi I TRUST HIM <3
2. The moral evil is the attendant justice which is
likely to befall the patient.
 The moral evil in ghost surgery lies in
ATTENDANT INJUSTICE
 Justice is giving the patient what he
deserves, what is due to him
 What the patient paid for should be
given to them
3. Professional fees
 The referring surgeon has no right to it
because he/she did not perform it!
 The ghost surgeon has no total right to it
because he is an accomplice!
 This is for medical service!
4. The ghost surgeon is likely to be excluded from
the pre-operative examination and the post-
operative care, and this is likely to be
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
Editor: Sarah Livelo
SURGERY AND RESIDENCY TRAINING
 In recent years, a great deal of controversy has
centered on the role of residents in the
operating room
 Allowing residents in teaching hospitals to
perform surgical procedures under the
supervision of attending surgeons
 This is a “disguised” form of ghost surgery
 Conversely, how will we train them if they do
not perform the procedure?
 Hospital training programs with residents
performing for consultants is the most common
form of ghost surgery
 The number one suspicion for ghost surgeons
are the residents
 If the guidelines are not properly
implemented, the residency training program
is a disguise, like a form of ghost surgery
particularly involving private patients (if the
consultant does not want to do the operation
especially at night when they are sleeping,
he would give it to the residents)
GUIDELINES
1. An operating surgeon is the performing surgeon
 As such, his duties and responsibilities go
beyond mere direction, supervision,
guidance, or minor participation.
2. The operating surgeon may be assisted by
residents or other surgeons
3. With the consent of the patient, the operating
surgeon may delegate the performance of
certain aspects of the operation to his assistants
provided this is done under participatory
supervision
 Therefore, HE MUST SCRUB!
 Importantly, dapat alam ng pasyente na may
assistance; nakalagay sa informed consent
yung mga pangalan ng assistant/s
4. Full disclosure to the patient is necessary if the
resident or other physician is to perform the
operation under non-participatory supervision
 In cases when the attending doctor cannot
make the operation
 Primary doctor should be informed of
the details in the OR
 For example, the resident calls you up
habang nasa event kang malayo. OB ka
kunyari, tapos fully dilated na yung
pasyente! Crowning na! Sure na hindi ka
aabot! Explain to patient that this is an
emergency and somebody must fill in
because the doctor is not yet there.
DISCLOSURE IS IMPORTANT. If the patient
requests for another doctor instead, respect
the request.
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
THE SURGEON’S OBLIGATION TO THE PATIENT
REQUIRES HIM TO PERFORM THE OPERATION
1. Within the scope of authority granted by the
consent of the operation.
 For example: If the appendix was taken out in a CS
operation, the surgeon may be liable and should
not ask for additional fee
2. In accordance with the terms of the contractual
relationship
3. With complete disclosure of facts relevant to the
need and performance of the operation.
4. Utilizing his best skill
5. If a resident is to operate upon and take care of
the patient, under the general supervision of an
attending surgeon who will not participate
actively, the patient should be so informed and
consent thereto
6. It is unethical to mislead a patient as to the
identity of the doctor who performs the
operation.
SEXUAL REASSIGNMENT
HERMAPHRODISM
1. Medical and scientific tests should be done to
determine which is the more predominantly
determined sex
 Considerations:
 External genital morphology
 Internal genital morphology
 Chromosomal sex
 Gender role
2. In cases where there is a total equivocal sex
identification
 The approach may be either towards
either sex
 Choice of sex depends on the individual
 In the case of infants or minors (to a certain
age), the parents determine after
consultation with specialists
SEXUAL REASSIGNMENT SURGERY
 Is it ethical to perform a surgery whose purpose
is to make a male look like a female or a female
to appear male? Is it medically appropriate?
 Sexual reassignment surgery (SRS)
violates basic medical and ethical
principles and is therefore not ethically or
medically appropriate
 The term “sexual reassignment surgery” is in itself
problematic
 Implies that the sexual identity is assigned at
birth and can actually be surgically
reassigned, in which the DNA already says
otherwise
 “I’m a woman locked up in man’s body, I
want to be a woman.”  They should be
evaluated by a psychiatrist if they meet the
criteria for sexual reassignment; siyempre,
kailangan baguhin boses mo, kailangang
tanggalin ung testicles and penis, then form
it as an artificial vagina/clitoris, they have to
take estrogen meds.
 Argh, it’s complicated.
 Sex is written on every cell of the body and
can be determined through DNA testing; it
cannot be changed
Transcriber: Nicxz Icaro
Formatting: Craig Angelo Reyes
Editor: Sarah Livelo
 It violates the principle of non-maleficence
(“primum non nocere” or “first do no harm”),
as it mutilates a non-diseased body
 Being “trapped in the bodies of the wrong
sex” is an irrational belief (a delusion or a
disordered perception of self)
 It does not accomplish what it claims;
it does not change a person’s sex and
does not provide benefits
IT IS MORALLY UNACCEPTABLE BECAUSE:
1. Since it is not definitely established that the
problem is biological, the procedure is not a cure
 Is there a pathologic lesion that tells you that the
person is gay? None. So there is no biological basis.
They are perfectly male, so it’s very psychological.
2. The procedure is an attempted palliation which is
drastic, destructive and irreversible
3. Surgical sex change does not solve the person’s
existential problem; it is primarily a case of
psychotherapy
 There is no evidence that gender identity confusion
that is contrary to the anatomical structures is
inborn; any attempt to change this through by
surgical means, forever dooms the individual’s
chances in overcoming sexual and psychological
difficulties, and it does not cure the problem.
4. Such mutilation involves a total lack of due
stewardship of human life and integrity of the
human person
5. There is no solid agreement that such procedure
does much good and help to the individual
6. There can be ambiguity about really wanting it
ORGAN TRANSPLANTATION
TYPES OF TRANSPLANTATION
1. Living donors (usually related to the recipient)
2. Dead/cadaver Donors (declared brain-dead or
clinically dead)
1. LIVING DONORS
 Requires:
 Consent from donor
 Functional integrity of the body is
maintained
 Absence of immediate adverse effect
(proportionate risk)
 Charity as the motive for organ donation
justifies the risk and the loss of anatomical integrity
 Organ donation is not an obligation
 Usually has good prognosis
2. DEAD/CADAVER DONORS
 Respect and reverence are due to the remains of
a human being
 Sacredness of human life
 Respect for the dead body signifies respect
for human life
 Respect for the author of life
 Respect for the dead person’s relative
 Culture and tradition should also be respected
 Consent from the deceased before death or
consent from the family if there is no will is needed
 Make sure that the donor is truly dead
 If he is not and you declare him to be, it is
considered murder
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
CRITERIA FOR TRANSPLANTATION
1. There is a serious need on the part of the recipient
that cannot be fulfilled in any other way.
 Needs and concerns
 Worth of the transplant expenses and personnel
involved
 Establishing the death of the donor
 Can be a criminal offense if the patient donor is not
yet dead
 The transplant surgeon is usually not part of the
team that declares a patient “clinically dead”
2. The functional integrity of the donor as a human
person will not be impaired even though anatomical
integrity may suffer
 Anatomical integrity
 Material or physical integrity of the human body
 Functional integrity
 The systematic efficiency of the human body
3. The risk taken by the donor as an act of charity is
proportionate to the good resulting for the recipient.
 The motive for donating is charity
 Only limited harm to the donor
4. The donor’s consent is free and informed
 The donor comes over, not driven by poverty or
ignorance to donate his organ, and sometimes, this
is like coercion due to certain circumstances (no
money for living) that provoked them just to
sustain their living conditions; therefore, this is not
really free
 Living Donor
 Has been informed of the benefits for him
 Has been informed of the risks he takes as a
donor
 Has signed the free and informed consent
form
5. The recipients for the scarce organs are selected
justly
 Need for a policy
 Need to determine “just selection”
 Wealth is not a basis or a determinant with who
receives an organ
 Transplant surgeon should never be involved in
the transaction of procuring/obtaining the organ;
it becomes immoral
DETERMINATION OF DEATH
 Transplantation requires organs that are well-
nourished by oxygenated blood
 The team must remove them as soon as possible after
death
 Determining the moment of death is a crucial issue
 Taking the heart out of a person not yet dead is not an
act of organ retrieval but an act of killing someone to
get his organs
 Obey the ‘‘dead donor rule’’
CRITERIA FOR CESSATION OF BRAIN FUNCTION
1. Irreversible coma
2. No spontaneous respiration and response to apnea test
for 6 minutes
3. Absence of the following brainstem reflexes
 Papillary, corneal, gag, and caloric tests
EXCLUSIONS TO THE ABOVE CRITERIA
1. Drug and metabolic intoxication
2. Hypothermia
3. Children (18 years old and below)
4. Shock
PHILIPPINE CRITERIA FOR BRAIN DEATH
 Irreversibility is recognized when the evaluation
discloses that:
a) The cause of coma is established and is
sufficient to account for the loss of brain function.
b) The possibility of recovery of any brain function is
excluded.
c) The cessation of brain function persists for at
least 24 hours of observation and therapy.
ORGAN DONORS POLICY
A. Living Donors
 Registration in donor centers (should be fully
competent adults)
 Screening of all donors
 Education; free and informed consent
 Identification
B. Cadaver Donors
 Free and informed consent of relatives, advance
directives
 Brain death criteria
C. Recipients (when deciding who gets the organ)
 Utilitarian Principle
 The one who needs it more gets the organ
 Egalitarian Principle
 First come, first served (first one to lose
their organ function is the one given)
 Social Work or Merit
 This is decided by value of judgment
D. No monetary compensation except for burial
expenses or attendant surgery
 No negotiations are allowed in exchange for an
organ
E. Confidentiality
 Organ donation is not an obligation, not to offer
an organ even if needed is not against charity.
 Great care should be taken in weighing the
merely potential benefits against the actual risk,
that is, a brief prolongation of life against a
lifelong risk to the donor.
 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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