MAJOR ETHICAL PRINCIPLES

1. Stewardship
Our bodies, our life, our human
nature and everything in this earth
are gifts we have dominion over.
We should not, as faithful stewards,
harm but rather improve and care for
them. We have to treat them with
utmost respect, use originality and
creativity to cultivate them, know and
respect their limits.

MAJOR ETHICAL PRINCIPLES

2. Totality
Totality refers to the whole. Every
person must develop, use, care for
and preserve all his parts and
functions for themselves as well as for
the good of the whole.
If a part or lower function harms the
whole, this part or lower function may
be sacrificed for the good or better
function of the whole.

MAJOR ETHICAL PRINCIPLES

3. Double effect
When an act is foreseen to have both good
and
bad effects, the principle of double effect is
applied. In order that such act be
permissible,
the following conditions should be met:
1. The direct freely chosen effect of the act
must be morally good while the other
indirect not freely chosen effect may be
physically harmful.
2. The action itself must be good or at least
neutral.

In order that such act be permissible, the

following
conditions should be met:
3. The foreseen beneficial effect must be
equal to or greater than the foreseen
harmful effect.
4. The beneficial effect must follow from
the action or least as immediately as
the harmful effect. The good effect
must not be produced by the bad effect.

MAJOR ETHICAL PRINCIPLES

4. Cooperation
Cooperation is the
participation of one agent with
another agent to produce a
particular effect or joint effect.
Cooperation becomes a problem
when the action of the primary
agent is morally wrong.

Cooperation may be:

1. Formal-when the secondary agent willingly
participates as when one agrees, advices,
counsels, promotes, or condones.
2. Material-when the secondary agent is not
willing to participate.
A. Immediate-when the action of the
secondary agent is inherently bound to the
performance of the evil action.
B. Mediate-when the action of the secondary
agent is not inherently bound to the
performance of the evil action. Formal
cooperation is not allowed. Material immediate
cooperation is also a rule not allowed.
When there is significant reason, and
scandal is avoided, material mediate
cooperation, may be permitted to prevent a
greater harm.

MAJOR ETHICAL PRINCIPLES

5. Solidarity
Solidarity means to be one with
others. In the provision of the
healthcare, it is most important for the
provider to be in solidarity with the
patient when seeking, always, the
latters best interest.
In a country like the Philippines, this
is most important while dealing with
the poor, the uneducated, the
disadvantaged and the marginalized.

MAJOR BIOETHICAL PRINCIPLES

1. Respect for person
Respect for person is the recognition of
the equality possessed by very
human being as a unique, worthy,
rational, self-determining creature,
having the capacity and right to decide
what is best for himself. It is not
undermined by states of suffering,
disability or disease.
Respect for person is the responsibility
of all to treat persons as an end and
never as means.

 Respect for person is manifest in autonomy (selfgovernance) or the right of noninterference. A

person should be allowed to determine his
own
destiny, to deliberate about his plans, choose
according to his own values, and to act
accordingly.
He should be allowed to be his own person
without
constraints from the actions of others or from
physical or psychological limitations.
X has a right to determine his course of action.
Y has an obligation not to constrain X.
This is best practiced in the principle of free and
informed consent.

2. Justice
Justice, also termed fairness, means to give to each
one what he deserves or what is his due.
X has a right to his due
Y has the obligation not to deprive X of his due
But man lives in a finite world. There are limits to
funds, medical supplies, healthcare services. The
needs of everyone, even if it is his due, cannot all
be served.
Justice also means to treat equals equally
X & Y are equal
X & Y should have equal benefits/burdens

Creating a healthcare policy

helps decide how limited resources
are to be distributed. It should
consider the principles of equality
(distributive justice), social justice,
and solidarity. The policy should state
in clear terms the criteria for
consideration, rank ordering, etc. and
this should be made public.

3. The inviolability of life

The principle of the inviolability of life is also
proposed as the sanctity, the dignity, or respect for
human life.
From the Judeo Christian tradition human life has
dignity because life is Gods gift. Man comes
directly from God, is created according to
Gods plan and destiny. It is God who is the
source, who sustains and perfects mans life.
From a humanistic point of view the experience of
being alive or the fear of losing life is evidence of its
sacredness.

 The principle of the inviolability of human life means

that life, in itself is sacred. It is not to be violated
opposed or destroyed but is to be affirmed, cherished,
respected, defended, and preserved.
Commitment to the principle of the inviolability of
life means choosing life and fighting to protect it.
Commitment to life overcomes commitment to death.
It is to be against violence, pollution of environment,
drug and alcohol addiction, treachery in human
relations.
X has a right to life.
Y has duty NOT to kill X.
These principles also includes measures for the survival
of the human species, and freedom to have children.

4. Non Maleficence
Non-maleficence means to do no, to prevent, to
remove or not to risk harm.
X has a right not to be harmed.
Y has an obligation not to harm X
Harm may be physical, mental, psychological,
social, financial, spiritual, etc.
5. Beneficence
Beneficence is the positive pole of nonmaleficence.
It means to do good, to provide a benefit.
Beneficence hinges on other duties such as fair
play, keeping promises, role commitments,
reciprocity.

Applied together with nonmalefiscence it entails

weighing benefits versus burdens then choosing the
action that brings the most benefit and the least
burden to those affected. This is the principle of
utility.
X has duty to benefit Y provided
Y is at significant risk
Xs action is needed
Xs action is likely to succeed
There is no significant risk for X
The benefit to Y outweighs any harm for X

APPLIED HEALTH ETHICS

A. Informed consent is an ideal
connected to the principle of autonomy
and respect for a person. Any procedure
to be done on a person may only be
administered with his free and informed
consent. This gives valid permission for
others to act in certain specific ways.
Two main functions:
1. Protective to safeguard against intrusion
of integrity.
2. Participative to be involve in medical
decision making.

B. The Beginning of Life

Both the Catholic Church and the Philippines Constitution

recognize the sacredness of life from the time of conception.
From fertilization through fetal life, until birth the human
being must be protected. Equally important is the respect for
the dignity of parents and newborn expressed in the method
new life is created. A child must be the fruit of the conjugal
union between husband and wife.

Artificial methods of reproduction which assist the conjugal

act praiseworthy procedures to help infertile couples. Those
that substitute or replace it are not acceptable

Caring for the pregnant patient is unique. Treating the mother

automatically treats the child and vice versa so that when
decisions are made, the health the health and welfare of the
other.

C. The end of life

Life is a gift, which as good
stewards, we have to protect and
defend. But life can be sustained for
only so long; ultimately, death
claims us all. Furthermore, life is
not the highest value and can be
given up for higher values.

C. The end of life

Many healthcare providers have

difficulties accepting death and
managing
the dying patient.

They see death as a failure of treatment,

are influenced by the technologic
imperative to use everything available,
are more comfortable treating than
not treating and hesitate to bring the
bad news of his condition to the dying
patient.

 Every healthcare provider must learn

how to face death and help his patient
accept death when dying is the only
option open.
No one needs to die neglected, alone,
shunted aside by disease, hooked on
tubes and to machines, or isolated from
families and loved ones, death with
dignity, humane death and a good death
must be available.

 An environment must be created

wherein the patient, his family, and
healthcare providers can accept death
calmly and peacefully with the
knowledge that appropriate care is
being given. They must be assured that
the patient will not be abandoned and
that he is forgiven for dying.

To attain these the healthcare provider

therefore must:
Communicate compassionately, tell
bad news early enough to provide
time for the patient to accept it and
make the best use of this most
important limited time of his: to say
goodbye, settle material matters, to
mend broken relationships, to express
love etc.
Use technology prudently. Recognize the
realm of medical futility and avoid
disproportionate means to maintain life
at all costs.

Relieve pain effectively. The dying

man often fears dying with pain. It
limits freedom and independence,
causes anxiety, rejection and
marginalization, and sense of identity.
The healthcare provider must relieve
pain effectively at the same time
accepting that intractable and severe
pain relief may necessarily decrease
consciousness and even risk the
shortening of life. He must also help
the patient understand the gift of pain
and utilize pain for good.

THE NEED TO REDEFINE DEATH

There is a widespread and increasing use of new
device for prolonging life (life support machines,
intravenous or feeding machines).
One element of the moral issue here is this: with the
use of these life-sustaining devices, we are able to
prolong life for a considerable period, or even to
save a persons life from impending death.
There are occasions or situations however, when
instead of prolonging or saving life, we are only
prolonging the dying process, hence prolonging
likewise the suffering of the dying individual.

Definitions of Death:
1. Physiological- a person is dead when the heart has
stopped beating. This is often called the traditional
understanding of death. since blood and breath are
essential to the continuation of life, when people
stopped breathing and pulsation stops, they are
pronounced dead. With the use of a mechanical
respirator, however, which can keep blood and
oxygen circulating almost indefinitely, an individuals
dying process is prolonged.

Definitions of Death:
2. Religious or philosophical definition- death means
the separation of the soul from the body. The
question is: How do we know that the soul has
already left the body?
3. Brain death- this refers to a condition in which the
brain is completely destroyed and in which the
cessation of function of all other organs are
imminent and inevitable. By and through the use of
electro-encephalography (EEG) and
electrocardiogram (ECG), health professionals can
determine the total or irreversible loss of circulatory
and respiratory functions. others include absence of
receptivity and responsiveness, absence of
movement or breathing and absence of reflexes.

Definitions of Death:
4. Cellular definition- refers to the disintegration of the
metabolic processes of the bodys substance. This
definition considers the irreversible loss of neo-cortical
activity as the only significant criterion because it
eliminates all capacity for consciousness and all social
integration possible. An EEG is needed for this
definition.

In the Medical Context

The brain death definition is very significant. Most
suitable donor organs come from patients who die
from injuries or diseases of the brain. In such
patients, blood circulation may be artificially
maintained after brain death, so that the organs
needed can be extracted with minimal ischemic
damage.
Inasmuch as destruction of the brain is the cause of
the donors death, there is a good reason to remove
these transplantable vital organs before cessation of
the donors artificially supported circulation. To avoid
any legal restraints and complications, however, this
matter requires the enactment of statutes
recognizing the use of brain-oriented criteria for
pronouncing death.

 A DNR Form used in the Commonwealth of Virginia

In medicine, a "do not resuscitate" or "dnr",
sometimes called a "No Code", is a legal order
written either in the hospital or on a legal form to
respect the wishes of a patient to not undergo CPR
or advanced cardiac life support (ACLS) if their
heart were to stop or they were to stop breathing.
The term "code" is commonly used by medical
professionals as a slang term for "calling in a Code
Blue" to alert a hospital's resuscitation team. The
DNR request is usually made by the patient or
health care power of attorney and allows the
medical teams taking care of them to respect their
wishes. In the health care community "allow
natural death" or "AND" is a term that is quickly
gaining favor as it focuses on what is being done,
not what is being avoided.

 Some criticize the term "do not resuscitate" because it

sounds as if something important is being withheld,
while research shows that only about 5% of patients
who require ACLS outside the hospital and only 15% of
patients who require ACLS while in the hospital
survive.
Patients who are elderly, are living in nursing homes,
have multiple medical problems, or who have
advanced cancer are much less likely to survive.

 Some areas of the United States and the

United Kingdom include the letter A, as in
DNAR, to clarify "Do Not Attempt
Resuscitation." This alteration is so that it is
not presumed by the patient/family that an
attempt at resuscitation will be successful.
Since the term DNR implies the
omission of action, and therefore
"giving up", some have advocated for
these orders to be retermed Allow
Natural Death. New Zealand and Australia
(and some hospitals in the UK) use the term
NFR or Not For Resuscitation. Typically,
these abbreviations are written without
periods between the letters, i.e. AND/DNR
not A.N.D./D.N.R..

 DNR compared with advance directive and

living will
Advance directives and living wills are documents
written by individuals themselves, so as to state
their wishes for care, if they are no longer able to
speak for themselves.
In contrast, it is a physician or hospital staff member
who writes a DNR "physician's order," based upon
the wishes previously expressed by the individual in
his or her advance directive or living will.
Similarly, at a time when the individual is unable to
express his wishes, but has previously used an
advance directive to appoint an agent, then a
physician can write such a DNR "physician's order"
at the request of that individual's agent.
These various situations are clearly enumerated in
the "sample" DNR order presented on this page.

 It should be stressed that, in the United States, an

advance directive or living will is not sufficient to
ensure a patient is treated under the DNR protocol,
even if it is his wish, as neither an advance directive
nor a living will is a legally binding document. It is also
the case that the wishes expressed in an advance
directive or living will are not binding.

When is CPR not of beneficial?

One approach to defining benefit
examines the probability of an
intervention leading to a desirable
outcome.
CPR has been shown to be have a 0%
probability of success in the following
clinical circumstances:
Septic shock
Acute stroke
Metastatic cancer
Severe pneumonia

In other clinical situations, survival from CPR is

extremely limited:
Hypotension (2% survival)
Renal failure (3%)
AIDS (2%)
Homebound lifestyle (4%)
Age greater than 70 (4% survival to discharge from
hospital)
How should the patient's quality of life be
considered?
CPR might also seem to lack benefit when the
patient's quality of life is so poor that no
meaningful survival is expected even if CPR
were successful at restoring circulatory
stability.

 Usage by country

Middle East
DNRs are not recognized by Jordan.
In Israel, it is possible to sign a DNR form as long as the
patient is dying and aware of their actions.
United Kingdom
In England, for DNR as for any medical treatment, by
default only the patient can give informed consent, if
they have capacity as defined under the Mental Capacity
Act 2005; if they lack capacity relatives will often be
asked for their opinion out of respect but it does not have
hard legal force on the doctors' decision. In this situation,
it is their doctor's duty to act in their 'best interest',
whether that means continuing or discontinuing
treatment, using their clinical judgment. Alternatively,
patients may specify their wishes and/or devolve their
decision-making to a proxy using an advance directive,
which are commonly referred to as 'Living Wills'.

 United States
In the United States the documentation is especially complicated in that
each state accepts different forms, and advance directives and living
wills are not accepted by EMS as legally valid forms. If a patient has a
living will that states the patient wishes to be DNR but does not have an
appropriately filled out state sponsored form that is co-signed by a
physician, EMS will attempt resuscitation. This is a little known fact to
many patients and primary care physicians that can cause patients to
receive treatments they do not want, and this law is currently being
evaluated for a constitutional challenge.
The DNR decision by patients was first litigated in 1976 in In re Quinlan.
The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's
parents to order her removal from artificial ventilation. In 1991 Congress
passed into law the Patient Self-Determination Act that mandated
hospitals honor an individual's decision in their healthcare. Forty-nine
states currently permit the next of kin to make medical decisions of
incapacitated relatives, the exception being Missouri. Missouri has a
Living Will Statute that requires two witnesses to any signed advanced
directive that results in a DNR/DNI code status in the hospital.
In the U.S., cardiopulmonary resuscitation (CPR) and advanced cardiac
life support (ACLS) will not be performed if a valid written "DNR" order is
present. Many US states do not recognize living wills or health care
proxies in the prehospital setting and prehospital personnel in those
areas may be required to initiate resuscitation measures unless a
specific state sponsored form is appropriately filled out and cosigned by
a physician.

Application of Moral Theories

Natural Law ethics- regards death as a part of nature;
it declares that a person is dead once the soul leaves
the body. When all vital functions of the brain
completely disappear or stop, extraordinary medical
measures may not be necessary but, in fact, useless.
Hence, it is morally wrong to prolong the suffering of
the dying individual by means of life-sustaining
machines in such circumstances.

 Utilitarianism- the brain death definition seems to be

in keeping with the utility precept, i.e, promoting as
much good as possible and avoiding harm or pain, if
the dying patient is detached from all life-support
machines. The pragmatists notions of practicality,
usefulness and beneficiality may justify the
application of the of the brain death definition issue
in the medical context. Joseph Fletcher, with his
situation ethics, accepts brain-related criteria for
pronouncing death in conjunction both with both
euthanasia and organic transplantations.

 Rawls concept of justice may also justify the

unplugging of life-sustaining machines if- and when
they are no longer useful to the dying personat least
in fairness to the patient so that they will not prolong
his suffering.
The same holds true of Ross twofold principle by which
to resolve conflicting duties.

Approach the patient holistically;

focusing on the entire person; giving
physical, psychological, mental,
emotional, moral and spiritual
support. The dying patient is lonely,
has needs, and worries about loss of
control. The healthcare provider must
provide palliative or comfort care,
minimize the patients symptoms,
and maximize his interaction with
others. He should provide support,
protection and if possible, security,
pray for and with his patient.

In summary, the healthcare provider must be, a

companion in his patients final journey, be in solidarity
with his patient, and be present to receive the gift of the
dying.

D. Suffering
Suffering is inevitable. A fundamental
tenet of healthcare tradition is the
commitment of the healthcare provider
to relieve suffering. Without
understanding suffering, however, the
healthcare provider cannot fulfill this
obligation. He may even cause harm by
denying or ignoring suffering especially
when this is not amenable to
pharmacologic or technologic
intervention, or by considering the relief
of pain as equivalent to the relief of
suffering.

D. Suffering
Suffering is wider than physical
pain or sickness, more complex,
more deeply rooted in humanity
itself. It is damage to the integrity
of a patients personhood.
The capacity for suffering, the
effect suffering has, and the
response to it, varies from person
to person.

D. Suffering

Suffering is wider than physical pain or

sickness, more complex, more deeply
rooted in humanity itself. It is damage to
the integrity of a patients personhood.

The capacity for suffering, the effect

suffering has, and the response to it,
varies from person to person.

 The healthcare provider must first

recognize the particular suffering of
his patient and carefully listen to
what the patient says. His presence
must manifest awareness of, bear
witness to, and validate the
suffering. He must sit with the
patient and touch him. He must
respond to it with compassion: to
alleviate whenever possible, to lend
strength and support always.

 He must help the patient locate it

spiritually, join Him with his
suffering; let it in and awaken his
love for God and fellowman. He
must help the patient make
suffering meaningful and peace
filled by seeing it not as a moral evil
in itself, but with human and
supernatural benefits when rightly
used.

Health professional relationships

A health professional deals not only with his
patient and his patients family but also with
colleagues in his profession, other healthcare
professionals, his professional organization
and society. Each of these relationships carry
mutual responsibilities and benefits.
He should, with colleagues both in his own
profession and in the other healthcare
professional, recognize that they all have a
common goal: better health for everyone.
They should work as a team in a climate of
mutual responsibility, support and respect.

 Mutual responsibility means each one doing his

best and helping the others do their best. It
means older members being powerful role
models whose behavior are living examples of
what younger members might aspire to be.
Mutual support means senior members teaching
junior members. Healthy members assisting
impaired colleagues and repairing defects
caused by them.
Mutual respect means listening to others
suggestions, encouraging others to play their
roles and acknowledging their contribution.
Mutual respect means preservation of the
others good name and avoidance of unfair
competition and solicitation of patients.

 The healthcare professional must work

towards uplifting the standards of his
profession through Continuing Nursing
Education program participation and self
regulation with correction of erring
members.
The healthcare professional, as a member
of society, must work towards the creation
of a safe environment, the implementation
of a just healthcare program and discovery
of truth through research.

Virtues of the Healthcare

provider
The manner healthcare is delivered
often rests on the kind of person the
healthcare provider is. Actions
intrinsically neutral became good or
bad, helpful or harmful depending
on the person concerned. A patient
trusts or mistrusts, depending on
what he thinks of a healthcare
providers character.

Virtues of the Healthcare provider

Virtues are acquired habits or dispositions to
do what is morally right. They are traits of
character that dispose its possessor to act in
accordance with moral principles, rules and
ideas. They catalyze action.
Everyday the healthcare provider is called
upon to act righteously: to do so, he must
posses virtues. These guide his decisions
about
where priority ought to be given. The most
common virtues cited as necessary for a
healthcare provider are fidelity, honesty,
integrity,
humility respect, compassion, prudence, and
courage.

Virtues of the Healthcare Provider

1. Fidelity is faithfulness. In the
relationship of trust every patient
must know that his healthcare giver
will keep his promises and keep the
patients best interest first in his mind.
2. Honesty is truthfulness. It is telling the
patient, the family, colleagues, and
society the truth about an illness, its
nature, prognosis, effectivity of care,
and research findings.

Virtues of the Healthcare

Provider
3.

Integrity is wholeness. It is acting in the

same way one says he should act and
believes he should act. A healthcare
provider who tells his patient smoking is
bad should himself not smoke.

4.

Humility is recognizing ones

capabilities and limitations. It is doing
ones best and asking for help as
needed. It is accepting deserved praise
graciously and denying underserved
praise. It is recognizing that the patient
knows what is best for himself.

Virtues of the Healthcare

Provider
5. Respect means paying attention to others.
It is listening attentively to a patients
complaints, or a colleagues opinion.
6. Compassion is loving kindness, a feeling
for those who suffer. It is self sacrifice
voluntarily given for the benefit of
another, or given with no hope of return,
gain, recognition, or payment but given
because the others needs are greater. It is
leaving the comforts of home to sit with a
dying patient.

Virtues of the Healthcare

Provider
7. Prudence is foresight: A habitual
deliberateness, caution and
circumspection in action. It is to look
before you leap or to consider how
different options may affect others
before making a decision.
8. Courage is doing what one sees as
right without undue fear, or standing
up against what one sees as wrong
even if it means standing up alone.

Vices of the Healthcare Provider

The authority and power of the healthcare
provider over the vulnerable patient, the
respect he gets from society, the economic
rewards of his profession sometimes lead
to the development of vices. The most
common of these are pride and greed.
Pride is inordinate self-esteem, conceit. It
is a behavior of superiority over others.
Greed is inordinate acquisitiveness, often
for wealth but also for power or position.