bioethics chapter3

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CHAPTER 3

THE CALLING OF THE HEALTH

CARE PROVIDER

The term calling signifies occupation, profession, or trade. It may imply a response of ahuman person to a demand, need, or invitation to share in talents, expertise, knowledge, andskills with other in this earthly course of human enterprise to attain quality of life. It may further

denote a vocation, which may determine what state in life a person wants to be. This vocation

includes the calling of the health care provider to enter into a contract with society in the area ofhealth as their profession. Taking care of the sick, the aged, the disabled, and other persons

afflicted with infirmities is, indeed, a noble profession.

The Health Care Profession

Various professions exist. They exist for the purpose of serving society with its various

needs. To meet those needs, professionals have to acquire and develop extensive knowledge,transforming virtues and special skills to live up to the distinguishing attributes of a profession.

What is a profession? A profession is a complex, organized occupation preceded by a long

training program (Greunding, 1985, as quoted by Burkhardt and Nathaniel, 2002). It is a calling

in which its members profess to have acquired special knowledge, by training, or by experience,or both, so that they may guide, advise, or serve others in their specialized field. Health care,

modifying the term profession, may refer to watchful keeping of the condition of being well or

not sick. It is a means of promoting the patients well-being marks the boundaries of the range ofoptions offered to a patient. It involves his/her informed consent, which is essentially limited to a

choice among medically accepted and available alternatives, geared towards promotion of his/her

welfare. Moreover, the well-being principle must be in harmony with autonomy. Patients

autonomy necessitates freedom from interference or outside control. In health care context, thepatients choice prevails over professionals assessment to value clients wish to be an

instrument of his/her own welfare, and not of other persons acts of will (Mappes and De Grazia,

2002). However, effective and successful promotions of the values of personal well-being andself-determination lies in shared decision-making and honest-to-goodness dialogue between the

patient and professional health care provider.

The Health Care Provider

A health care provider may be considered as a professional duly authorized to engage in,

and granted by applicable law monopoly over health care services. Health care providers mayinclude, but not limited to, physicians, nurses, therapists, dentists, ophthalmologists, pharmacists,

dietitian-nutritionists, and medical technologists.

The Nurse: A Mother Surrogate

The word nurse is derived from the Latin verb nutrire, which means to feed, nourish,

or suckle. As a noun, a nurse is one who suckles a child not her own(Websters NewTwentieth Century Unabriged Dictionary). As a verb and noun, the dictionary definition implies


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that nursing involves caring for children, especially young children, caring for those who are

childlike in their dependence, such as the sick, the injured, the aged, and the handicapped.

Likewise, it implies that the basic function of a nurse is identical with that of a mother who, inthe latters absence, acts as a mother surrogate to the patient who has serious emotional needs.

The patient needs motherly encouragement of recovery, reassurance of well-being, sympathy,

understanding, anxiety, fear, boredom, and distress, and somebody to confide in and talk to.Under this situation, the person he/she really needs is his/her mother, and the prime concern andjob of a nurse is to be a mother surrogate, if and when the biological mother is unavailable.

The mother role of a nurse, however, is limited to the nurturing component of maternalrole, and is devoid of elements of power and authority that may threaten patients self-

determination. Along with a mother role, the nurse assumes a subservient role or position, which

is compatible with authority. Under this role, the nurse can do nothing to influence or change the

course of treatment of the patient.

The Nurse as a Professional

A professional is one who bound by values and standards other than those of his/her

employing organization, setting ones own rules, seeking to promote standards of excellence and

being evaluated, and looking for approval from ones own professional peers (Beletz, 1990:18).

This immediately preceding description of a professional fits a nurse as such. A professionalnurse is one who finished and acquired or gained a high level of specialized skills and knowledge

through long years of study in nursing academic setting. This expertise distinguishes him/her

from non-professionals, and equips him/her to meet the needs of society, thus, fulfilling thepurpose of the nursing profession, Moreover, aside from expertise, there are other defining

attributes related and applicable to nursing profession, namely: autonomy, accountability,

authority, and unity. The table below demonstrates their interrelationship.

Characteristics of Nursing Profession

Attributes Definitions/Meanings/Description

Application/Implication to

Nursing Profession

Expertise Competence or special knowledge

and skills in particular field ofoccupation / calling

Passing Government Board

Examination and issuance ofCertificate of Registration or

License to practice

professional nursing

Autonomy Self-governing, self-regulating,

independence;

Self-regulation is a mark for

collective professional autonomy,

while self-determination is a mark

for responsibility, accountability,independence, and willingness to

take risk for individual autonomy.

Autonomous practice serves

as safeguard to patient andhealth care providers; like thenurse, he/she is legally and

ethically required to use

independent judgment in

making nursing decisionaffording safeguard to the

clients.


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Accountability Responsibility, liability, and

answerability for carrying out onesobligation or duty;

Grounded in the moral principles

of fidelity and respect for thedignity, worth, and self-

determination of clients.

Readiness of a nurse to

assume responsibility as aconsequence of his/her

independent decision and

free acts.

Authority Permission, legitimacy, power, and

expertise on some subject or field;

A form of permission for a

profession to exist and for its

members to legitimately practice.

Authority is granted through

the power of examinationand issuance of license to

protect the public from the

misfits and professionals job

territory by establishing amonopoly

Unity Oneness, union of parts forming a

complex whole;

Relates to the ability of nurses toorganize and be cohesive to

achieve the professions goal.

Through unity, nursing is

elevated to a nobleprofession, which is

characterized by expertise,autonomy, authority, and

accountability.

The Client

A client is a person of group for whom a doctor, a lawyer, a nurse, or other professional,

person, or service acts. He/she may be a student, a patient, or a customer who has a need or want,

and he/she looks for the professional (a physician, nurse, or teacher) to get and satisfy that need.

In the health care profession, the client is referred to the patient or any person afflicted withinfirmity or disability.

Patients Rights and Duties

As a noun, and taken in an abstract sense, right means justice, ethical correctness, or

consonance with the rules of law or the principles of morals. In a concrete sense, it means a

power, privilege, faculty, or demand inherent in one person and incident upon another (BlacksLaw Dictionary). On the other hand, duty refers to what a person ought to do. It applies to what a

person ought to do at all times because it is legally or morally right (The World Book

Dictionary). Right and duty are two inseparable concepts. For every right, there is a

corresponding duty. Patients claim of his/her right to effective health care requires or demands aduty to collaborate with physicians, nurses, and other health care providers.

Patients Right

The American Hospital Association (1992) promulgates and adopts a Patients Bill of

Rights. This Bill is presented for consideration and application under Philippine context. It isshown at the table below.


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Patients Bill of Rights

1. The patient has the right to a considerate and respectful care.2. The Patient has the right to and encourage to obtain from physicians and other direct

caregivers relevant, current, and understandable information concerning diagnosis,

treatment, and prognosis.

Except in emergencies when the patient lacks decision-making capacity and the

need for treatment is urgent, the patient is entitled to the opportunity to discuss and

request information related to the specific procedures and/or treatments, the riskinvolved, the possible length of recuperation, and the medically reasonable alternatives,

and their accompanying risks and benefits.

Patients have the right to know the identity of physicians, nurses, and othersinvolved in their health care, as well as when those involved are students, residents, or

other trainees. The patient also has the right to know the immediate and long-term

financial implications of treatment choices within the institution.3. The patient has the right to make decisions about the plan of care prior to and during thecourse of the treatment, and to refuse a recommended treatment of plan of care to theextent permitted by law and hospital policy, and to be informed of the medical

consequences of this action. In case of such refusal, the patient is entitled to other

appropriate care and services that the hospital provides, or be transfer to another hospital.

The hospital should notify patients of any policy that might affect patient choices withinthe institution.

4. The patient has the right to have an advance directive (such as living will, health careproxy, or durable power of attorney for health care) concerning treatment or designating a

surrogate decision-maker with the expectation that the hospital will honor the intent of

that directive to the extent permitted by law and hospital policy.5. The patient has the right to every consideration of privacy. Case discussion, consultation,

examination, and treatment should be conducted so as to protect each patients privacy.

6. The patient has the right to expect that all communications and records pertaining tohis/her care will be treated as confidential by the hospital, except in cases such assuspected abuse and public health hazards where reporting is permitted or required by

law. The patient has the right to expect that the hospital will emphasize the

confidentiality of this information when it releases it to any other parties entitled toreview information in these records.

7. The patient has the right to review the records pertaining to his/her medical care, and tohave the information explained or interpreted as necessary, except when restricted by

law.8. The patient has the right to expect that, within its capacity and policies, the hospital will

make reasonable responses to the request of the patient for appropriate and medically

indicated care and services. The hospital must provide evaluating service and/or referral

as indicated by the urgency of the case. When medically appropriate and legallypermissible, or when a patient has so requested, the patient may be transferred or must

first have accepted the patient for transfer. The patient must also have the benefit of

complete information and explanation concerning the needs for, risks, benefits, and


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alternatives to such transfer.

9. The patient has the right to ask and be informed of the existence of business relationshipsamong hospitals, educational institutions, and other care providers, or prayers that may

influence the patients treatment and care.

10.The patient has the right to consent to or decline to participate to proposed researchstudies or human experimentation affecting care and treatment requiring direct patientinvolvement, and to have those studies fully explained prior to consent. A patient who

declines to participate in research or experimentation is entitled to the most effective care

that the hospital can otherwise provide.

11.The patient has the right to expect reasonable continuity of care when approached and tobe informed by the physician and other caregivers of available and realistic patient care

options when hospital care is no longer appropriate.

12.The patient has the right to be informed of hospital policies and practices that relate topatient care, treatment, and responsibilities. The patient has the right to be informed of

available resource for resolving disputes, grievance, and conflicts, such as ethics

committees, patient representatives, or other mechanisms available in the institution. The

patient has the right to be informed of the hospitals charges for service and availablepayment methods.

Along with or relative to the Patients Bill of Rights, the Council on Ethical and Judicial

Affairs of the American Medical Association (1993) made statement asserting and spelling outsupplementary and/or complementary patients rights that physicians and allied health care

providers are enjoined to foster. The table below shows the following rights.

Patients Rights

1. The patient has the right to receive information from physician and to discuss thebenefits, risks, and cost of appropriate treatment alternatives. Patients should receive

guidance from their physician as to the optimal course of action. Patients are also entitledto obtain copies or summaries of their medical records, to have their questions answered,

to be advised of potential conflicts of interest that their physician might have, and toreceive independent professional opinions.

2. The patient has the right to make decisions regarding the health care that is recommendedby his/her physician. Accordingly, the patient may accept or refuse any recommended

medical treatment.

3. The patient has the right to courtesy, respect, dignity, responsiveness, and timelyattention to his/her needs

4. The patient has the right to confidentiality. The physician should not reveal confidentialcommunication or information without the consent of the patient, unless provided by law

or by the need to protect the welfare of the individual or the public interest.5. The patient has the right to continuity of health care. The physician has an obligation to

cooperate to the coordination of medically indicated treatment with other health careproviders treating the patient. The physician may not discontinue treatment of a patient as

long as further treatment is medically indicated, without giving the patient sufficient

opportunity to make alternative arrangements for care.

6. The patient has the basic right to have available adequate health care. Physicians, alongwith the rest of society, should continue to work towards this goal. Fulfillment of this


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right is dependent on society, providing resources so that no patient is deprive of

necessary care because of an inability to pay for the care. Physicians should continuetheir traditional assumptions as part of the responsibility for the medical care of those

who cannot afford essential health care. Physicians should advocate for patients in

dealing with third parties when appropriate.

Patients Duties/Responsibilities

From the above-cited rights, we may derive these corresponding duties and/or

responsibilities of a patient. The first and foremost requirement from a patient is his/her whole-hearted cooperation and/or active participation in the course of treatment. This collaborative

relationship is essential in addressing health-related needs towards the effectiveness of care and

patient satisfaction and delight. From this basic requirement and premise, other specific duties

and/or responsibilities may ensue. Burkhardt and Nathaniel (2002) suggest some of theseresponsibilities that the patient should follow:

To provide honest information about past illness, hospitalizations, medications, and othermatters related to health status

To take initiative in requesting additional information or clarification about his/her health

status or treatment when he/she does not fully understand such information andinstruction.

To ensure that the health care institution has a copy of his/her written advance directive ifhe/she has one;

To inform his/her physician and other health care providers, like the nurse, if he/sheanticipates problems in following the prescribed treatment;

To be aware of the hospitals obligation to be reasonably efficient and equitable inproviding care to other patients and the community

To make reasonable accommodations to the needs of the hospital, other patients, medicalstaff, and hospital employees;

To provide necessary information for health care insurance coverage and/or claims, andto work with the hospital to make payment arrangements orderly and easy; and

To recognize and discern the impact of his/her lifestyle on his/her personal health.

Health Care ProviderClient Relationship

Relationship signifies a state or condition that exists between people or groups that deal

with one another. It implies a nexus or connection that binds parties for a common objective. Inthe matter of health care delivery, important players, entities, or clientele are involved with

significant part to play in decision-making affecting health. These parties in collaborativerelationship or in teamwork are the health care providers such as the physician, nurses, and otherallied professionals, and the clients or patients with their families as the case may be. In this

setup, we may speak of and limit to physician-patient or nurse-patient relationship, in either case.

There are models or types that describe or direct the range or extent of this relationship. In hisarticle, Client and Profession, edited by Rowan and Zinaich (2003), Paul Faber presents five

(5) different types or modes of professional-client relationship. These are shown in the table

below.


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Professional-Client Relationship

Types/models Descriptions

Application/Implication to

health care

1. Agency Relationship The professional doesnot make decision, butthe client does. Theonly thing the

professional does is to

implement part ofclients decision. The

professional works as

the agent of the client.

As applied to healthcare, the responsibilityto analyze, consider,and decide in the best

alternative, and

become educated aboutthe problem and its

corresponding

solution, lies with the

client/patient

The implication is thatagency relationshipupholds patients valueof self-determination

or autonomy in the

promotion of his/herpersonal well-being.

2. Paternalism Metaphorically, it issimilar to a father-

child relationship

The professional as

caring parent, and theclient as the child.

The professionalassumes responsibility

to analyze, consider,

and decide on solutionto the problem of the

client, who is onlycalled to implement

some of the decisionsor none at all. Under

this setup, the clients

self-determination andfreedom are curtailed

to a great extent.

However, there is nocurtailment if and

when the client acts

freely due to theabsence of coercion,presence of informed

consent, and to his/her

being competent; the

absence of any of theseconditions qualifies the

relationship to be


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appropriately

paternalistic.

3. Contractual An agreement enteredinto and executed byand between the

professional and client,stipulating the extentof their respective

responsibility in a joint

effort to meet a need.

The contractualrelationship is doableif and when the levels

of knowledge of theproblem area betweenthe professional and

client are more or less

equal; otherwise, therelationship is not

appropriate and the

clients needs cannot

be met.

4. Affinity A relation anchored ontrust between the

professional and client.The latter trusts the

former due to someconnection or

confidence arising

from friendship,

expertise, familyrelation, or

membership in

religious or ethnicgroup. Under this

relationship, there is anevolving division of

responsibilities aimedat the clients well-

being.

The relationship isappropriate and

applicable when theneeds of the client are

met withoutencroaching upon

his/her freedom.

5. Fiduciary As s noun, fiduciarymeans a person

holding the characterof a trustee. In a

fiduciary relation, the

trustee is the

professional who isheld in trust for the

welfare of the client.

In health care, theprofessional

(physicians, nurses,and other health care

providers) are the

trustees in whose

highest standard ofknowledge and

expertise are set, and

in whom the welfareand health of human

life are entrusted. They

are unconditionally,legally, and morally


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obligated with utmost

diligence by virtue ofthe nature of their

profession.

In summary, the above-cited types of professional-client relationship spell out the extentof task each partner does appropriately to meet a need. The five (5) tasks described are:

1) The need or problem must be analyzed;2) To consider various alternatives or options to respond to the need;3) To decide on the best option;4) Education of the client must be done so that there is an informed consent; and5) Final decision must be implemented.The five modes of relationship (agency, paternalistic, contractual, affinity, and fiduciary)

differ extensively in terms of who (professional or client) performs or responds to the

required task. Form among the models of professional-client relationship, it is the contentionthat the most appropriate and commendable is the fiduciary relationship. Do you agree?Why?

The Qualities And / Or Characteristics of Effective Health Care Providers

The concept of quality is a dynamic state associated with people, services, processes, and

environment that meets or exceeds expectations (Goestch and Davis, 1997). It applies to anydistinctive feature or characteristic of an individual. As applied to health care providers, qualities

are professionals proficiencies that conform to clients or patients expectation, measured

through the satisfaction of clients needs, and treat them with integrity, respect, and courtesy.

Qualities may refer, likewise, to desirable personal attributes or traits that health care providers,such as nurses, may possess. They must have and live a quality life first before they can

understand the patients perspective of what constitutes quality in their own lives. Nemo dat

quod non habet (Nobody gives what he/she does not have), as the Latin saying goes. To beeffective in quality service, health care providers must have or possess, among others, the

following qualities/ characteristics listed in the table below:

Personal Qualities / Characteristics

Kinds Meanings, Descriptions, and Implications

Self-respect Proper regard for the dignity of ones character

or position, with appreciation or recognition of

its obligation of worthy conduct. As humanpersons, health care providers must have a

strong sense of self-worth, of who they are in

terms of their rational, theological, social,historical, and biological essence. They should

have, too, a sense of pride of what they are in

terms of their calling or profession, so that theycan easily relate to their patients the beauty of


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life that is worth living with and dying for.

Self-Transcendence The quality of going beyond ones own self; it

is self-giving, selfless love, the death of self sothat others may live. For health care providers,

like nurses, it implies capacity, readiness, andwillingness to sacrifice their comfort zone forthe well-being of their client/patient.

Service-Oriented The quality of being helpful, useful, and

generous to others. It implies a value-added

attitude of dedication to ones work, notmindful of remuneration paid, time spent, or

schedule given. Health care providers, like

nurses, must bear in mind that the very nature

of their profession is service to the sick,

primarily for their welfare, and incidentally formoney just enough for them to survive and live

a quality of life.

Simplicity The quality of being sincere, true, orstraightforward. It implies absence of show or

pretension. In other words, for a human person,

like a nurse, to be simple, he/she must live withintegrity, and not with a split personality.

He/she must act according to who and what

he/she really is, and not to what he/she is not.

He/she must possess only what he/she needs sothat others may not be deprived and suffer.

Toward this end of simplicity, he/she becomes

an advocate of sustainable humandevelopment.

Sense of Personal Responsibility andAccountability

The ability to respond to a problem or need,

which calls for decision-making, and aconcomitant accountability to answer for anyconsequence thereafter. It implies total

commitment and a sense of social duty, which

requires an unfailing service to the needy forthe good of society, or the common good.

Risk-Taking Personality The quality of being courageous, strong, open,and vulnerable. It implies leaving ones

comfort zone and going to his/her courage

zone, which is characterized by innovation,change, pressure, exploration, and risk for the


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possibility of failure or error. The health care

providers, like nurses, have to make a stand infavor of patients well-being, even to the extent

of losing their comfort zone. With courage,

they disturb the comfortable, and comfort the

disturbed.

Patience The quality of being willing to put up waiting,

pain, or anything that annoys, trouble, or hurts.

It implies calmness and self-control, andapplies when one is either enduring something

unpleasant or merely waiting or doing

something that requires steady effort. The

caring for the sick is a demanding job becauseit involves protection, preservation, and

extension of healthy human life. It demands an

enduring attention and empathy fromcommitted health care providers.


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CHAPTER 4

VIRTUES, VICES, AND HABITS OF A

HEALTH CARE PROVIDER

The health care profession does exist not only by operation of law, but also by applicationof value-based ethics and the practice of virtues. In a legally-based ethics, a professional has tomeet minimum requirements of applicable laws that define the extent of his/her administrative,

civil, or criminal liabilities. Beyond legal definitions, value-ethics or the ethics of rights and

duties may be observed to spell out obligations in resolving moral dimension. However, virtue-based ethics transcends the legal and moral levels in the hierarchy of ethical sensitivity.

Questions may arise from these three-tiered systems of obligations: if an act is legal, is it moral?

If it is moral, is it spiritual?

Virtues of the Health Care Provider

Virtue is referred to as a particular moral excellence. It is synonymous to uprightness orintegrity it is simply a praiseworthy trait of human character (Veatch 2007), or a character trait

that is morally valued. It is a way of actions, a disposition, or a good habit (Rowan and Zinaich,

2003). Aristotle sees it as a habit that is in the middle between two extremes of deficiency and

excess. This is his doctrine of the golden mean. Being virtuous entails acting in moderation.Thus, the moral virtue of courage lies in a mean between the extremes of cowardice (deficiency)

and foolhardiness (excess) (Ibid.:43). Moreover, Aritstotle distinguishes moral virtues from non-

moral. The former are habits that are necessary for being a morally good person, such as honesty,generosity, non-malevolence, fairness, kindness and courage. The latter virtues, on the other

hand, are practices that may make a human person good in other ways such as optimism,

cleanliness, and musical talents (Ibid.:42-43).

List of Virtues

Virtues may vary among professional, secular, philosophical and religious ethicalapproaches or systems. Notwithstanding this variation, we may focus on and agree to a list of

virtues, which may deem appropriate for and necessary to a virtuous life of a health care

provider. In the health care profession, his/her personal life must be characterized by the virtuesof:

1) Fidelity2) Honesty3) Integrity4) Humility5) Respect6) Compassion7) Prudence8) Courage


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Fidelity

Fidelity is referred to steadfast faithfulness. It is associated with pledge of loyalty or thepractice of keeping promises. In the health care profession, faithfulness associated with keeping

of promises is demonstrated when professionals, like nurses, spontaneously and consistently

show in their personal and professional life their wholehearted support in upholding applicablelaws, code of ethics, policies, and promises entered into with clients/patients. Likewise,faithfulness associated with loyalty in the professional-client relationship gives rise to an

independent duty to keep contract in force and effect.

Honesty

Honesty means the quality of being honorable and upright in character and actions. It

emphasizes fairness and uprightness in relations with others, refusal to steal, telling a lie, ormaking misrepresentation. To be fair, upright, and straightforward is to be honest with oneself

and in his/her human acts. Self-honesty demands that he/she must not ever fake or try to be

something or somebody he/she is not. He/she must be a first-rate version of himself/herself, andnot a copycat or second-rate version of others. Moreover, to be honest is synonymous to being

morally incorruptible, principled, truth-loving, veracious, real, good, and genuine. The absence

of many of these characteristics negates the virtue of honesty, and gives way to the vices of

plasticity, artificiality, caprices, and vanity. In the health care profession, this virtue must aboundand shine.

Integrity

Like honesty, the virtue of integrity means the uprightness in character and actions. It

implies undivided or unbroken conditions, completeness, and wholeness. It applies more directly

to character than to actions, and means soundness of character and possession of very highstandards of right and wrong. In health care service, a nurse of integrity can be trusted. He/she

can easily attract and win friendship and reliance from his/her client or patient.

The absence of integrity splits the personality of a nurse or any health care provider.

He/she practices the profession not because of its idealism of service to humanity, but because of

material consideration/comfort.

Humility

Humility is meekness of heart. A person, who is meek, acts with a gentle spirit. It callsfor submission, docility, and courtesy. It implies freedom from pride and arrogance, lowliness of

mind, a modest estimate of ones worth, and acceptance of ones own human imperfection,

sinfulness, and self-abasement. In the health care profession, professionals, like the nurses

epitomize the way humility works in their life. Nursing, by its nature, means rendering humbleservice to the sick and needy.


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Respect

The virtue of respect means esteem or honor. Esteem or honor is a quality by which aperson shows recognition or high regard to self-worth, self-respect with dignity, respect for

authority, and respect for others with tolerance.

Self-worth signifies a favorable estimate or opinion of oneself. It is a self-esteem, that is,when one knows well who he/she is, his/her strength and capabilities, as well as his/her

weaknesses or limitations, and that he/she can be a worthy instrument of service for others.

Self-respect is an appropriate regard for oneself. It is a proper regard for the dignity of

ones character or position, with recognition of its obligations of worthy conduct. It implies,

then, recognition of worth specifying the element of approval or disapproval. It also implies

proper pride that evokes confidence in ones worth as a human person, and prompts concern tosustain it. To sustain self-respect, one must take good care of his/her body, mind, and emotions.

Respect for authority is due regard to a person or persons with the right to givecommands and power to enforce obedience. These persons may be natural or juridical. In the

Philippine context or jurisdiction, natural persons in authority include parents, teachers, elected

and appointed government officials, like the Baranggay chairman, mayors, governors, judges,

justices, congressmen, senators, cabinet members and secretaries, the Vice-President, andPresident of the Philippine Republic. The judicial persons may include Congress or Parliament,

as the case may be, who enacts laws like the Philippine Nursing Act of 2002 (R.A No. 9173), the

Board of Nursing that promulgates the Nursing Code of Ethics, and/or the Philippine NursingAssociations Incorporated (PNA) that embodies the ideals of the nursing profession.

As applied to health care providers, their moral obligation is to obey authorities and give

them due respect. They must see the practicability, necessity, and benefits of obedience andrespect to their respective profession. House rules, school regulations, ethical rules of conduct,

and laws are binding in their conscience. Conscience prompts and enjoins them to follow and

respect authority figures for the sake of the common good, societal order and harmony, andpublic welfare.

Respect for others may refer to due regard to immediate and distant relatives, neighbors,peers, classmates, friends and non-friends. For health care providers, these others may refer to

clients or patients whom they respect and treat with utmost care, diligence, and tolerance.

Respect with tolerance is willingness of one to be patient towards others, whose opinions or

ways differ from him/her. It is a virtue that respects and upholds human rights. It recognizesdiversity of cultures and forms of human expressions. It calls for the eradication of biases,

prejudices, and insensitivity (APNIEVE, 34).

Compassion

Compassion signifies sympathy. It implies feeling for anothers sorrow or hardship that

leads to help or pity. To be compassionate is to wish to be of help to those who suffer and whoare in dire need of service. It is an act of opening ones heart to truly feel the difficulties and


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hardships that another person is experiencing at the moment or here-and-now. It is characterized

by related virtues of love and care, sympathy, kindness, and concern for others. To be a genuine

and virtuous health care provider, compassion must be in the vein of his/her personal andprofessional life in order for his/her relation or dealing with patients to be significant and

meaningful.

Prudence

The virtue of prudence signifies carefulness, precaution, attentiveness, and good

judgment as applied to action or conduct. This term, in legal parlance, is commonly associatedwith care and diligence, and contrasted with negligence (Blacks Law Dictionary). It

emphasizes cautious good sense in giving thought to ones actions and their consequences. It

applies discernment or keenness in seeing, perceiving, or understanding a problem, situation, or

issue. To be prudent means to be sensitive, discreet, judicious, and wise. To act with wisdom isto think with foresight, that is, one has to have the ability to see what is likely to happen and

prepare for it accordingly (The World Book Dictionary). In the health care profession, this virtue

of prudence is a tall order, considering the fact that these professionals, like physicians andnurses, deal with human life. In their decision-making process or judgment, they make or break,

let live or let die their patients. It is expedient that health care providers possess the virtue of

prudence to be instruments of healthy and long human life, and not to be causes of undesirable

loss of it.

Courage

The virtue of courage signifies bravery and fearlessness. However, courage applies to

moral strength that makes a person face any danger, trouble, or pain steadily and without

showing fear. On the other hand, bravery applies to a kind of courage that is shown by bold,

fearless, and daring action in the presence of danger. The hairline difference is that the former ismore of a state or quality of mind and spirit that enables and prompts one to face danger, fear, or

vicissitudes with confidence and resolve. The latter shows or demonstrates courage concretely,

bodily, and with determination.

Vices of the Health Care Provider

The human person is a rational animal. This philosophical perspective makes him/her a

living paradox. He/she is a rational being, as well as an animal being. The characteristic of

rationality raise him/her to the level of the spirits. As such, his/her thoughts, dispositions, and/or

human actions tend towards virtuous life as a gateway/passage to the spiritual world. Thecharacteristics of animality put him/her down to the level of the brute. As such, his/her acts move

towards evil or vicious life. What he/she does are acts of man under the influence or dictate of

the reptilian brain. All persons, including the health care providers, are subject to this human

imperfection, and are prone to the commission of vices.

A vice is an evil fault, an imperfection, an immoral conduct, tendency, practice, or habit.

As applied to an animal nature of a person, it is a bad habit or failing. The human person has so


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many vices. As applied and attributed to health care providers, these vices may include, but not

limited to the following: 1) fraud, 2) pride, and 3) greed.

Fraud

The vice of fraud is synonymous to the vices of bad faith, dishonesty, deceit, infidelity,unfairness, perfidy, unfaithfulness, and other analogous terms. It embraces all diverse means thathuman ingenuity can devise, and which are resorted to by one individual to take advantage over

another by misrepresentations, false suggestions, or by suppression of truth. It also includes all

surprise, trick, cleverness in deceiving, pretense, disguise, and any unfair way by which anotheris cheated (Blacks Law Dictionary).

Fraud is either actual or constructive. The former consists in deceit, artifice, trick, design,

and some direct and active operation of the mind. It is something said, done, or omitted by aperson with the design to perpetrate what he/she knows to be a cheat or deception. The

constructive fraud, on the other hand, consists in any act of commission or omission contrary to

legal or ethical duty, trust, or confidence reposed. It is contrary, as well, to good conscience andoperates to the injury of another (Ibid.).

In relation to the Nursing Profession, a nurse may be guilty of and penalized for fraud as

defined by the Philippine Nursing Act of 2002 (R.A. 9173) in the following instances:

He/she practices nursing in the Philippines without a certificate ofregistration/professional license and professional identification card or special temporarypermit, or without having been declared exempted from examination in accordance with

the provision of R.A. No. 9173;

He/she uses the certificate of registration, professional license, professional identification,

and/or special temporary permit of another;He/she uses an invalid certificate of registration/professional license, a suspended orrevoked certificate of registration/professional license, or an expired or cancelled specialtemporary permit;

He/she gives any false evidence to the Board in order to obtain a certificate ofregistration/professional license, a professional identification card, or special permit;

He/she falsely poses or advertises as a registered and licensed nurse, or uses any othermeans that tend to convey the impressions that he/she is a registered and licensed nurse;

He/she appends B.S.N., R.N. (Bachelor of Science in Nursing, Registered Nurse), or anysimilar appendage to his/her name without having been conferred to said degrees or

registration; or

He/she as a registered and licensed nurse, abets or assists the illegal practice of a personwho is not lawfully qualified to practice nursing.

Pride

The vice of pride is antonymous to the virtue of humility. It is synonymous to conceit

which both mean a high opinion of oneself. Pride implies pleased satisfaction with what one is,has, has done, or is doing. It is synonymous with vanity, that is, too much pride in ones looks,


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abilities, or accomplishments. It suggests neither proper self-respect nor personal dignity because

of real-worth, but excessive self-love and arrogance because of imagined superiority. On the

other hand, conceit implies too much high opinion of ones own abilities and accomplishments.It suggests an unpleasantly assertive manner (The World Book Dictionary). A proud and

conceited person does not recognize his/her mistakes. He/she thinks that he/she is always right

and never goes wrong. He/she points at others to be the culprit, the sinner, the guilty, and nothim/her. He/she is just perfect. This kind of person is so called the conventional wisdom personwho is totally closed to change, dialogue, and a truly virtuous life. How about a health care

provider like a nurse, is he/she prone to this vice of pride? If his/her personal life is clothed with

pride and conceit, then, the nursing profession is not meant for him/.her because he/she is calledto live with utmost humility, in humble service to the sick, disabled, disturbed, the weak and

powerless.

Greed

The vice of greed is the quality of wanting more than ones share. It is synonymous to

avidity, avarice, cupidity, covetousness, and other analogous terms. To be greedy means to wantor desire to get for oneself, more than what he/she needs. A greedy person is: a miser who is

eager to accumulate much money/wealth, a glutton who wants to eat food excessively, a coveter

who wants more things, more wives, or husbands belonging to another, a cupid who desire to

arrow more lovers (men, women), a dictator who has an avid desire for more power, and a ravenor plunderer who desire to get more things through stealing, robbery, kidnapping, car napping,

and other corrupt means.

Greed is antonymous to the virtue of simplicity, which is the absence of or freedom form

luxury, vanity, and any form of greed. Simplicity regulates human wants and calls for

moderation in taking only what are necessary to sustain good life. This virtue of simplicity, and

not greed, must be instilled and integrated in the personal and professional life of a health careprovider. He/she becomes an epitome of a simple life that the sick, disabled, and the deprived or

needy will look up to with hope.

Habits of a Health Care Provider

The law of repetition, as applied in education, requires that one do things again and againuntil he/she learns. Students undertake routines in school, at home, and in other places doing the

same things they did yesterday, the previous day, and every day for the last semester, or the

whole academic year. Most of their student life is habitual. Likewise, in the health care

profession, the professionals, like nurses, do things routinely and most of the time, they arehardly aware that they have habits.

What is a habit?

A habit is a disposition or condition of the body or mind acquired by custom or a usual

repetition of the same act or functions (Blacks Law Dictionary). It is also understood as an

inclination to perform some particular action, acquired by repetition, and characterized by adecreased power of resistance and an increased facility of performance (Padilla, 2005:38). From


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the two immediately preceding definitions, there is a commonality in the use of the term

acquired, which may imply that habit is not inborn. It will either make one or break him/her,

for he/she becomes what he/she does repeatedly. Relative thereto, the writer Samuel Smiles(quoted by Covey, 1998:8) puts the impact of a habit this way:

Sow a thought, and you reap an act;Sow an act, and you reap a habit;Sow a habit, and you reap a character;

Sow a character, and you reap a destiny.

The immediately preceding beautiful statements may imply that one is still on top of

his/her habits. He/she can control, redirect, or change them, geared towards an improved

healthful quality of life. For this reason, good habits in and bad habits out will be a tall order.

Bad Habit

A bad habit is a negative behavior pattern. It may be equivalent to a vice when it hasmoral implications due to its intimate relation to moral behavior like the habits of drug addiction,

cursing, excessive drinking (wine), smoking, gambling, and eating. These instances of bad habits

become vices if and when one knows the consequences, but he/she still does and repeats them

intently, voluntarily, and consciously, without any effort to avert or avoid them. However, thereare habits considered as bad, but short of elements to be a vice. Nevertheless, these habits may

become recipes for disaster. Covey (1998) lists seven (7) common bad habits or characteristics as

shown in the table below.

Bad Habits Description/Meaning/Implication

1. Reactive One tends to act in response to someinfluence or force. He/she does not takeresponsibility for his/her life, and isconcerned only for his/her rights and

never for his/her corresponding duties.

He/she blames everybody else and onlydoes anything in response to what

others have done. It is a toe for a toe, an

eye for an eye, and a tooth for a toothdisposition.

2. Begin with no end in mind One does not believe in planning or inhaving vision-mission goals; whatever

will be, will be (que sera, sera). He/sheis only concerned of the here-and-now

existence and not tomorrow, which is

uncertain or may never come.

3. Put First Things Last One does not have priorities. He/shedoes whatever comes, and importantthings can wait for tomorrow. It is a

maana habit attitude, or


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procrastination.

4. Think Win-Lose One sees life as survival of the fittest.He/she competes to win and makes sure

others lose by all means. In case ofloss, he/she does not accept defeat. In

the win-lose proposition, the law of thejungle applies.

5. Seek First To Talk, Then Pretend toListen

One makes it a point to monopolize thetalking, and impresses upon others that

he/she knows best with incomparableideas. He/she lets others air their views

with a pretext to listen. In this habit,

there is an evident superiority complex,

which may give way to a vice of pride.

6. Do not Cooperate One does not see the importance ofteamwork. He/she thinks that nobody

can do it, except himself/herself7. Wear Yourself Out One thinks that he/she is an institution,

and does not need to improve, or learn

new things, for he/she has vast

reservoir of stocked ideas.

Good Habits

A good habit is a positive behavior pattern. It is analogous to a virtue. Virtuous persons

live persistently with good habits. There are seven (7) good habits vis--vis the seven (7) bad

habits, which Covey (1998) listed. These good habits are shown in the table below.

Good Habits Meaning/Explanation/Implication

1. Be Proactive A person, who is proactive, makeschoices based on values and virtues.

He/she anticipates trends and works to

promote their development. He/she isactive in advance. What he/she does is

preventive. He/she prevents or keeps a

person or thing from doing something

or making progress, or acting or setting

up an obstacle to stop him or it. He/shetakes responsibility for his/her life.

He/she thinks before he/she acts, and

makes things happen.

2. Begin with the End in Mind One defines his/her vision-missiongoals in life. He/she is a visionary,mission-oriented, and goal-directed.

He/she plans to search for the


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eschatology of life. He/she draws up a

blueprint to guide him/her indiscovering the meaning and purpose of

human life.

3. Put First things First One prioritizes and does the mostimportant things first. He/she managestime so that activities and action plans

comes first in the order of importance.Due to this habit, he/she learn to

overcome fears, and become

courageous with strong will power tosay yes to priorities, and no to

unimportant things.

4. Think Win-Win A win-win proposition is a belief thateverybody can succeed. It is anchored

on justice and equity. Everyone gets

what is his/her due, for there are morethan enough opportunities for all. It is a

smorgasbord or an all-you-can-eat

buffet. There are no sad and angrylosers, but all are happy and satisfied

winners.

5. Seek First to Understand, Then to beUnderstood

One opens himself/herself and listens topeople genuinely to understand them

who they are. He/she listens with

his/her eyes, heart, and ears, stands intheir shoes, and practices mirroring or

reflection. To be understood necessarilyfollows leading to a healthy dialogue.

6. Synergize A synergize is a harmonizer. He/sheprovides unity and support. He/she

encourages people to work together toachieve more. The key to synergy is

teamwork

7. Sharpen the Saw To sharpen ones saw is to take a breakor rest, and receive back what he/she

has given in work; resting is receiving.

It is a good habit to rejuvenate, unleash,

take a lateral move, relax, and treatoneself to a little tender loving care.


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CHAPTER 5

BASIC ETHICAL PRINCIPLES

A principle is a truth that is a foundation for other truths. What constitutes truth? It is

conceived as an agreement of thought and reality, an eventual verification (of hypothesis, theory,or doctrine), and consistency of thought with itself. Law and moral ethics are principles. Legaland ethical principles are basic truths that guide decision analysis and decision-making. For

health care providers, like nurses, knowledge of and interest in legal and ethical truths are

indispensable conditions in the practice of their profession. Consistent adherence to theseprinciples may minimize, if not avoid totally, mistakes, lapses, or vices in the health care

services. This chapter limits its presentation to and/or discussion on the following basic ethical

principles:

Stewardship;

Totality;

Double Effect;Cooperation;

Solidarity;

Ross Ethics; and

Some major bioethical principles of:o Respect for persono Respect for justiceo Non-maleficence, ando Beneficence

Principles of Stewardship

A steward or stewardess is a person appointed in the place or stead of another. He/she

takes charge of representing and protecting anothers interest, and sees to it that the service is

carried out faithfully. This management and supervision for others stewardship.

The principle of stewardship entails concomitant values and/or virtues of responsibility

and accountability. Responsibility is the duty involved when one accepts the task of

management. It is the ability of one to respond freely to a call for quality service. This responseis characterized by the values/virtues of worthy, good servant. These characteristics imply

reliability and is the state of being answerable or liable for carrying out ones right and duty. It

goes hand-in-hand with responsibility. Both are obligations that a person is bound in law or

justice to perform.

By virtue of their chosen profession, the health care providers, like nurses, are changed

by society as stewards in the health care services. They are called and mandated to take care ofor look after the well-being of the sick, disabled, and other people suffering from physical and

psychological infirmities. Equipped with knowledge, skills, right attitude, values, and/or to

restore and help sustain good health of those people whom they are changed to serve.


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Principle of Totality

The term totality connotes wholeness, completeness, or entirety. The principle oftotality applies to any entity that is made up of parts that together constitute as a whole. But the

whole is greater than any of its parts. As applied to the human person, his/her whole physical

body is more important and valuable than any of its part. It may be ethical and legal to sacrifice apart of ones body for the good of his/her whole body. On this basis, a cancerous leg may beamputated, or breast be operated. Removal of either part does not reduce the integrity of the

human person. But to reduce or remove a part from the whole unnecessarily or out of vanity, will

be contrary to moral integrity or integrity of creation. Transsexual operation or plastic surgery ofa natural flat nose is typical examples.

Principle of Double Effect

The principle contemplates on two effects or outcomes arising from the performance of

an action. The first or primary effect results from the agents intent, desire, wish, or will, while

the secondary effect is only allowed, tolerated, or permitted. Moreover, the principledistinguishes performance of a good act that has both good and evil effects, from performance of

an evil act so that good effect may result therefrom.

There are four (4) conditions or elements to consider or fulfill before an action withdouble effect is justified, namely:

The action done or course chosen must be morally good, or at least morally indifferent orneutral;

The good effect must come directly form the action itself, and is not coming from orfollowing as a consequence of secondary evil effect;

The good effect must be intended or willed and the evil/ harm merely tolerated orallowed, with sufficient reason; and

The good effect must outweigh or at least be equivalent in importance to the evil effect.

Application of the Principle of Double Effect To an Actual Case

Case 1:

Ces Drilon of ABS-CBN was kidnapped for ransom. As a policy, payment of ransom

money is absolutely prohibited. However, non-payment would mean loss of her life. The familyof the victim allegedly paid secretly despite the prohibition and she was released alive. Did the

family of the victim act morally?

Analysis:

The action had two effects: it is violated the no-ransom policy and it saved human life.

First, the action of saving human life is, in itself, morally good. Second, such good effect is adirect result of the action itself and not a result of the violation of the policy. Third, the intent,

desire, or wish of the family is to save the life of the victim, and not to go against the policy,


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violation of which is merely allowed or tolerated. Finally, the saving of the victims life

outweighs or is in proportion to the violation of the no-ransom policy, for in the hierarchy of

values, life is more valuable or important than property.

The Principle of Cooperation

To cooperate means to work together, to unite in producing a result, or to desire, intend,or wish in a common thing. Cooperation, then, implies that one works with others in the

performance of an act to accomplish a goal. To be able to work with others, he/she should have

the knowledge, skills, attitudes, and traits that can guarantee harmonious relationship with others.However, concerted acts may turn out to be either good or evil. If it is good, the morality of

cooperation promotes undoubtedly the total well-being of clients. However, the principle of

cooperation poses moral problem, when and where acts done are evil, immoral, and illegal.

In concerted evil acts, participants may be considered either as principals by

indispensable cooperation, or as accomplice who cooperates by previous or simultaneous acts. A

co-principal is one who cooperates in the commission of an evil when one does another act,without which it would not have been accomplished. Prior to the performance of such another

act, there is an evident conspiracy or unity of evil intent and purpose in the perpetration of an

offense. On the other hand, an accomplice is someone who knows the evil design of the principal

by induction, and agrees or concurs with the latter of his/her purpose, that the giving material ormoral aid, support, or assistance to facilitate the accomplishments of an offense.

Illustrative Example/Situation

Case 2:

The spouses H and W have been legally married for more than a decade, but not blestwith a child. They have had regular treatment in the clinic of Dr. X and Nurse Y. The conclusive

medical finding is: Low blood count of H is incurable. X and Y, knowing and feeling the great

desire and eagerness of the couple to have a child, suggested tubal or human insemination. Wprefers the latter option (human insemination) with the consent or approval of H, who even goes

his way to look for a partner who may have a carnal knowledge or act with his wife.

Analysis:

The principals, by induction, were Dr. C and Nurse Y because they induced their clients

to resort to evil means. The co-principal, by indispensable cooperation, was the spouse W whoconcurred with the means, and preferred to have carnal knowledge or sexual intercourse with a

man who is not her husband. The accomplice was spouse H who facilitated the

commission/accomplishment of the adulterous act of W.

Moreover, the foregoing case would not fall under the principle of double effect. The

action is neither morally good nor indifferent. It is evil: an immoral and criminal act. The good

effect: to have biological child, comes from or is a consequence of the evil effect. As a rule, it is


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not morally permissible to do evil in order that good may be derived from it. In this instant case,

the end will not justify the means.

The Principle of Solidarity

To be solid means to be firmly united. It follows that solidarity implies unity orfellowship, arising from common responsibility and interest. Sense of solidarity or unitycharacterizes quality standing of any profession like nursing. It relates to the ability of its

members to organize and standardize the professional values of competence, autonomy,

authority, and accountability. Toward this end, there arises the need for a cohesive professionalassociation to solidify harmonious fellowship or relationship of its members who work together

to meet the health care needs of society. With the principle of solidarity, one-for-all and all-for-

one policy is a tall order.

Ross Ethics (Mappes and De Grazia, 2002: 24-27)

W.D. Ross is an English philosopher. In his book entitled, The Right and Good(1930), heunderscores his concern to provide a justifiable account of cases of conscience, or ethical

situations confronting people with a pervasive conflict of duties. Which duty takes priority over

other pressing duties? To solve this dilemma and provide a defensible account of conflict-of-duty

situations, he deems it necessary to introduce the idea of prima facie duty. He, otherwise,intends to call it conditional duty, which is, on its face, prevailing until overcame or overridden

by a more impelling prima facie duty. The prima facie duties have no single basis, but arise or

sprung from several morally significant relations such as nurse-patient, physician-nurse,lawyer-client, employer-employee, promisor-promisee, and teacher-student relationship. Each of

these relationships is the basis or foundation of a prima facie duty. Where one is faced with two

or more competing prima facie duties, he/she has to make a reflective, considered decision and

come up with only one these duties. This binding duty is the actual duty.

Accordingly, Ross proposes seven (7) classifications or divisions of prima facie duties.

They are as presented in the table below:

Prima Facie Duties

Classifications/Divisions Description/Meaning Illustrative Examples

1. Duties of fidelity Fidelity is related tothe concept of

steadfast

faithfulness or

loyalty. The dutiesinclude keeping

promises, honoringcontracts and

agreements, and

telling the truth.They rest on the

persons previous

Professionalresponsibilities/social roles

of: Physician as

physician Nurse as nurse Teacher as teacher


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acts.

2. Duties of reparation Reparation is the actor fact of giving

satisfaction orcompensation for

wrong or injurydone. The duties

include rectifyingthe wrong

perpetrated,

returning the goods,wealth, or any

property stolen,

restoring the

reputation ofsomeone slandered,

and/or payingdamages for injuriessuffered.

A returns the cell phone andsays sorry to B, the victim

C admits cheating and

accepts punishment for the

same

3. Duties of gratitude Gratitude isthankfulness or a

desire to do a favor

in return. The dutiesrest upon previous

acts of another

person, and include

beneficial services

provided by them.The principle of

reciprocity applies

If one has provided qualityservice to others when they

are in need, the latter stand

under a duty to reciprocateservice for the former when

the same is in need.

4. Duties ofbeneficence

Beneficence is thepractice of doing

good, or an act ofkindness. The duties

include going or

searching out to theneedy and making a

difference in their

life.

To visit the sick, theprisoners, or the victims of

calamities

To share ones bounty tothe needy

5. Duties of non-maleficence

Non-maleficence isthe act of not doing

evil or injuring

harm to others. Theduty includes not to

make the condition

of others being

The duties of not to kill, toinflict corporal punishment,

to commit arson, and/or to

defraud others


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worse or difficult.

6. Duties of justice Justice connotes justconduct, fair

treatment, or givingand receiving what

one deserves. Theduties include

benefits based onmerits, and

rectifying unjust

patterns ofdistribution

If a nurse works eight (8)hours plus overtime, he/she

must receive the agreedlegal compensation plus

overtime pay. It is givingwhat is due him/her.

7. Duties of self-improvement

Include the duty tomake better onescharacter, mind, or

the like by his/her

own effort. TheDivine Provider

helps those who

help themselves, orthe sick gets well if

he/she cooperates

with the health careprovider

A nurse keeps on studyingthings related to his/herprofession, attends

capacity-building seminars,

and takes graduate studies.

Major Bioethical Principles

Appropriate identification, analysis, interpretation, and resolution of health problems orissues are made possible and facilitated by way of reference to relevant bioethical principles.Mappes and De Grazia (2002) suggested and came up with four major set of principles, namely:

1) The principle of respect for autonomy;2) The principle of non-maleficence;3) The principle of beneficence; and4) The principle of justice.

The Principle of Respect for Autonomy

Autonomy is one of the four basic principles under the ethics of respect for other people,the other three (3) of which are fidelity, veracity, and avoidance of killing. These latter aspectswere dealt on closely, but briefly under the Ross ethics. However, it is expedient to know the

nature of the ethics of respect for persons. It deals or focuses on actions such as right or wrong,

not based on the consequences they produce, but on their inherent content or form (formalism).Likewise, it considers certain behaviors or actions simply to be ones duty, regardless of the

consequences (deontology) (Veatch, 2007:65).


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The term autonomy comes from two Greek words autos, which means self, and

nomos, rule or governance, thus, the idea of self-rule, self-governance, or self-determination

applies or extends to individuals. The principle of respect for autonomy means acknowledgementof the persons right to hold views and opinions, to make decisions and choices, and to take

action based on personal values, virtues, traditions, and beliefs (Kuan, 2006:53). It implies

recognition of the individuals worth with the capacity to develop by oneself. It stresses the rightof an independent decision-maker to determine for himself/herself what will be done to his/herbody. As applied to health care service, this right of self-determination may limit what

physicians, nurses, and other health care providers can do to their patients. Thus, the principle

requires that health care professionals must not interfere with the effective exercise of patientautonomy (Mappes and De Grazia, 2002). This autonomy gives rise to the notion of informed

consent. Informed consent means that the patient is given the opportunity to autonomously

choose a course of action in regard to plans for health care. The choice includes the right to

refuse interventions or recommendations about care, and to choose from available therapeuticalternatives (Burkhardt and Nathaniel, 2002: 209).

The Principle of Non-Maleficence

Under the Ross ethics, the concept of non-maleficence was discussed briefly in relation to

duties. As a principle, it requires health care professionals to act in such a manner as to avoid

causing harm to patients. It includes deliberate harm, risk of harm, and other harms that mayhappen during the performance of beneficial acts. It prohibits experimental research that assumes

negative impact on participants, and the performance of unnecessary procedures for economic

gain or self-interest. The principle may also include the avoidance of harms as a consequence ofdoing good (Burkhardt and Nathaniel, 2002:50). The concept of non-maleficence may be

summed up by the quotations as follows:

Do not do to others what you would not wish done to yourself.

- Confucius Do not do to others that which would cause You pain if done to you.

- MahabharataThe Principle of Beneficence

The term beneficence comes from two Latin words bene, which means well orgood, and facere, to do or make. Thus, beneficence etymologically means doing what is

good. It implies the duty to actively do good for patients. It is associated with the concept or

virtues of kindness, benevolence, altruism, or humanitarianism. It is described as healing with

attention to the psychological, social, and spiritual dimensions of disease, injury, or physicalproblems (Ibid: 314). The principle of beneficence has three major components, namely: 1) do or

promote good, 2) prevent harm, and 3) remove evil or harm. When one does or promotes the

good, he/she is an agent of goodness, and an ambassador of goodwill. Prevention of harm is apro-active disposition. It implies planning and foresight of health care providers who take


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appropriate actions to safeguard and sustain their patients well-being. Removal of evil or harm

is a reactive disposition. It requires health care professionals to do all they can to restore or bring

back their patients good health.

Principle of Justice

The term justice is associated with the concepts of fairness, rightfulness, deservedreward or punishment, and equity. The principle requires that social benefits, like health care

services, and social burdens, like payment of taxes, be distributed in accordance with the

demands of justice (Mappes and De Grazia, 2002:28). It implies a sense of duty to treat allpeople without bias to age, socio-economic status, race, or gender. It applies community

extension of necessary treatment to all or to those in need, even though they may not have the

means to pay for such treatment (Burkhardt and Nathaniel, 2002:313). The principle of justice

may be concluded by the saying that goes:

Justice delayed is justice denied.

Its application and implication to health care profession in relation to the client or

patients well-being in Philippine context may be considered as the following:

Slow and delayed enactment and implementation of the Cheaper Medicine Act (R.A. No.9052) have denied the poor and the needy affordable medicines and aggravated their

plight to the extent of loss of life.

Sick people are denied access for quality treatment in private hospitals due to lack offinancial capacity to pay.

To massive out-flux of Filipino doctors nurses to foreign countries may deny necessaryhealth care services to patients.


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CHAPTER 6

ISSUES/CASES OF BIOETHICAL CONCERNS

This final chapter attempts to apply ethico-moral, spiritual, and legal concepts andprinciples to issues/cases that affect the health care providers, like the nurses, vis--vis patientswell being. In the practice of their profession, they face a concrete dilemma about what

appropriate actions to take. The topics herein to be presented are standard problem areas, among

others, in bioethics. These are:

1) Plastic Surgery;2) Organ Transplant and Donation;3) Sterilization;4) Abortion; and5) Euthanasia.

Plastic Surgery

Plastic/Cosmetic surgery is a branch of the science of surgery that focuses on the

reconstruction or repair of deformity, defect, or bodily injury, and/or improves the appearance orfunction of outer parts of the body. The surgery may entail the use of bone, cartilage, tendons,

and skin being taken from other parts of the body or applying artificial substitutes. However,

face lifting, which is the cosmetic removal of excess fat and tightening of the skin, is a delicateand often unsuccessful operation, and the same carries the added risk of infection (The New

Websters International Encyclopedia, 1996).

The legal and moral dimensions of surgical intervention may be anchored on theprinciples of totality, autonomy with patients complementary value of informed consent, and

double effect. In order for plastic/cosmetic surgery to become legally and morally permissible, it

has to comply with the following conditions:

The functional integrity of the human body must not be lessened, unless a sacrifice of anypart, through surgery, is an extreme necessity to preserve the health and life of the wholebody.

Both surgeon and patient must have good intention Surgeon must respect patients autonomy and obtain the latters informed consent The intent or motives must be reasonably higher than or proportionate to the

extraordinary means employed or allowed

Organ Transplantation and Donation

Organ transplantation involves the removal of a major or minor part of the human body

from one person, and then surgically implanted in another persons body to replace a lost or

diseased organ. This immediately preceding description implies an interplay between a giver andbeneficiary, or between a donor and a donee. This relation brings us to the idea of a donation. A


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donation is an act in which the owner of a thing voluntarily transfers the title and possession of

the same from himself/herself to another person, without any consideration. By the civil law,

donations are either intervivos (between living persons) or mortis causa (in anticipation ofdeath). The former is an act by which the donor diverts himself/herself, at present and

irrevocable, of the things given, in favor of the donee who accepts it. The latter is one which is

made in contemplation, fear, or peril of death, and with intent that it shall take effect only in caseof the death of the giver (Blacks Law Dictionary).

The moral dimension of organ transplantation involves three (3) major issues, namely:

1) The fundamental morality of transplanting body parts;2) The ethics of organ procurement; and3) The ethics of allocation (Veatch, 2003).The first moral issue tries to resolve whether transplantation is an intervention or tampering

with the humans basic nature in ways that go beyond what is morally acceptable of human

conduct. The issue revolves around the idea of human control of life. There are two contentionson the issue: the pessimistic and conservative view, and the optimistic and interventionistic

advocacy. The former view contends that medical manipulation is playing God, which role

goes beyond the primary purpose of medicine - to save life, cure diseases, and relieve suffering,

and that basic changes in the human species, or lessening the functional integrity of humancreation lead to bad and harmful biological effects, and that there are moral limits on how far

humans should go in using their knowledge of science to change their nature (Ibid,: 109-150).

On the otherhand, the optimistic view claims that mans use of medical science has improvedthe /situation. It speaks of human as a co-creator with a moral duty to user their knowledge of

science not only to combat diseases, but also to improve on nature. Along with this latter

objective, the proponents are concerned of the viability of intervention in genetics (Genetically

Modified Organisms, or GMO) and birth technology, such as artificial insemination andcontraception, in vitro fertilization (test tube baby), and cloning.

The second issue on organ procurement for transplant is much less controversial. Differentcountries vary in ways of obtaining the same. The several modes of procurement are:

1) A dead person is considered as State property, and it could be automatically taken andused for good social purposes;

2) Routine salvaging of organs of the dead in the absence of explicit objection; and3) Donation with consent of the person from whom the corpse is taken (Ibid: 137).The third and final issue is on organ allocation. There are two (2) principles that may govern

acceptable allocation, namely: 1) principle of social utility, and 2) principle of issue. The social

utility principle is the natural consequence of the application of beneficence and non-maleficence.

The principle takes into consideration all benefits and harms to all parties. Its goal is the greatestaggregate good. It employs the standard measurement of cost benefit analysis to determine

potential benefits and potential costs of alternative uses of resources. This principle is the basis

for allocation: to give the organs to the patients who would benefit most. On the other hand, theprinciple of justice applies when allocation of resources, like organs on the basis of social utility,


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are not morally satisfactory. It demands that people in similar situations should be treated equally

on the basis of needs-based justice. Priority application of either principle in terms of organ

allocation determines practical matters, like who has a better right to live more, and who has toaccept the reality of death for lack of resources.

Sterilization

Sterilization is a surgical procedure designed to prevent conception. It is a medical

interventions, which makes a client or a patient incapable of reproduction. In females, the

fallopian tubes are cut and tied to prevent eggs from reaching the womb, thus, providingpermanent contraception. The methods employed includes:

1) Ophorectomy (complete removal of the ovary, which manufactures germinal cells)2) Salpingectomy (removal of salpinx of eustachean tube or fallopian tube)3) Hysterectomy (removal of uterus)In males, sterilization may be achieved by:

1) Castration (removal of testicle)2) Emasculation (removal of reproductive glands)3) Vasectomy (the vas deferens on each side is tied off and cut to prevent sperm cells from

reaching the seminal vesicles)

Sterilization may be indirect or direct. The former is the outcome of a therapeuticintervention on a diseased part of the human body. The removal of which, cure the same and

serve the whole organism. The intervention is anchored on the principle of totality. Therefore, it

is morally licit and permissible to perform indirect sterilization. On the other hand, the direct

sterilization makes procreation not possible. It includes eugenic and contraceptive or preventivesterilization. Eugenic sterilization is done to avoid the birth of a defective or diseased offspring,

geared towards the improvement of human race. Preventive sterilization suppresses ovulation to

avoid risk of getting pregnant, which pregnancy may aggravate a disease of a woman. The twoimmediately preceding methods are all morally illicit because they lessen the functional integrity

of the human body when such methods do not preserve the health and life of the total well-being

(Padilla, 2005). In a word, direct sterilization disables a woman from procreating. Moral liabilitymay fall upon the implementers, as well as policy-makers under the principle of command

responsibility in the promotion of the use of contraceptive pills and surgical sterilization to

control population growth. Such course of action by these policy-makers and those who

implement is tantamount to silent abortion for which they are solidarily answerable.

Abortion

Abortion is the premature expulsion of fetus or child prior to normal birth. It is either byspontaneous or by induced termination. The former is a miscarriage, that is the fetus or baby is

born before it is able to live. The latter implies knowing the destruction of the life of an unborn

child, or the intentional expulsion or removal of the same from the womb, other than for theprincipal purpose of producing a live birth or removing a dead fetus (Blacks Law Dictionary). A


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physician and a nurse, or midwife, are criminally liable for causing an abortion or assisting in

causing the same by taking advantage of their scientific knowledge and skills. However, if the

abortion is done to save the life of the mother, there is no criminal liability. This is known as

therapeutic abortion. But abortion, without medical necessity to warrant, is legally and morally

punishable, even with the consent of the woman or her husband.

There is a wide range of potential reasons for the phenomenon of abortion. Amongothers, these reasons are: (Mappes and De Grazia, 2002)

If the fetus is allowed to develop normally and come to term, the pregnant woman herselfwill die;

It is not the womans life, but her health, physical or mental, that will be severelyendangered, if the pregnancy is allowed to continue;

The pregnancy will probably or surely produce a severely impaired child;

Pregnancy is an outcome of rape or incest.

The pregnant woman is unmarried, and there will be the social stigma of illegitimacy;

Having a child or another child will be an unbearable financial burden; andHaving a child will interfere with the happiness of the woman, the joint happiness of thecouple, or the family as a unit.

The Pros and Cons of Abortion: Their Moral Dimensions

The abortion issues involves two opposing camps that divergent positions: the Pro-lifeversus the Pro-choice.

The Pro-life position is anti-abortion. It resolves that abortion is illegal and immoral,

based, among others, on the following grounds:

Human life begins at conception;

Sanctity or value of life: the unborn child has all the rights as a human person;

Abortion starts the domino effect, ending in complete disregard for the value of humanlife;

Abortive methods are medically and psychologically dangerous to the womans life and

procreativity;

Dangers in pregnancy are relatively safe due to the advances of medical science;

Economic reasons are irrelevant and unacceptable; and

Viable options to abortion for unwanted babies due to deformity, born out wedlock, orarising from rape and incest.

Under the foregoing premises, proponents of Pro-life, conclusively hold that abortion isan illegal and immoral act. It constitutes murder of an unborn, innocent, and helpless person.

Because this person possess humanity, he/she must be accorded all human rights, such as the

right to life and live.

One the other hand, the Pro-choice position is for abortion. It resolves that abortion is

legal and moral based on reasonable grounds. Among these grounds are:


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Womans autonomy: she has an absolute right over her own body, and she should not beforced to bear a child that she does not want;

Human life begins at birth: Actual birth determines the existence of life. If the fetus isstill within the womans body, it is, therefore, part of her body, and is subject to her free

choice to give life or take it away from the unborn;

Problem of unwanted or deformed child. Only really wanted children must be born;otherwise the unwanted add to the problems of over population, pollution and economics,

and the same becomes a burden to society;

Abortion is relatively safe. The availability of qualified medical personnels (physician,nurse, or midwife) guarantee safe performance and minimal danger;

Domino effect argument is not tenable. Abortion will not enhance loss of reverence forhuman life in any other areas. Instead, the experience of abortion makes woman more

loving of their wanted children; and

Pregnancy poses danger to the mothers life. In a situation where the mother and childslife are both in danger, that of the mother takes precedence or priority, over that of the

child. Thus, abortion is permissible to save a womans life.

Under the foregoing grounds, advocates of Pro-choice conclusively hold that abortion is a

legal and moral act. It is an absolute right to privacy regarding health care decisions like a

womans reproductive choice. Therefore, any form of intervention is a violation or infringement

on this privacy.

Euthanasia

The term euthanasia comes from two Greek words eu, which means good and

thanatus, which means death, or a good death. It implies mercy killing. It applies to a

practice of hastening or causing the death of a person suffering from an incurable disease, as an

act of mercy. It is a painless killing to end ones life as a matter of right. It is allowing someoneto die in an easy death, without using medical science and technologies to keep him/her alive.

Under the foregoing definitions, there are three key concepts or phrases that needdistinction, namely:

1) Mercy killing2) Mercy death3) Allowing someone to die,

Mercy killing is the involuntary or unintentional termination of the life of a patient by

someone. It does not require his/her permission or request. On the contrary, mercy death meanssomeone takes direct action to terminate a patients life upon his/her request. It is an assisted

suicide or murder. Allowing someone to die implies withdrawal of treatment, and acceptance of

the fact that the patients illness has reached a point where and when no cure is possible, orfurther curative treatment has no useful purpose. In this situation, he/she should be allowed to die

a natural death in comfort, peace, and dignity (Padilla, 2005:142-143).


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The above-cited concepts or phrases may be classified into active and passive

euthanasia. The active euthanasia is intentional and voluntary. It is an act in which the

physician, nurse, or other health care providers not only provide the means of death, but alsoadminister it. Passive euthanasia is an act in which the patients receive the means of death from

the physician or nurse, but activate the process themselves. Proponents of the latter process

invoke respect for the patients autonomy in choosing to end his/her life. Proponents to theformer process invoke sanctity or value of life. Proponents to the former process invoke sanctityor value of life, and such act violates the mandate not to kill human beings (Burkhardt and

Nathaniel, 2002:225).

bioethics chapter3

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