UNIT 2A: SEXUALITY and HUMAN Gutenberg University of Mainz,

REPRODUCTION Germany.
TOPICS:
What is Human Sexuality?
1. WHAT IS HUMAN SEXUALITY?
2. MARRIAGE
• Fundamentals of Marriage  Sexuality is an integral part of being
• Issues on Sex Outside Marriage and human. It begins before birth and lasts
Homosexuality until the end of life.
• Issues on Contraception, its Morality,
& Ethico-Moral Responsibility of  Sexuality is essential to the continued
Nurses existence of humanity.
3. ISSUES ON ARTIFICIAL REPRODUCTION, ITS  Sexuality is not just about the process of
MORALITY, AND ETHICO MORAL RESPONSIBILITY OF
NURSES reproduction. Its objective meaning is
• Assisted Reproduction Technologies not mainly biological, but existential.
(ART)
 Its value does not flow from the
• Artificial Insemination
• In Vitro Fertilization biological order; it springs forth from the
• Surrogate Motherhood order of existence.
4. MORALITY OF ABORTION, RAPE AND OTHER
PROBLEMS RELATED TO DESTRUCTION OF LIFE. The Personal Values of Sexuality and of the
What are Contemporary definitions of Transmission of Human Life∗ by Angel R. Luno
Sexuality?
Biologically, sexuality is Psychologically, sexuality
defined as an aggregate is the behavior directly  Sexuality opens the possibility of a unique
of characteristics that associated with the new embodiment of human love. From the
differentiates between meeting of the two ethical standpoint, it can be said that this
the two types or parts of genders - and in some
fact meets a true necessity. Things cannot
the organism which species with copulation
reproduce by means of which can lead to be otherwise, in as much as the sexual
the fusion of gametes and fertilization (Broadhurst, activity represents a point of encounter not
which thus also create a 1980). between two sexes, but between two
connection of genetic
people of the opposite sex, and in the face
material from two
different sources. of the person the only right attitude is love.
(Zimmerman, 2011) The person can never be utilized as a pure
means for achieving a purpose: be this
 From Zimmermann, R. (2011). pleasure, procreation, or anything else. God
Marriage, sexuality, and holiness: is love. Being that God created man in His
aspects of marital ethics in the Corpus image and likeness, man has been created
Paulinum. Acta Theologica, 31(2), 363-
out of love and is destined to love.
393.
 Whether you find yourself agreeing with it
 Zimmerman- a German Theologian, or not, you owe it to yourself to at least be
New Testament Scholar and Ethicist, aware of this alternative vision. And you
currently Professor at the Johannes may be surprised to discover that the

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 biblical picture of sex isn’t a narrow view
calculated to restrict, but rather, actually,
it’s a larger view calculated for maximum
liberation and increased pleasure.
According to Rev. Angel Rodríguez Luño:
Spanish Priest, Professor and Author of several
books
 The relationship between human sexuality
and the divine work of Creation is
understood from a few basic ideas.
 Man is the only creature that God willed for
its own sake.
 This implies that the person who comes into
existence is immediately conceived of and
willed by God, who creates through His
Wisdom and Love, and not because of the
need of a triggered cosmic instinct.
 Thus, no person is the fruit, casual or
necessary, of a mere biological mechanism.
There is a projection and divine decision in
the origin of each rational being.
Ethical Consequence of Human Sexuality
Moral principles derived from the anthropological
and axiological structure of sexuality are basically
two:
1. Sexual activity is ethically valuable when it
is performed within the context of
marriage. The criterion of ethical
rationality is contradicted when:
a. it takes place outside of marriage
or
b. against marriage (adultery).
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2. Any exercise of sexuality in the context of
marriage must respect the ethical inseparability
between its two aspects:
interpersonal openness to potential
communion of the procreation.
spouses
 Men and women exercise sexual activity
freely and responsibly.
 Sexual activity is valuable in itself if they
remain bound to conjugal love.
 Sexuality is ordered toward life, but also
toward love.
NOTE: Whether you find yourself agreeing with it
or not, you owe it to yourself to at least be aware
of this alternative vision. And you may be surprised
to discover that the biblical picture of sex isn’t a
narrow view calculated to restrict, but rather,
actually, it’s a larger view calculated for maximum
liberation and increased pleasure
• Choosing a Partner/ Dating - Timeless truth
from the Garden Wedding
Genesis 2:18-23 -New International Version (NIV)
18
The Lord God said, “It is not good for the man to
be alone. I will make a helper suitable for him.”
19
Now the Lord God had formed out of the ground
all the wild animals and all the birds in the sky. He
brought them to the man to see what he would
name them; and whatever the man called each
living creature, that was its name.
20
So the man gave names to all the livestock, the
birds in the sky and all the wild animals.
But for Adam[a] no suitable helper was found.
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21
So the Lord God caused the man to fall into a
deep sleep; and while he was sleeping, he took one
of the man’s ribs[b] and then closed up the place
with flesh.
22
Then the Lord God made a woman from the rib [c]
he had taken out of the man, and he brought her
to the man.
23
The man said, “This is now bone of my bones and
flesh of my flesh; she shall be called ‘woman,’ for
she was taken out of man.”
 First Things First:
Adam first met his Master,
then God gave him his Mission and
only then did God gave him his Mate.
– Not many people have reversed that
sequence without experiencing undesirable
consequences
 God’s provision for Adam’s Needs
– Be still and WAIT…
Marriage
 is the first holy relationship that God
ordained.
 the lifelong union of a man and a woman is
holy because it symbolizes in human form
the unseverable love of Christ for his bride,
the church.
 TO TAMPER with the relationship is to
MEDDLE WITH GOD’S ORIGINAL DESIGN.
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4 inviolable marriage principle:
1. a man shall leave his father and mother ---
SEVERANCE- act of separation
2. and shall cleave to his wife --- PERMANENCE
3. and they shall become one flesh --- UNITY
4. & the man & the woman were both naked &
were not ashamed --- INTIMACY
Some differences between men and women
overlap- those differences are real but not rigid.
How will you recognize real love?
• Real love is a response to the total person
– Eros = “I love you IF …
(you do such and such to please
me)”
– Phileo = “I love you BECAUSE …
(of some particular trait)”
– Agape = “I love you IN SPITE OF …
(the weaknesses I see in you)”
Consider sex as a present from God marked.
“For greatest enjoyment, do not open until
marriage”
 Sex prevents other aspects of love from
developing. Sensuality hinders sensitivity
 Premarital sex injects fear and guilt into the
relationship
– “Marriage should be honored by all,
and the marriage bed be kept pure,
for God will judge the adulterer and
the sexually immoral” – Heb. 13:4
 Lays foundation of mistrust and lack of
respect
 It causes you to compare one person with
others
 It deceives you into thinking you’re in love
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 – Real love stands the test of time; It’s
strong enough to stand alone
without the support of physical
intimacy
 Among Christians, dating is a contract. God
makes us responsible for keeping his image
in the life of another person untarnished. So
far as we are able, we must preserve the
other person’s values and sense of dignity.

The Holy Scriptures Speaks about Love,

Marriage & Sex!

(Proverbs 30:18-19 KJV)

18
There be three things which are too wonderful
for me, yea, four which I know not: 19 The way of
an eagle in the air; the way of a serpent upon a
rock; the way of a ship in the midst of the sea; and
the way of a man with a maid.

Rights and Obligations between Husband and

wife According to EO 209, Family Code of the
Philippines

• Art. 68. The husband and wife are

obliged to live together, observe mutual
love, respect and fidelity, and render
mutual help and support. (109a)
• Art. 69. The husband and wife shall fix
the family domicile. In case of
disagreement, the court shall decide.
• The court may exempt one spouse from
living with the other if the latter should
live abroad or there are other valid and
compelling reasons for the exemption.
However, such exemption shall not
apply if the same is not compatible with
the solidarity of the family. (110a)

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UNIT 2B: DIGNITY IN DEATH AND DYING
TOPICS
• Euthanasia and Prolongation of Life
• Inviolability of Human Life
• Euthanasia and Suicide
• Dysthanasia
• Orthothanasia
• Administration of Drugs to the Dying
• Advance Directives
• DNR or End of Life Care Plan
EUTHANASIA AND PROLONGATION OF LIFE
WHAT IS EUTHANASIA - Greek Word: euthanatos –
means easy death or good death
- painless inducement of quick death
(Ethics of Health Care by Edge & Groves)
- Euthanasia is the termination of a very sick person's
life in order to relieve them of their suffering. A person
who undergoes euthanasia usually has an incurable
condition. But there are other instances where some
people want their life to be ended.
- In many cases, it is carried out at the person's request
but there are times when they may be too ill and the
decision is made by relatives, medical doctors or, in
some instances, the courts.
- The Netherlands and Belgium permit euthanasia
performed by a doctor, and define it as the act,
undertaken by a third party, which intentionally ends a
person's life at his or her request. This means that
physicians no longer face prosecution for carrying out
mercy killings if they are performed with due care under
established guidelines.
1. passive euthanasia – which involves doing nothing to
preserve life
2. active euthanasia – which requires actions that
speeds the process of dying.
a. voluntary euthanasia – the process is
initiated by patient request
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b. Involuntary euthanasia – implemented
without patient permission, ignores the patient’s
autonomous rights which could bring about the death
of an unwilling victim.
GUIDELINES FOR EUTHANASIA
a. The patient must request the assistance freely and
frequently, after careful consideration.
b. The physician may act on the request only if the
patient is terminally ill, with no hope of improvement
and in severe pain.
c. The physician must consult with another physician
and file a report with the coroner.
- The Oregon (USA) Death with Dignity Act attempts to
ensure that abuse does not occur in Physician assisted
Euthanasia. The law requires that the patient:
 Be a capable adult
 Is an Oregon resident
 Have a terminal illness
 Voluntarily requests a prescription for a
lethal drug orally and in writing,
witnessed by two individuals (not the
physician, nor a relative, nor an heir,
nor works in the facility where the
patient is receiving care)
The Physicians responsibility include:
 Determines that the patient has a
terminal illness, is capable, and has
made the request voluntarily
 Provide information to the patient
regarding the diagnoses, prognoses,
risks, & probable results of taking the
medication as well as other feasible
alternatives such as palliative care,
hospice care, and pain control.
The Physicians Responsibility Include:
 Refer the patient to a consulting
physician to confirm diagnosis,
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 prognosis, and for a secondary
confirmation that the patient is capable
and acting voluntarily.
 Refer the patient to counselling if there
is any indication of mental disorder
 Request that the patient notify his next
of kin of his decision (compliance not
required
 Offer to the patient the opportunity to
rescind the request at any time
 Complete all appropriate
documentation and reports as required
by law.
THE ETHICS OF EUTHANASIA
Euthanasia raises a number of agonizing moral
dilemmas:
 is it ever right to end the life of a terminally ill
patient who is undergoing severe pain and
suffering?
 under what circumstances can euthanasia be
justifiable, if at all?
 is there a moral difference between killing
someone and letting them die?
 should human beings have the right to decide
on issues of life and death?
*There are also a number of arguments based on
practical issues.
*Some people think that euthanasia shouldn't be
allowed, even if it was morally right, because it could be
abused and used as a cover for murder.
At the heart of these arguments are the different
ideas that people have about the meaning and
value of human existence.
- Existence is the state of being alive or being
real. ... The noun existence can be used many different
ways, but it always has to do with being alive or with
simply "being". (vocabulary.com)
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- Every human being has priceless value and
unlimited potential regardless of the circumstances of
their conception. The word human denotes something
so unique and so valuable that it is reserved for only
one species: homo sapiens. In the created
order, humans stand alone as the crowning expression
of our Creator (humancoalition.org, 2016)
Psalm 139:13-16 ESV
For you formed my inward parts; you knitted me
together in my mother's womb. I praise you, for I am
fearfully and wonderfully made. Wonderful are your
works; my soul knows it very well. My frame was not
hidden from you, when I was being made in secret,
intricately woven in the depths of the earth. Your eyes
saw my unformed substance; in your book were
written, every one of them, the days that were formed
for me, when as yet there was none of them
The ethics of euthanasia By Ethicist Arthur Dyck
1. An individual’s life belongs to that individual
to dispose of entirely as he or she wishes;
2. The dignity that attaches to the personhood
by reason of the freedom to make choices demands
also the freedom to take one’s own life;
3. There is such a thing as life not worth living
whether the cause be distress, illness, physical mental
handicaps, or even sheer despair for whatever reason;
4. What is supreme in value is the human
dignity that resides in the human’s rational capacity to
choose and control life and death.
Why people want Euthanasia?
1. Most people think unbearable pain is the main
reason people seek euthanasia, but some
surveys in the USA and the Netherlands showed
that less than a third of requests for euthanasia
were because of severe pain.
2. Terminally ill people can have their quality of
life severely damaged by physical conditions
such as incontinence, nausea and vomiting,
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 breathlessness, paralysis and difficulty in
swallowing.
3. Psychological factors that cause people to think
of euthanasia include depression, fearing loss of
control or dignity, feeling a burden, or dislike of
being dependent.
Opponents of Active Euthanasia
1. On religious grounds: Life is a gift from God, it is a
trust, we are bound to hold not only the lives of others
inviolate but also our own, since to take our life is to
destroy what belongs to God.
2. Nonreligious argument: Once allowed even with
some guidelines or prohibition will open more
problems. Is there something so persuasive about
putting others to death, that if allowed, would become
gross and commonplace?
 Lack of availability especially in the
Philippines
 § Comes in a variety of forms:
 § Community volunteer programs
 § Home Services
 § In-hospital palliative care unit
 § In-hospital hospice teams
The Hospice Alternative
- A place of rest for the weary traveler, the
concept in modern times is to offer rest and
comfort (old definition)
- Program to provide:
o Palliative care to relieve pain and
suffering rival the intensity of curative
efforts found in acute care settings.
o Basic philosophy is that dying is a
natural part of life
o Abatement of pain
o Provide an environment that
encourages dignity
o Does not cure or treat intensively
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PROLONGATION OF LIFE
-Medical care to prolong life can keep one alive when
organs stop working well. The treatments extend life,
but do not cure illness. These are called life-sustaining
treatments.
-Among the most poignant of the questions that often
have to be answered is whether a patient on the brink
of death should be allowed to die then and there, or
whether measures should be taken to keep him alive a
little longer even when there is no hope of recovery.
Replacement of Disabled Vital Organs
- What if medical science should learn how to replace
vital organs, or at least to provide them with “spare
parts”?
This is the most exciting and controversy-provoking
area of medical research today. Two routes to
replacement of vital organs or organ parts are being
followed:
1. Development of mechanical gadgets to take over
functions of a disabled human organ and
2. Implantation of a healthy organ or body part from
another creature—animal or human—into the patient's
body.
Advances in ‘Spare part’ Surgery on the Heart
- Striking successes already have been achieved in
providing man-made replacements for parts of the most
vital of all organs: the heart. (Dr. Michale DeBakey)
a. “The use of artificial arteries fabricated from plastic
materials for the replacement of diseased arteries is
now commonplace,”
b. “Similarly the replacement of diseased and poorly
functioning' heart valves by artificial valves is being
employed daily in most medical centers.”
c. The major advance expected next is the artificial
heart itself
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Supply of Life-Saving Artificial Kidneys
Advances in medical treatment of this kind always entail
difficult decisions on choice of patients.
When a procedure has been proved reasonably safe
and beneficial but treatment facilities are scarce, as in
the case of the artificial kidney, the tendency is to select
patients who are in the prime of life and who have no
serious complicating disease, those with the best
prospects for living out a normal span if the disability to
be treated is overcome.
Questions to Answer in Prolongation of Life
 What if replacement of vital organs prolongs
the life of an individual but at the same time
debases the quality of that life?
 What if a life-saving procedure is so demanding
of specialist manpower and so costly that it is
available only to the well-to-do?
 Then there is the question of how many months
or years of life are worth the cost of certain
treatments in terms not only of money but also
of human suffering, of the use of medical
manpower, and of the effects on society.
 Doctors always have had to balance hoped-for
benefits against possible harm from particular
medical or surgical procedures. Drastic new
forms of surgery and the proliferation of new
drugs with known and unknown side-effects
now have vastly multiplied and complicated the
doctors' dilemmas.
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Dr. Michael E. DeBakey, pioneer in artificial heart
development asks these questions if and when an
artificial heart is developed and made available:
 Should this life-saving device be made
available to every patient, even the
hopeless victim of stroke, cancer, or
senility?
 Or should an unbending and restrictive
criterion for use be outlined?
 Why and how does one determine
death due to other causes?
 And who decides when to terminate
the power flow in such cases?
A British physician, Sir George W. Pickering of Oxford
University - said it was time for the medical profession
to consider revising its unquestioned goal of
preserving life. He warned that medical science may be
able some-day to replace all vital organs except one:
the human brain. Accordingly, the time may come
when “those with senile brains and senile behavior
will form an ever-increasing fraction of the inhabitants
of the earth.”
Hebrews 9:27 ESV - And just as it is appointed for man
to die once, and after that comes judgment,
Life-sustaining Treatments
Treatments to extend life can include the use of
machines. This equipment does the work of the body
organ, such as:
 A machine to help with breathing
(ventilator)
 A machine to help kidneys (dialysis)
 A tube into the stomach to provide food
(nasogastric or gastrostomy tube)
 A tube into the vein to provide fluids
and medicines (intravenous, IV tube)
 A tube or mask to supply oxygen
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Things to consider in Prolongation of Life
 Life-sustaining treatment is likely to be
expensive. It may consume a patient's life
savings, deny him his desire to make a modest
bequest, saddle a burdensome debt on
survivors. It may leave a lonely widow penniless
or deprive minor children of necessities.
 Both clergymen and physicians have approved
consideration of the financial angle in such
cases. Defining the term “extraordinary
measures” which need not be taken to hold off
death, a Jesuit priest said they would include
those which are too costly in money, time and
effort, relative to the patient's condition and
“what is left of life's potential.”
TOPIC NO.2 INVIOLABILITY OF HUMAN LIFE
Genesis 2:7 ESV
Then the Lord God formed the man of dust from the
ground and breathed into his nostrils the breath of life,
and the man became a living creature.
Human life at any stage of development, from the
moment of conception until its natural decline, must be
respected and protected. Inviolability means that no life
can be directly killed. Since life is the most precious gift
of God and it is sacred, it is inviolable. No one can
directly dispose of an innocent human life and justify it.
"Thou shalt not kill," our Blessed Lord commands.
The Sanctity of Life Date: by David P. Gushee
The concept of the sanctity of life is the belief that all
human beings, at any and every stage of life, in any and
every state of consciousness or self-awareness, of any
and every race, color, ethnicity, level of intelligence,
religion, language, gender, character, behavior, physical
ability/disability, potential, class, social status, etc., of
any and every particular quality of relationship to the
viewing subject, are to be perceived as persons of equal
and immeasurable worth and of inviolable dignity and
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therefore must be treated in a manner commensurate
with this moral status.
This concept of the inviolability of life by David Gushee
can be explained in four points and they are:
1. First, the sanctity of life is a concept that one
believes in. It is, in other words, a moral
conviction.
2. Second, it is a moral conviction about how
human beings are to be perceived and treated.
Belief in the sanctity of life prescribes a certain
way of looking at the world, in particular its
human inhabitants (with implications for its
non-human inhabitants). Related to how human
beings are to be treated.
3. The third thing to notice about this definition
is its universality. Rightly understood, the sanctity of life
is among the broadest and most inclusive
understandings possible of our moral obligations to
other human beings.
4. All human beings are included (each and
every human being), at all stages of existence, with
every quality of experience, reflecting every type of
human diversity, and encompassing every possible
quality of relationship to the person who does the
perceiving. This means that each of these human beings
has a value that transcends all human capacity to count
or measure, which confers upon them an elevated
status that must not be dishonored or degraded.
-The Inviolability of Life view is that intentional killing is
not ethical and should not be legally permissible, yet
that it is often acceptable to withdraw life support. Even
if a particular medical treatment is worthless, the
human patient is never worthless.
-The Inviolability of Life principle allows that if some
treatment is more burdensome than beneficial, it may
be withheld or withdrawn, even if the patient’s life is
shortened as a side effect.
Ethical Implications: Kaczor, 2015
(https://www.thepublicdiscourse.com/2015/01/14129
/)
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  If terminally ill patients with six months to live
may receive help in dying, why should a person
with longer to suffer be denied similar
assistance?
 If killing benefits a patient, why deny this
benefit to the disabled, who are unable to
commit suicide?
 In practice, even modest limits on physician-
assisted suicide are frequently ignored and
cannot serve as adequate defense of the
vulnerable.
 Even aside from undiagnosed depression, if
assisted suicide is legal, how many competent
adults nearing the end of life would be
pressured into ending their lives to avoid being
“selfish”?
 Scholars in medical law such as Bernard Dickens
argue:
 that assisting in suicide, abortion, and
euthanasia are core practices in the
medical profession and
 that a failure to perform these services
violates the rights of autonomy of
patients.
In this view, health care professionals do not have the
ethical or legal right to conscientiously reject anti-life
practices. If such arguments prevail in law, then health
care professionals will be faced with momentous
decisions:
 either act against the
inviolability of human life or
 leave the medical profession.
o Bernard Dickens is Professor Emeritus
of Health Law and Policy in the Faculty
of Law, Faculty of Medicine and the
Joint Centre for Bioethics at the
University of Toronto. He has been a
consultant to the World Health
Organization and Council for
International Organizations of Medical
Sciences
 Such a choice would drive many people
of faith out of the health care
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profession or into a schizophrenic
division between their practice of
medicine and their practice of faith.
 Forcing such a choice would also
burden many non-religious people of
good will who hold that all human
beings are equal, endowed with
inalienable rights.
TOPIC NO. 3. EUTHANASIA AND SUICIDE
 It is important to differentiate between
killing (involuntary euthanasia) and
suicide.
 Suicide (from Tom Beauchamp co-
author of The Principles of Biomedical
Ethics) offers a precise definition of
suicide that separates it from the
process of passive or active euthanasia.
Suicide differs from Euthanasia in that
the health care provider does not
participate in the act of bringing about
death.
A person has committed suicide when:
1. That person brings about his or her own
death.
2. Others do not coerce him or her to do the
action; and
3. Death is caused by conditions arranged by
the person for the purpose of bringing about his or her
own death.
Death
• Psychological death occurs when the person
begins to accept their death and to withdraw
from others psychologically. They may be less
interested in normal activities, world events,
and social relationships. This can occur much
sooner than biological death.
• Biological Death versus Clinical Death. ... The
first stage is called Clinical Death. Clinical
death is not necessarily permanent. An
individual's brain can stay alive for about 4-6
10
 minutes after breathing and heartbeat have
stopped.
- It is a practice that aims to extend the life of
terminal patients, but subjects them to much
suffering.
Scripturally may be simply defined as the termination
of life. It is represented under a variety of aspects in  This practice does not extend life; it
Scripture: rather extends the dying process.

1. "The dust shall return to the earth as it was"  The advancement of science and its
(Eccl 12:7 ). implementation oftentimes
compromises the quality of life of
2. "Thou takest away their breath, they die" people who suffer, affecting their
dignity.
( Psalms 104:29 ).
- Sometimes it is the family that facilitates
Dysthanasia, when:
Death is the permanent cessation of all biological
a. the family members do not accept the condition
functions that sustain a living organism. Phenomena
of the patient and
which commonly bring about death include:
b. insist on continuing treatment when the
o aging, o homicide,
healthcare providers have already explained the
o predation, o starvation,
futility of treatment
o malnutrition, o dehydration,
o disease, o and accidents
o suicide, o or major trauma
resulting in Topic no. 5. ORTHOTHANASIA
terminal injury.
 Orthothanasia means death at the right time,
neither disproportionately abbreviating nor
extending the dying process.
The Whole brain approach: According to this view,
when the entire brain is nonfunctional but  Orthothanasia is a more positive dimension of
cardiopulmonary function continues due to a respirator the right to die and consists of dying humanely,
and perhaps other life-supports, the mechanical peacefully, an ideal death. It is the process of
assistance presents a false appearance of life, the humanization of death and alleviation of
concealing the absence of integrated functioning in the pain, but it does not abusively prolong death
organism as a whole. with the implementation of futile treatment,
which would cause more suffering to terminal
patients.

Topic no. 4: DYSTHANASIA  Orthothanasia is the practice of not avoiding

patients' death, rather it ceases investments
o it is translated as "difficult or painful death, that extend life.

o used to indicate the extension of the dying

process through treatment that only prolongs
patients' biological life. - Orthothanasia is not applied to cases limited to
intense suffering of any nature, whether it is
o It has neither quality of life nor dignity. pain or discomfort.

o It can also be called “Therapeutic Obstination". o It means suspending measures only

(Bioethics Dictionary) related to the concept of therapeutic

11
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 obstination, focusing on the
maintenance of well-being and taking
necessary measures to meet this goal.
- Nurses play a vital role in implementing
Orthothanasia when they give:
o priority to comfort and pain relief in a
calm and pleasant environment aiming
at quality of life,
o the most positive dimension of the right
to die,
o not abusively extending the process
through high-end technology, but
rather, interaction between teams.
- The initiation or continuation of medical actions
that have no other aim but to prolong the
patient’s life when the patient is facing
irreversible death.
- To insist on prolonging merely biological human
life at all costs is a serious assault on a person’s
dignity.
- Not everything that is technically possible is
ethically admissible, and unjustified
disproportionality, beyond what is medically
reasonable, only prolongs the agony.
- The appropriate individual and social approach
to death avoids the performance of futile
therapeutic measures, and supports limitation
of therapeutic effort and proportionality based
on palliative care. Iglesias Lepine M., Echarte
Pazos J. Medical and nursing care for patients
expected to die in the Emergency Department.
Emergencias 2007; 19: 201-210.
TOPIC NO. 6. ADMINISTERING DRUGS TO
THE DYING
(NICE Guideline Care of the Dying Adult 2015)
 When it is recognized that a person may be
entering the last days of life, review their
current medication and, after discussion and
agreement with the dying person and those
important to them, stop any previously
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prescribed medicines that are not providing
symptomatic benefit or may cause harm.
 When involving the dying person and those
important to them in making decisions about
symptom control in the last days of life:
o Use the dying person’s individualized
care plan to help decide which
medicines are clinically appropriate for
the individual when managing
symptoms in the last days of life.
o Discuss the benefits and harms of any
medicines offered
 NICE is National Institute for Health and Care
Excellence from the UK the guideline covers the
clinical care of adults (18 years and over) who
are dying during the last 2 to 3 days of life. It
aims to improve end of life care for people in
their last days of life by communicating
respectfully and involving them, and the people
important to them, in decisions and by
maintaining their comfort and dignity.
 When considering medications for symptom
control, take into account:
o the dying person’s preferences
alongside the benefits and harms of the
medication
o any individual or cultural views that
might affect their choice
o any other medicines being taken to
manage symptoms
o any risks of the medication that could
affect prescribing decisions, for
example prescribing cyclizine to
manage nausea and vomiting may
exacerbate heart failure.
 Decide on the most effective route for
administering medicines in the last days of life
tailored to the dying person’s condition, their
ability to swallow safely and their preferences.
 Consider prescribing different routes of
administering medication if the dying person is
unable to take or tolerate oral medication.
Avoid giving intramuscular injections and give
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 subcutaneous or intravenous injections as
appropriate for the setting.
 Consider using a syringe pump to deliver
medications for continuous symptom control if
more than 2 or 3 doses of any ‘as required’
medication is needed within 24 hours.
 For people starting treatment who have not
previously been given medications for symptom
management, start with the lowest effective
dose and titrate as clinically indicated.
 The management of pain in the last days of life
should follow principles of pain management
used at other times, for example:
• matching the medication to the severity
of pain and
• following the dying person’s preferred
route of administration.
 Ensure that plans are in place for regular
reassessment, at least daily, of the dying
person’s symptoms during treatment to inform
appropriate titration of medication.
TOPIC NO. 7 ADVANCE DIRECTIVES
(Health Care Ethics: Edge and Groves)
- a written statement of a person's wishes
regarding medical treatment, often including a
living will, made to ensure those wishes are
carried out should the person be unable to
communicate them to a doctor.
- are legal documents that allow one to spell out
decisions about end-of-life care ahead of time.
They give a way to tell one’s wishes to family,
friends, and health care professionals and to
avoid confusion later on.
- A medical or health care power of attorney is
a type of advance directive in which a person is
appointed to make decisions when unable to do
so.
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- There are two main types of advance
directive —
o the “Living Will” and
o the “Durable Power of Attorney for
Health Care.” There are also hybrid
documents which combine elements of
the Living Will with those of the Durable
Power of Attorney. A Living Will is the
oldest type of health care advance
directive.
- An advance directive helps loved ones, and
medical personnel make important decisions
during a crisis. Having an advance directive in
place ensures that one’s wishes regarding
one’s health care are carried out, even when
unable to make wishes known.
The Five Wishes of Advance Directives
- Wish 1: The Person I Want to Make Care
Decisions for Me When I Can't.
- Wish 2: The Kind of Medical Treatment I Want
or Don't Want. ...
- Wish 3: How Comfortable I Want to Be. ...
- Wish 4: How I Want People to Treat Me. ...
- Wish 5: What I Want My Loved Ones to Know.
TOPIC NO 8. DNR OR DO NOT RESUSCITATE
 A DNR order is created, or set up, before an
emergency occurs. A DNR order allows you to
choose whether or not you want CPR in an
emergency. It is specific about CPR. It does not
have instructions for other treatments, such as
pain medicine, other medicines, or nutrition.
 The doctor writes the order only after talking
about it with the patient (if possible), the proxy,
or the patient's family.
 A do-not-resuscitate order, or DNR order, is a
medical order written by a doctor. It instructs
health care providers not to do
cardiopulmonary resuscitation (CPR) if a
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 patient's breathing stops or if the patient's
heart stops beating.
 also known as no code or allow natural death, is
a legal order, written or oral depending on
country, indicating that a person does not want
to receive cardiopulmonary resuscitation (CPR)
if that person's heart stops beating.
 Ethicists and physicians are divided over how to
proceed if the family disagrees. At many
hospitals, the policy is to write a DNR
order only with patient/family agreement.
Nevertheless, CPR should generally be provided
to such patients, even if judged futile.
 means that no CPR (chest compressions, cardiac
drugs, or placement of a breathing tube) will be
performed.
 Ethical implications:
o DNR, this acronym has been the epicenter of
numerous legal disputes,
o a source of great distrust in medicine,
o and has been associated with eliciting great
moral distress and strong emotions from not
only health care professionals but patients and
families alike.
 DNR Guidelines
o DNR orders should be documented in
the written medical record.
o DNR orders should specify the exact
nature of the treatments to be
withheld.
o Patients, when they are able, should
participate in DNR decisions. Their
involvement and wishes should be
documented in the medical record.
o Decisions to withhold CPR should be
discussed with the health care team.
o DNR status should be reviewed on a
regular basis.
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C. NURSING ROLES AND RESPONSIBILITIES
(From Death and Dignity by Peter Allmark: Journal of
Medical Ethics:2002)
https://jme.bmj.com/content/28/4/255
It is commonly said that health care professionals
should seek to ensure that terminally ill people in their
care should die with dignity. This seems to involve two
claims.
 The first is that lives without dignity should be
ended.
o This might be by the withdrawal or
withholding of life-preserving
treatment, or by the direct
administration of some life-ending
treatment.
o Those who advocate non-voluntary
euthanasia for the severely
handicapped may endorse such a view,
although it is unclear how death, either
induced or natural, adds dignity to an
“undignified” life.
 The second claim is that people should be
allowed to make the choices necessary to
procure a death with dignity.
 This second claim is the one more commonly
used, often by those advocating assisted suicide
or voluntary euthanasia.
 The idea seems to be that certain conditions are
such that palliative treatment is insufficient to
ensure a death with dignity and that therefore
euthanasia should be used.
 The key element of this conception is that
dignity is largely something that someone
brings to death; it is not something that health
care professionals can confer.
• Dignity - the term may also be attributed to
actions; hence one might speak of someone
conducting herself in a dignified way.
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(Kass L. Averting one’s eyes or facing the music?—on
dignity in death. Hastings Center studies1974;2:67–80.)
The more common use of the phrase “death with
dignity” attaches to the second and third senses of
death (transition and process)
Kass suggests that the discussion of death with dignity
conceals four senses of the term “death”.
1. Non-being—the rather mysterious state of being
dead;
2. Transition—the point at which one moves from being
to non-being;
3. Process—the period leading to death. This is not
entirely straightforward as we are in this process from
the moment of conception. In practice it usually means
a period in which there is an awareness of what will end
a particular person’s life and, roughly, when.
4. The fact of mortality—death as a universal truth that
attaches to us all.
Criticisms of Death with Dignity:
1. Ramsey suggests that death is an indignity, an
affront to life. And the term death with dignity
is not acceptable. (Ramsey P. The indignity of
“death with dignity”. Hastings Center Studies
1974;2:47–62)
Ramsey moves from the quasi-existentialist belief that
death is an indignity for all people, to the view that
every person’s process of dying is undignified.
2. Coope has a far more robust critique. He suggests
that it is not clear that the notion makes any sense at
all. One can die in undignified circumstances (such as
with trousers down in a brothel), but he questions
whether one can die with dignity any more than one
can be born or breathe with dignity. (Coope C. “Death
with dignity”. Hastings Center Report1997;27:37–8)
He considers that dying with dignity is whatever the
dying person thinks it is. For example:
o if someone thinks it is undignified to die in a
confused state, or incontinent, or heavily
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dependent on others, then it is undignified for
him.
1. Death without indignity
We have seen that “indignity” conveys the idea of an
affront. Hence, a death without indignity would be one
in which no such affronts occur.
o What would such affronts be?
o To understand this one would need to ask
whether there is a dignity that all humans
possess simply because of being human and, if
so, how is it affronted?
A potential answer to this draws on an
Aristotelian idea.6 The unique and essential feature
distinguishing humans from other animals is rationality,
the ability to reason and to act upon reasons. Human
dignity would, therefore, arise from this feature. We
would affront such dignity by failing to acknowledge
this in an individual; instead treating them as an object
or an animal.
For example: if one were to engage in euthanasia
without consent (“involuntary euthanasia”) then this
would look like an affront to someone’s dignity (even if
he would have chosen that option had it been offered);
it looks as though one has “put someone down” like a
dog.
Another example of an affront to human dignity would
be failing to tell someone of his terminal diagnosis in
order to avoid upsetting him. This is an affront because
it removes the ability for him to make choices about his
own life.
2. Death with dignity
Whilst inflicting indignity on others is a moral failure, a
failure to recognise their human dignity, it does not
remove their dignity either in its minimal or fullest
sense. If someone is subject to involuntary euthanasia,
or lied to about his diagnosis, then he is wronged,
affronted; but he may still live his life, and die his death,
with (greater or lesser) dignity in the face of that
indignity. Christ (and other martyrs) suffered great
indignities but, none the less, died with dignity.
Mohammed Ali was praised for the dignity with which
he faced his Parkinson’s disease. People die with dignity
because of their personal qualities, their virtues,
15
whatever the circumstances in which they die: indignity  Indeed, perversely the indignities enabled him
is suffered; dignity is earned. to demonstrate his dignity.

It follows that a dignified death will be something XIII. BIOETHICAL ISSUE: DEATH AND
earned. Someone who lives a good life, lives REDEFINITION OF DEATH
virtuously, will die in that way. For the rest of us,
death with dignity will be, like life with dignity,
something to aim for but only partially to achieve. The
potential for dying with dignity may also be lost in WHAT Constitutes death?
those who lose their reasoning capacities—for By Thomas Furlow
example, through dementia-inducing illnesses.
Similarly, unbearable (and uncontrollable) pain or
other suffering may undermine someone’s ability to
reason and to choose and, hence, to die with dignity.

Health professionals cannot ensure that someone dies

with dignity.

1. They can, on the other hand, contribute to a

death without indignity.

2. This will involve ensuring that, as far as possible, they
respect people’s autonomy and use of human reason.
3. It will also involve removing barriers to dignity that
can be removed, such as (controllable) pain.
On these occasions, health care professionals are
making an indirect contribution to death with dignity.
Eg. A man in long term care with terminal lung cancer
screams in pain but after a few minutes of pain
medication he is able to get up and join his co-patients
and seem to enjoy his time with them and can even
joke with the nurses. When the pain starts, he would go
back to bed and lie still and scream for pain until it was
time for his medication again.
 For a man dying in great pain, health care
professionals could and should remove
indignities; in doing so they could help him to
die without indignity.
 In the end, however, the man’s strength of
character was such that he had a dignified
death; in other words, he had a death with
dignity in the face of indignity.
Redefining the concept of life
 Social Life – One’s interpersonal
relationships. The most vulnerable of
the aspects of our being and usually is
the first to die.
 Biographical or Intellectual life– our life
events; life that is captured in
relationships, dreams and expectations ;
that truly separate us from other life
forms and make us uniquely human. The
part of us that separates us from the
rest of the biological world. ,
consciousness, interaction, derived from
the highest level of the brain or the
cerebrum.
 Biological life- living being - controlled
largely by the brain stem. It is not
uniquely human, because it shares
common features with non-human life
forms. The last to die.

16
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DEATH is the irreversible cessation of life.
 The event of life’s ending.
 Causes the permanent nonexistence of
the individual.
 Death involves a complete change in the
status of a living entity - the loss of its
essential characteristics.
 Ideas about death vary with different
cultures and in different times.
 Been traditionally seen as the departure
of the soul from the body
 the essence of being human is
independent of
physical properties. Because the soul has no
corporeal or bodily manifestation, its
departure cannot be seen or objectively
determined, hence the cessation of
breathing has been taken as the sign of
death.
In modern times:
 Death has been thought to occur when
the vital function cease – breathing and
circulation (as evidenced by the beating
of the heart) .
 This view has been challenged however
as medical advances have made it
possible to sustain respiration and
cardiac functioning through mechanical
means.
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 More recently the concept of BRAIN
Death has gained acceptance.
Rapidly advancing technology has raised
moral questions and introduced new
problems in defining death legally.
Among the issues debated are:
a) Who shall decide the criteria for
death? physicians, legislatures,
or each person for himself.
b) Is advancement of the moment of
death by cutting off artificial
support morally and legally
permissible?
c) Do people have the right
to demand that extraordinary measures
be stopped so that they may die in
peace?
d) Can the next of kin or legal
guardian act for the comatose dying
person under such circumstances?
Two important reasons why there is a need to
redefine death: (Timbreza)
1. Because of the increasing and
widespread use of new devices for
prolongation of life or life support
machines:
a. artificial respirator
b. electronic pacemaker
c. IV injection
d. Feeding tubes
17
2. There is a great demand for
cadaver organs for transplantations
such as the eyes, heart, kidneys and
bone marrow. The chances of
successful organic transplant are higher
if the required organ is removed from the
cadaver immediately after death, usually
in terminal cases.
One element of the moral issue involved
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 person’s 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.
Several Definitions of Death:
1. Physiological Definition – the heart
stopped beating, this is the traditional
understanding of death.
> blood and breath - when people
stop breathing and pulsation stops,
the individual is pronounced dead.
> With mechanical respirator which
can keep blood and oxygen circulating
almost indefinitely, an individual dying
process is prolonged.
2 . Religious or Philosophical Definition -
separation of the soul and body .
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 The soul is viewed as principle
of life, it animate and gives
form to the body.
 The soul makes the body
distinctively human with
rationality and freedom.
 If soul departs from the body -
the person ceases to be
human because with death, the
substantial union of the body and
soul has been dissolved.
 There is uncertainty regarding
the precise time of the soul’s
departure, which may be cited as
the weakness of the religious or
philosophical definition.
3. Brain Death Definition - the brain is
completely destroyed, in which the cessation
of function of all organs are imminent and
inevitable.
 Use of electro-encephalography (EEG)
and electrocardiogram (ECG), HCPs can
determine the total or irreversible loss
of circulatory and respiratory functions.
 Also include absence of receptivity and
responsiveness, absence of movement
or breathing and absence of reflexes.
3.1 Brain Death - irreversible loss of brain
activity is the sign that death has gained
a lot of acceptance.
- A criterion for determining death of a
person, is justifiable in the context of organ
transplantation .
- The question now lies what about those
who were proclaimed brain dead: those
18
with irreversible loss of brain functions? On
a vegetative state? He may be proclaimed
brain dead, but may appear to be alive
because the body is sustained by life support.
Harvard Medical School Criteria for Brain
Death Definition :
 Unreceptivity and unresponsiveness
 No spontaneous movement or breathing
 No reflexes
 Flat EEG of confirmatory value
4. Somatic Death or Cellular Death Definition
– is the death of the organism as a whole,
usually precedes the death of the individual
organs, cells and parts of cells
 Marked by cessation of
heartbeat, respiration,
movement, reflexes, and brain
activity.
 The time of somatic death is
difficult to determine.
 Disintegration and breakdown of
the metabolic processes of the
body’s substance
 Irreversible loss of the neo-
cortical activity as the only
significant criterion, because it
eliminates all capacity for
consciousness and all social
integration impossible.
 An EEG is needed for this
definition.
EMS
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. Insuch patients,
blood circulation may be artificially
maintained after brain death, so that
the organs needed can be extracted
with minimal ischemic damage. –a good
reason to remove those transplantable
vital organs before cessation of the
donor’s artificially supported circulation.
 To avoid any legal restraints and
complications, .. matter requires
the enactment of statutes
recognizing the use of brain-
oriented criteria for pronouncing
death.
 Without statutory or case law
recognition of the use of brain-
related criteria for pronouncing
death, a valid medical declaration
of death could be considered
illegal and the physician or
hospital concerned can be
criminally liable (e.g., for
extracting organs to be
transplanted).
 A statute giving general recognition to
this concept would be helpful to the
parties involved by freeing them from
any legal complications in connection
with organ transplants based on
informed consent either on the part of
the donor or of the donor’s immediate
relatives.
19
  THANATOLOGY – It is the scientific
study of death.
 THANATOLOGISTS – those who
study the surroundings and inner
experiences of persons dying or
near death.
Types of Death:
• Timely Death – involves people
who have incurable diseases
and only has a limitted
time to live (terminal
disease state)
• Untimely Death – sudden death
due to accidents and acts of
violence (vehicular
accidents, murder).
• Intentional – intentionally getting
your own life (suicide)
• Unintentional – not intending to
end one’s life; death just
happened unexpectedly (cardiac
arrest, disease)
• Subintentional - introducing
harmful chemicals to the body
through ingestion, injection, etc.
(substance use)
STAGES thru which a Dying person go through:
1. Shock and Denial
“No! It can’t be true! Not me!”
2. Anger or Rage /resentment
“Why me?”
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3. Bargaining
“I promise to be/do…..if you let me live
long enough.” “ If I am good, then can I live?
“ “I don’t want to die now…. When…”
4. Depression - “ What’s the use”
Reaction or anticipation
5. Acceptance
Realizes that death is inevitable
Fears of the Dying:
1. Fear of the unknown
2. Fear of loneliness
3. Fear of loss of family and friends
4. Fear of loss of body
5. Fear of loss of self-control
6. Fear of pain
7. Fear of loss of identity
8. Fear of regression (retreat to an
earlier pattern of behavior or
stage of development)
Attitudes Towards Death Include:
1. Cognitive attitudes – indicate how dying
individuals think about death indicate
acceptance and denial.
2. Affective attitudes – bear out the
feelings of the dying individual may
include depression, sense of loss and
fear. The dying individual feels very bad
and depressed about his/her impending
death. One just feels dejected, sad and
lost.
3. Behavioral attitudes - include anger or
irritability, bargaining, resentment and fear.
20
 The dying person may become irritable or
may easily become emotionally upset
without reason or cause. He usually
becomes bitter and resentful.
ATTITUDES TOWARDS DEATH ACROSS
THE LIFE CYCLE:
1. Under 5 yrs old
Animistic (belief that natural objects
have souls); Death is separation similar
to sleep.
2. Ages 5 – 10 yrs old
Developing sense of mortality; Fear of
abandonment if parents die.
3. Puberty (11-16 yrs. old)
Able to conceptualize death as realistic,
universal, irreversible, and inevitable.
4. Adolescence (17-21 yrs. old)
Preoccupied with issues related to body
image and control of environment.
5. Young Adults (22-35 yrs. old)
Focus on issues like not having chance to marry
or have children or ifmarried having to leave
spouse and children. May also fear threats of
potential isolation.
6. Middle-aged Adults 36-50 yrs. old)
May feel frustrated in hopes to become
involved with next generation.
7. Elderly (51 &  yrs. old)
Must confront increasing reality of own
mortality.
EMS
 GRIEF – is a subjective feeling
precipitated by death of a loved one.
 MOURNING – is a process by which grief
is resolved.
 BEREAVEMENT – is being in the state of
mourning.
Grief Therapy:
1. Regular visits.
2. Grieving person is encouraged to talk
about loss and about the deceased.
3. Encourage the person to take on new
responsibilities and to develop a sense
of autonomy.
Several Views of Death
a. Nikolai Berdyaev – a Russian theologian,
states that only death can give meaning
to life. Without death, life would be
meaningless. Death is a path or an
intermission number between the
present and thereafter.
b. Epicurus – the Athenean thinker argues:
Either there is immortality or there is
none. If there is, then we should be glad
there is death, for once we are dead we
shall become immortal; if there is none,
then death is our final liberation from
pain and suffering.
c. Martin Heidegger – a German
existentialist, views death as the
completion of life, for unless and until
one dies, one’s life is not yet complete.
Death is a great equalizer of men, for as
far as the coffin and the grave are
concerned, all are equal.
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 d. Jesus Christ – “I am the resurrection and
the life; he that believes in me, though
he were dead, shall live again; and
whoever lives and believes in me shall
never die.” (John 11:25-26)
Terms:
After somatic death, several changes occur that
are used to determine the time and
circumstances of death:
1. Algor Mortis - cooling of body after
death.
2. Rigor Mortis - stiffening of the skeletal
muscles after death. It begins 5-
10 hours after death and disappears
after 3-4 days.
3. Livor Mortis- reddish blue discoloration
on the underside of the body resulting
from the settling of the blood. Clotting –
begins shortly after death and autolysis
(death of cells).
4. Putrefaction- the decomposition that
follows is caused by the action of
bacteria and enzymes.
Applying the Ethical theories
Natural Law Ethics
• Regards death as a part of nature
• It declares that a person is dead
once the soul leaves the body.
• Although one can hardly
determine the precise point in
time when the soul has departed
from the body, natural law
moralists do not disagree with the
brain death definition.
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• When all vital functions of the
brain completely disappear or
stop, extraordinary medical
measures may not be necessary
but, in fact, useless.
• It is morally wrong to prolong the
suffering of the dying individual by
means of life-sustaining machines
in such circumstances.
Utilitarian principle
> Accepts the brain death definition
since it is in keeping with the utility
precept, i.e., promoting as much good
as possible and avoiding further harm
and pain, if the dying patient is detached
from all life-supporting machines.
> The donations of transplantable
vital organs - with informed consent is
warranted by the greatest happiness
(good) for the greatest number principle.
.
Pragmatist Perspective
 Notions of practicality, usefulness
and beneficiality may justify the
application of the brain death
definition issue in the medical
context.
. Situation Ethics
 Accepts brain-related criteria for
pronouncing death in conjunction
22
 with both euthanasia and organic
transplantations.
Rawl’s concept of Justice
 Justifies the unplugging of life-
sustaining machines if and when
they are no longer useful to the
dying person – at least, in fairness
to the patient, so that they will not
prolong his suffering.
The Significance of Advance Directives
or Living Will and Do not Resuscitate
(DNR) Order
Advance Directives
 It is a document where a person
give instructions about future
medical care should he or she be
unable to participate in medical
decisions due to serious illness or
incapacity. AD may provide a
patient’s personal instruction that :
 Direct a physician not to put him
on prolonged life support if in the
future , his condition is such that
there is little or no hope of
reasonable recovery
 Specify a treatment to follow.
 Name a substitute decision –
maker , a person who will make
the medical decisions on behalf of
the patient when the latter is
EMS
incapacitated or in a condition
where he cannot make a decision.
 ADVANCE DIRECTIVES : (Edge,
2006)
Advance directives ensure that the
personal wishes of the patient with
regard to life-sustaining treatment will
be honored. It is a measure of
protection.
 Highlight the individual’s right to
self determination- which entitles
every individual to informed
consent including the right of a
person of legal and sound mind to
voluntarily refuse diagnostic and
treatment procedures after he is
informed of the medical
consequences of his decision; and
provided that his refusal will not
jeopardize public health and
safety.
Two forms of AD
1. LIVING WILL or Instructional
directives: a person specifies
directives for his health care in the
event that decision making
capacity is lost due to terminal
illness or impending death.
2. .MEDICAL POWER OF ATTORNEY–
or Proxy Directive - the patient
specifies a surrogate decision-
maker (AN AGENT or PROXY) to
make the decision for him in the
23
 event of incapacity. The patient
chooses someone who can make a
decision according to patient’s
values.
Significance of AD
 Specific directions to the family
members or doctors on how
treatment should be carried out:
 AD can promote peaceful death.
 Reduce stress for the families
when the person facing death is
unable to make treatment
decisions. (many families – unable
to make decision of stopping life
support until the patient is close to
death. )
Role of the nurse
 Should seek to improve knowledge
and skills in addressing end of life
issue and providing
compassionate care both to the
patient and the family .
 Culturally sensitive .. In the
country, AD is a new concept.
 Patient advocate– as to what the
patient’s and family’s values are;
and preferences for end of life
care. (Entails assessment and
communication skills)
EMS
 The nurse should ensure that the
patient has sufficient info to be
able to fully comprehend his own
medical condition , all treatment
options available for them life
care. (Entails assessment and
communication skills)
 Proper Documentation. If a nurse
is present when patient writes
the AD, the nurse has the
responsibility to document the
event in the patient’s chart
including an assessment of the
patient’s condition at the time
when the AD is signed.
 Advance directives are living wills,
nurses should let the patient know
his rights with regards to AD
including the right :
1. To inform those concerned
on a need to know basis.
2. To change his AD anytime he
wants.
 When a patient’s AD is
disregarded, nurses can advocate
for the patient by contacting the
hospital, or institution’s ethics
committee.
 Nurse should be familiar of the
laws and the policies of the
institution she works for
concerning advance directives.
24
Reasons for establishing a Durable
Power of Attorney (proxy directive)-
According to: Society for the Right to
Die
1. To give or withhold consent to specific
medical or surgical measures with
reference to the principal’s condition,
prognosis, and known wishes regarding
terminal care ; to authorize appropriate
DNR GUIDELINES:
end- of – life , including pain –relieving
procedures
2. To grant releases to health care
providers.
3. To employ and discharge health care
providers.
4. To have access to and to disclose
medical records and other personal
information.
5. To resort to court, if necessary, obtain
court authorization regarding medical
treatment decisions.
6. To expend or withhold funds
necessary to carry out medical
treatments.
Do not Resuscitate (DNR) Order
DNR Order
 Also called NO CODE , a DNR is a
written order usually placed on a
patient’s medical chart to indicate
that there should be no attempt to
restart a failed heartbeat or apply
CPR to restore normal breathing.
EMS
 A DNR order can be changed and
experts say it should be reviewed
regularly. In a DNR situation, a
patient is still provided comfort
care.
 Without such an order, emergency
medical technicians are legally
required to perform CPR.
 DNR order should be documented
in the written medical record.
 DNR orders should specify the
exact nature of the treatments to
be withheld.
 Patients, when they are able,
should participate in DNR
decisions. Their involvement and
wishes should be documented in
the medical record.
 Decision to withhold CPR should be
discussed with the health care
team.
 DNR status should be reviewed on
a regular basis.
Language of DNR
 NO CODE or “DNR” - a written
order placed on a patient’s medical
chart to avoid the use of CPR
efforts . In previous times, the
chart were often labeled with
devices as “Red tags” or “purple
dots” to designate DNR status.
25
  SLOW CODE - this is a practice
where the health care team slows
the process of emergency
resuscitation so as to appear to be
providing the care but in actual
fact is only providing an illusion.
The intent of the practice is more
for family comfort than patient
benefit.
 CHEMICAL CODE - similar in intent
to slow code, the team provides
DRUGS needed for resuscitation
but does not provide the other
services.
Care for the Dying (A Good Death)
 Or Dying with Dignity.
Palliative care
 It is being well-cared for by the
people who care, often by family
members, amidst familiar
surroundings, respected with
control over environment and
destiny, and basic needs met
without feeling dependent or a
burden on others , with pain
managed , and without
unnecessary measures or heroics.
Issues In Caring for the Dying Include:
REFUSAL OF TREATMENT
EMS
• RESPECT for AUTONOMY
• Psychological value of following the
1. patient’s wishes
• Involving the family /substitute decision-
Refusal maker
of
• The doctor has no separate and
independent right to make decisions for
treatme
the patient
• No obligation in the part of doctor or he is
compelled to provide what is viewed as
nt “futile”, harmful, optional or against one’s
values
•Time has come when cure is no
longer feasible
•Approach is to seek the patient’s
2. best interest holistically—physical,
Palliative emotional, psychological, social and
spiritual needs
Care
•In a loving, skilled, compassionate
manner.
•As to minimize symptoms and
maximizes interaction with others.
 It is willing and living as a human
being while accepting rather than
denying impending death –with
hope , faith, love and peace.
 It is given for irreversible fatal,
terminal conditions.
 It recognizes that the time has
come when cure is no longer
feasible, so the focus gradually
moves to care.
 Its approach is to seek the
patient’s best interest holistically—
physical, emotional, psychological,
social and spiritual needs– in a
loving, skilled, compassionate
manner.
26
  It uses common sense in
prioritizing the medical and moral
support given as to minimizes
symptoms and maximizes
interaction with others.
THE HOSPICE ALTERNATIVE
• Set up to provide palliative care,
abatement of pain, and an
environment that encourages
dignity, but they do not cure or
treat intensively.
• However, pain suppression in
medical practice is not absolute.
HOSPICE MOVEMENT
-- the development of centers for
providing palliative care for the
terminally ill that focus on the process of
relieving pain.
•No one dies ALONE
•Talk to client re: Illness,
prognosis, --led to realistic
expectations
•“bad news be given early
3. Role of enough for the patient to
the make the best use of
Physician remaining limited time–
giving opportunity to
prepare for death
•Never discuss hastening
death nor give empty
reassurances of healing
EMS
UNIT 3B: NURSE ETHICO-MORAL
OBLIGATIONS
ETHICAL FRAMEWORKS FOR DECISION
MAKING
1. ETHICAL SYSTEMS AND
PRINCIPLES
2. PATIENT’S BILL OF RIGHTS
3. PROFESSIONAL CODE OF ETHICS
4. INSTITUTION POLICIES
5. LAWS
Generally the moral conflicts arising in
nursing can be categorized into one of the
three types.
 Moral uncertainty-failure of the
nurse to recognized the nature of the
ethical problem
 Moral dilemma- involving a conflict
between two or more ethical
principles with no obvious solution.
 Moral distress- when there is conflict
between the nurse’s knowledge of
ethically appropriate action and what
is actually happening in the situation.
DIFFERENT METHODS OF DECISION
MAKING USED IN NURSING
 TRADITIONAL PROBLEM-SOLVING
PROCESS
This method consist of a step by step
process which is more or less consist of the
following:
1. Identify the problem
27
 2. Gather data to analyze the problem (legal or illegal,
moral or
3. Explore alternative solutions immoral) what
are the
4. Evaluate the alternatives: weigh burdens/disadvan
benefits and burdens tage and
benefits/
(advantage/disadvantages)
advantages of
each course of
5. Select the appropriate solution
action identified?
6. Implement the solution
R Review criteria , What are the
weigh options ethical principles
7. Evaluate the results
against the values of the people
of those involved involved in the
MORAL METHOD
in the decision decision making?
Prioritize which
 Moral method incorporates nursing course of action
process and biomedical ethics. It is is most aligned
especially useful in clarifying ethical with the values
problems encountered in nursing ethics of the
practice the result from conflicting people involved
obligations. indecision
making?
STEPS DESCRIPTION GUIDE Decide the best
QUESTIONS(BUT course of action
NOT LIMITED TO to take
THESE):
A Affirm position Make a
and act, develop systematic plan
M Massage the What is the
the on how to
problem-Collect problem?
implementation implement the
data about the What is the cause
policy chosen course of
ethical problem of problem?
action
and who should be Who are the
implement
involved in the people involved?
decision-making Who will make
L Look back, After
the decision?
evaluate the implementation,
decision making evaluate the
O Outline options, What courses of
results.
identify action are
What are the
alternatives and available?
positive
analyze causes What are the
results/benefits/
and consequences legal and moral
advantages?
implications of
What were the
each?
negative
Course of action?
results/burdens/
28
EMS
 disadvantages? C. WHAT VALUES ARE INVOLVED
Weigh the
benefits against Think through the shared values that
the burdens. are at stake in making this decision. Is
Was the people there a question of trust? Is personal
involved in the
autonomy a consideration? Is there a
decision making
and affected by question of fairness? Is anyone to be
its satisfied by harmed or helped?
the results?
What were the D. WEIGH THE BENEFITS AND THE
reasons for BURDENS
satisfaction and
dissatisfaction of Benefits-broadly-might include such
the people things as the production of goods (
involved? physical, emotional, financial, social etc.)
for various parties, the satisfaction of
preferences, and acting in accordance with
various relevant values(such as fairness).
GUIDE TO MORAL DECISION MAKING Burdens might include causing physical or
A. RECOGNIZING THE MORAL emotional pain to various parties,
DIMENSION imposing financial costs, and ignoring
relevant values.
The first step is recognizing the decision
as one that has moral importance. E. LOOK FOR ANALOGOUS CASES
Important clues include conflicts between Can you think of other similar
two or more values or ideals. decisions? What course of actions was
B. WHO ARE THE INTERESTED PARTIES? taken? Was it a good decision? How is the
WHAT ARE THEIR RELATIONSHIPS? present case like that one? How is it
different?
Carefully identify who has a stake in
the decision. In this regard , be imaginative F. DISCUSS WITH RELEVANT OTHERS
and sympathetic. Often there are more The merits of discussion should not
parties whose interest should be taken
be underestimated. Time permitting,
into consideration than is immediately
obvious. Look at the relationship between discuss your decision with as many persons
the parties. Look at their relationships with as have a stake in it. Gather opinions, and
yourself and with each other, and with ask for the reasons behind those opinions.
relevant institutions. Do these Remember that your ability to discuss
relationships bring special obligations or others may be limited by the other
expectations? peoples expectations of confidentiality.

29
EMS
G. DOES THIS DECISION ACCORD WITH  Two-fold or double effect
LEGAL AND ORGANIZATIONAL RULES?
 ETHICS COMMITTEES
Some decisions are approximately
 Spiritual adviser
made based on legal considerations. If one
options, is illegal, we should at least think STEP ACTIVITIES
very seriously before taking that option.
Decisions may also be affected by rules set Step 1: Know:
by the organizations of which we are collect,  Problem
members . analyze, and  Client’s and family
For example, most professional interpret data wishes
organizations have Code of Ethics which  Physician's belief
are intended to guide individual decision  Your personal
making. Institutions (hospitals, banks, ethical philosophy
corporations) may also have policies which
limit the options available to us. Step 2: state  State dilemma
Sometimes there are bad laws , or bad the dilemma clearly what are the
rules, and sometimes those should be conflicting ethical
broken. But usually it is ethically important principles
to pay attention to laws and rules.  Who are the people
involve in the
H. AM I COMFORTABLE WITH THIS problem-is it the
DECISION? nurse or only the
patient?
Sometimes your ‘gut reaction’ will
 Focus attention on
tell you’ve missed something. Questions to ethical principles
be asked in this regard might include:  Follow the clients
wishes first. In case
 If I carry out this decision, would I be
of unconsciousness,
comfortable telling my family about
consider family
it? My clergymen? My mentors?
input.
 Would I want children to take my  Any good ethical
behavior as an example? analysis and solution
is dependent upon
 Is this decision one which a wise, good problem
informed, virtuous person would identification and
make? fact gathering. The
 Can I live with this decision? discernment of good
facts leads to an
accurate
30
EMS
 identification of the
ethical values and a
determination of
values in conflict.
Step 3: What are the possible
Consider courses of action according
choices of to the clients wishes,
action physicians and the nurses
opinion?
Step 4: What are the
Analyze consequences of the
advantages identified courses of
and action? What are the
disadvantages benefits and burdens of
of each each action?
course of Identify the realistic
action actions? What are the
acceptable and can be
implemented courses of
actions?
One may choose guided by
hospital policies, law, code
of ethics and personal
ethical philosophy.
The best solutions are
those that least infringe on
the rights of the parties
interested in the outcome
to the dilemma.
Step 5: Make  Ideally, a
the Decision collaborative
decision is made by
client, family, Dr.
and nurse and
produces fewer
complications
EMS
Clients wishes, by virtue of
the principle of autonomy,
always supersede decision
by health care providers
If patients has no decision
making capacity, physician
and nurse decision should
always be for the good of
the patient not for health
providers personal interest
and gain.
 Ethical dilemmas
produce differences
of opinion and
expect that not
every one will be
pleased with the
decision and
possible
consequences.
 It has been said that
this is the most
difficult part of the
decision making
process: following
through with the
action, and then
living with the
consequences
31
 ETHICAL DECISION MAKING IN NURSING
PRACTICE
WHEN MAKING CLINICAL
JUDGEMENT, NURSES HAVE THEIR
DECISIONS ON CONSIDERATION OF
CONSEQUENCES AND OF UNIVERSAL
MORAL PRINCIPLES, BOTH OF WHICH
PRESCRIBE AND JUSTIFY NURSING
ACTIONS.
-ANA
ROLE OF THE NURSE
1. Nurses working in areas where
they are frequently providing direct care to
terminally ill or dying patients should seek
to improve their knowledge and skills in
addressing end of life issues and providing
compassionate care both to the patient
and his family through adequate
continuing education to be able to provide
proper end of life care.
2. Nurses must be culturally
sensitive as to how every patients
perception of AD is different. In the
Philippines, advance directive is a new
concept . In a study of United States, it has
been found out that it is the more
educated and different Caucasian patients
who commonly indicated that they
completed an AD because they wanted
some control over end life decisions.
- While a substantial number of non-
caucasians, poorly educated , uninsured
and lower income patients indicated they
EMS
did not wish to complete an AD for “fear of
putting things like this in writing.”(Meza et
al, 2000).
3. Although nurses providing direct patient
care to terminally ill individuals are often
engaged in conflicts about what treatment
course is best for them, their major role as
patients advocate is not engage in debates
and arguments but to initiate a discussion
with dying patients and their families
about their life values and preferences for
end – of-life care, So that they can help
the patient exercise their right to die in a
way that they choose and with dignity, and
at the same time enable the family to
maximize the quality time spent with their
loved one. This responsibility requires
assessment and communication skills.
(Norton, S. A. & Talerico, K. A. 2000).
4. The nurse must ensure that the patient
has sufficient information to be able to
fully comprehend his own medical
condition, all treatment options available
for him, including their risks and benefits,
and the consequences and benefits of
appointing or not appointing someone else
to make treatment decisions in the event
of incapacitation before the patient makes
the decision to write or not to write an
advance directive.
5. Proper documentation. If a nurse is
present when the patient writes AD, the
nurse has the responsibility to document
the event in the patients chart including an
assessment of the patient’s condition at
the time when the AD was signed.
32
 6. Advance directives are living wills,
nurses should let the patient know his
rights with regards to AD including the
right.
 To inform those concerned on a
need to know basis
 To change his AD anytime he wants
7. When a patients AD is disregarded,
nurses can advocate for the patients by
contacting the hospital or institutions
ethics committee.
8. The nurse should be familiar of the laws
and the policies of the institution she
works for concerning advance directives.
ETHICAL DECISION MAKING ALGORITHM
IDENTIFY POTENTIAL ETHICAL DILEMMA
COLLECT, ANALYZE, AND INTERPRET DATA
CLINICAL APPLICATION BIOETHICAL
DECISION-MAKING MODEL
SITUATION:
Mrs. LA VASQUES, a 67 year old woman, is
hospitalized with multiple fractures and
lacerations cause by automobile
ACCIDENT. Her husband, who was killed in
the accident, was taken to the same
hospital. Mrs. La Vasques, who had been
driving the automobile, constantly
question Kate Murillo, her primary nurse ,
about her husband .
The Surgeon, Dr. Mario Gonzales, has told
the nurse not to tell Mrs. La Vasques about
the death of her husband; however, he
does not give the nurse any reason for
these instructions. Ms Murillo expresses
concern to the charge nurse, who says the
surgeons order must be followed. Ms.
Murillo is not comfortable with this and
wonders what she should do.

IDENTIFY POTENTIAL ETHICAL DILEMMA NURSING ACTIONS

1. Identify The Moral Aspects to determine
whether a moral situation exists.
DILEMMA CANNOT DILEMMA CAN BE
BE RESOLVE BY A RESOLVED BY A 2. Gather relevant facts related to the
NURSE NURSE issue
3. Determine ownership of the decision
TAKE NO ACTION LIST POTENTIAL
SOLUTIONS 4. Clarify and apply personal values
5. Identify ethical theories and principles
UNACCEPTABLE
ACCEPTABLE 6. Identify applicable laws or agency
CONSEQUENCES
CONSEQUENCES policies
TAKE NO ACTION 7. Use competent interdisciplinary
ETHICAL DECISION
resources

DILEMMA RESOLUTION 33
EMS
8. Develop alternative actions and project
their outcomes on the client and family.
Possibly because of the limited time
available for ethical deliberations in the
clinical setting, nurses tend to identify two
opposing, either- or alternatives (e.g., to
tell or not to tell) instead or generating
multiple options (DeWolf 1989,80). This
creates a dilemma even when none exists.
9 . Apply nursing codes of ethics to help
guide actions. Codes of nursing usually
support autonomy and nursing advocacy.
10. For each alternative action, identify the
risk and seriousness and consequences for
the nurse.
11. Participate actively in resolving the
issue
12. Implement The Action
13. Evaluate The Action Taken
1. Identify The Moral Aspects to determine
whether a moral situation exists.
CONSIDERATIONS
In this situation , the ethical dilemma is
either to tell the truth or to withhold it. There is
conflict between the values of honesty and
loyalty: the primary nurse wants to be honest
with Mrs. La Vasques without being disloyal to the
surgeon and the charge nurse. Her choice will
probably be affected by her concern for Mrs. La
Vasques and perhaps by the surgeon’s incomplete
communication with her.
EMS
2. Gather relevant facts related to the
issue
CONSIDERATIONS
Data should include information
about the client’s health problems.
Determine who is involved, the nature of
their involvement, and their motives for
acting. In this case, the people involved are
the client (who is concerned about her
husband)the husband (who is deceased),
the surgeon, the charge nurse, and the
primary nurse, motives are not known.
Perhaps the nurse wishes to protect
her therapeutic relationship with Mrs. La
Vasques from psychologic trauma and
consequent physical deterioration.
3. Determine ownership of the decision
CONSIDERATIONS]
In this case, the decision is being
made for Mrs. La Vasques. The surgeon
obviously believes that he should be the
one to decide, the charge nurse agrees. It
would be helpful if caregivers agreed on
criteria for deciding who the decision
maker should be.
4. Clarify and apply personal values
CONSIDERATIONS
We can infer from this situation that
Mrs. La Vasques values her husband’s
welfare, that the charge nurse values
policy and procedure, and that Ms. Murillo
34
seems to value a client’s right to have
information. Ms. Murillo needs to clarify
her own and the surgeon’s values, as well
as confirm the values of Mrs. La Vasques
and the charge nurse.
5. Identify ethical theories and principles
CONSIDERATIONS
For example, failing to tell Mrs. La
Vasques the truth can negate her
autonomy. The nurse would uphold the
principle of honesty by telling Mrs. La
Vasques. The principles of beneficence and
nonmaleficence are also involved because
of the possible effects of the alternative
actions of Mrs. La Vasques’ physical and
psychological well-being.
6. Identify applicable laws or agency
policies
CONSIDERATIONS
Because Dr. Gonzales simply “ gave
instructions” rather an actual order,
agency policies might not require Ms.
Murillo to do as he says. She should clarify
this with the charge nurse. She should also
be familiar with the nurse practice act in
her state or province.
EMS
7. Use competent interdisciplinary
resources
CONSIDERATIONS
In this case, Ms. Murillo might
consult literature to find out whether
clients are harmed by receiving bad news
when they are injured. She might also
consult with the chaplain.
8. Develop alternative actions and project
their outcomes on the client and family.
Possibly because of the limited time
available for ethical deliberations in the
clinical setting, nurses tend to identify two
opposing, either- or alternatives (e.g., to
tell or not to tell) instead or generating
multiple options (DeWolf 1989,80). This
creates a dilemma even when none exists.
CONSIDERATIONS
TWO ALTERNATIVE ACTIONS, WITH
POSSIBLE OUTCOMES, FOLLOW:
1. Follow the charge nurse’s advice and do
as the surgeon says. Possible outcomes: (a)
Mrs. La Vasques might become
increasingly anxious and angry when she
finds out that information has been
withheld from her; or (b) by waiting until
Mrs. La Vasques is stronger to give her the
bad news, the health care team avoids
harming Mrs. La Vasques’ health.
2. Discuss the situation further with
the charge nurse and surgeon , pointing
out Mrs. La Vasques right to autonomy and
information. Possible outcomes: (a) the
surgeon acknowledges Mrs. La Vasques
35
right to be informed, or (b) states that Mrs.
La Vasques health is at risk and insist that
she not be informed until a later time.
Regardless of whether the action is
congruent with Ms. Murillo’s personal
value system , Mrs. La Vasques best
interests take precedence.
9 . Apply nursing codes of ethics to help
guide actions. Codes of nursing usually
support autonomy and nursing advocacy.
CONSIDERATIONS
If Ms. Murillo believes strongly that
Mrs. La Vasques should hear the truth,
then as a client advocate , she should
choose to confer again with the charge
nurse and surgeon.
10. For each alternative action, identify the
risk and seriousness and consequences for
the nurse.
CONSIDERATIONS
If Ms. Murillo tells Mrs. La Vasques
the truth without the agreement of the
charge nurse and surgeon, she risks the
surgeon’s anger and a reprimand from the
charge nurse. If Ms. Murillo follows the
charge nurse’s advice, she will receive
approval from the charge nurse and
surgeon; however, she risk being seen as
unassertive, and she violates her personal
value of truthfulness. If Ms. Murillo
requests a conference, she may gain
respect for her assertiveness and
professionalism, but she risk the surgeon’s
EMS
annoyance at having his instructions
questioned.
11. Participate actively in resolving the
issue
CONSIDERATIONS
The appropriate degree of nursing
input varies with the situation. Sometimes
nurses participate in choosing what will be
done; sometimes they merely support a
client who is making the decision. In this
situation, if an action cannot be agreed
upon, Ms. Murillo must decide whether
this issue is important enough to merit the
personal risks involved.
12. Implement The Action
13. Evaluate The Action Taken
CONSIDERATIONS
Ms. Murillo can be begin by asking
“Did I do the right thing?” Involve the
client, family, and other health members in
the evaluation, if possible. Ms. Murillo can
ask herself whether she would make the
same decisions again if the situation were
repeated. If she is not satisfied, she can
review other alternatives and work
through the process again.
AUTHOR UNKNOWN
“ LIFE IS NOT MEASURED BY THE NUMBER OF
BREATHS WE TAKE BUT BY THE MOMENTS THAT
TAKE OUR BREATH AWAY.”
36

Unit 3a:
bioethics research
IMPORTANCE OF ETHICS IN RESEARCH
 ETHICS IS IMPORTANT IN RESEARCH
BECAUSE IT KEEPS THE RESEARCHER
FROM COMMITTING ERROS WHILE
SEEKING KNOWLEDGE AND TRUTH.
IT PROMOTES ESSENTIAL VALUES
THAT HELP RESEARCHERS WORKING
ON A TOPIC TO HAVE A COMMON
UNDERSTANDING OF HOW THINGS
SHOULD GO ABOUT
 SINCE RESEARCH MAY INVOLVE
EXPERTS COMING FROM DIFFERENT
FIELDS OF EXPERTISE, ETHICS BINDS
THEM TOGETHER BY CONSIDERING
THE IMPORTANT VALUES SUCH AS
ACCOUNTABILITY, COOPERATION,
COORDINATION, MUTUAL RESPECT,
AND FAIRNESS AMONG OTHERS.
ETHICAL PRINCIPLES GUIDING
RESEARCH
 RESPECT FOR HUMAN DIGNITY
 RESPECT FOR FREE AND INFORMED
CONSENT
 RESPECT FOR VULNERABLE PERSONS
 RESPECT FOR PRIVACY AND
CONFIDENTIALITY
 RESPECT FOR JUSTICE AND
INCLUSIVENESS
 BALANCING HARMS AND BENEFIT
 MINIMIZING HARM
 MAXIMIZING BENEFIT
EMS
RESPECT FOR HUMAN DIGNITY
 Dignity implies that each person is
worthy of honor and respect for who
they are, not just for what they can
do. In other words, human
dignity cannot be earned and cannot
be taken away.
 Dignity is the right of a person to be
valued and respected for their own
sake, and to be treated ethically. It is
of significance in morality, ethics,
law and politics as an extension of
the Enlightenment-era concepts of
inherent, inalienable
rights. Wikipedia
RESPECT FOR FREE AND INFORMED
 Individuals are generally
presumedto have the capacity and
right to make free and informed
decisions
 in practical terms within the ethics
review process, the principle of
respect for persons translates into
the dialogue, process, rights, duties
and requirments for free and
informed consent by the research
subject.
RESPECT FOR VULNERABLE PERSONS
 Respect for human dignity entails
high ethical obligations tards
vulnerable persons – to those
whose diminished competence
and/or decision-making capacity
make them vulnerable
 Children, institutionalized
persons or others who are
37
 vulnerable are entitled, on
grounds of human dignity, caring
solidarity and fairness to special
protection against abuse,
exploitation or discrimination
 Ethical obligations to vulnerable
individual in the research
enterprise will often translate
into special procedure to protect
their interests.
RESPECT TO PRIVACY AND
CONFIDENTIALITY
PRIVACY - REFERS TO CAPACITY OF
INDIVIDUALS TO CONTRL WHEN AND
WHAT CONDITIONS OTHERS HAVE ACCESS
TO THEIR BEHAVIORS, BELIEFS AND
VALUES.
CONFIDENTIALITY - REFERS TO LINKING
INFORMATION TO A PERSON’S IDENTITY
INFORMED CONSENT SHOULD
INDICATE HOW RESEARCHER WILL
PROTECT CONFIDENTIALITY OF
PARTICIPANTS
SOME PROCEDURES THAT CAN ENSURE
CONFIDENTIALITY
 OBTAINING ANONYMOUS
INFORMATION
 CODE DATA SO THAT IDENTITY INFO
IS ELIMINATED
 DO NOT RELEASE OR REPORT
INDIVIDUAL DATA
 LIMIT ACCESS THAT COULD REVEAL
INDIVIDUAL IDENTITY
 REPORT DATA ONLY IN GROUP
FORM
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 USED COMPUTERIZED METHODS
FOR ENCRYPTING DATA
RESPECT FOR JUSTICE AND
INCLUSIVENESS
 JUSTICE CONNOTES FAIRNESS
AND EUITY
 JUSTICE ALSO CONCERNS THE
DISTRIBUTION OF BENEFITS AND
BURDENS OF RESEARCH
 ON THE OTHER HAND, JUSTICE
ALSO IMPOSES DUTIES NEITHER
TO NEGLECT NOR DICRIMINATE
AGAINST INDIVIDUALS AND
GROUPS WHO MAY BENEFIT
FROM ADVANCES IN RESEACRH.
BALANCING HARMS AND BENEFITS
 BASED ON THE PRINCIPLE OF
BENEFICENCE
o ONW SHOULD DO GOOD AND
ABOVE ALL DO NO HARM
 FREEDOM FROM HARM, FREEDOM
FROM EXPOITATION, RISK-BENEFIT
RATIO
 RISK-BENEFIT RATIO:
o CONSIDER HOW
COMFORTABLE YOU WOULD
FEEL HAVING FAMILY
MEMBERS PARTICIPATE IN
THE STUDY
o WOULD BE COMFOTABLE
o BENEFIT TO THE SCIENTISTS
AND THE SOCIETY, AS A
WHOLE
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 BALANCING BENEFITS AND RSIKS OF
MEDICATION
BENEFITS RISKS
 EFFICACY  SAFETY
 CONVENIENCE  TOLERABILITY
 LIFE EFFECTS
MINIMIZING HARM/MAXIMIZING
BENEFITS
 THIS CORE ETHICAL CONSIDERATION
FOCUSES ON TRYING TO PROMOTE
POSITIVE CONSEQUENCES BY
BALANCING HARMS (OR BURDENS)
WITH BENEFITS.
 HARMS AND BENEFITS COME IN A
VARIETY OF TYPES
o EMOTIONAL
o PHYSICAL
o ECONOMIC
o SOCIAL
 IN DOING SO ONE MUST CONSIDER
WHICH ACTIONS WOULD DO THE
LEAST HARM WHILE PROVIDING THE
MOST BENEFIT
 THIS EMPHASIS IS CENTRAL TO THE
ETHICAL APPROACH KNOWN AS
UTILITARIANISM.
THE NUREMBERG CODE
 THE NUREMBERG CODE IS THE MOST
IMPORTANT DOCUMENT IN THE
HISTORY OF THE ETHICS OF MEDICAL
RESEARCH
 THE CODE WAS FORMULATED 50
YEARS AGO, IN AUGUST 1947, IN
NUREMBERG, GERMANY, BY
AMERICAN JUDGES SITTING IN
JUDGEMENT OF NAZI DOCTORS
ACCUSED OF CONDUCTING
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 MURDEROUS AND TORTUROUS
HUMAN EXPERIMENTS IN THE
CONCENTRATION CRAMPS.
 VOLUNTARY CONSENT
 FRUITFUL RESULTS FOR THE GOOD
OF SOCIETY
 ANTICIPATED RESULTS WILL JSUTIFY
THE PERFORMANCE OF EXPERIMENT
 AVOID ALL UNNECESSARY PHYSCAL
OR MENTAL SUFFERING
 NO RESEARCH SHOULD BE
CONDUCTED WHERE THERE IS A
REASON TO BELIEVE THAT DEATH OR
DISABLING INJURY WILL OCCUR.
 THE DEGREE OF RISK TO BE TAKEN
SHOULD NEVER EXCEED THAT
DETERMINED BY THE
HUMANITARIAN IMPORTANCE OF
THE PROBLEM TO BE SOLVED.
The nuremberg code
the charter defined three categories of
crimes:
 crimes against peace (including
planning, preparing)
 starting or waging wars of
aggression or wars in violation of
international agreements,
 war crimes (including violations of
customs or laws of war, including
improper treatment of civilians and
prisoners of war) and crimes against
humanity (including murder,
enslavement or deportation of
civilians or persecution on political,
religious or racial grounds).
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 It was determined that civilian officials
as well as military officers could be
accused of war crimes.
NUREMBERG CODE (1948)
BACKGROUND AND EVOLUTION
OF RESEACRH ETHICS
HOW DID IT EVOLVE
THE NEED TO HARMONIZE
 PUBLIC DISASTERS, SERIOUS FRAUD
AND ABUSE OF HUMAN RIGHTS
 TRIALS OF WAR CRIMINALS –
NUREMBERG CODE 1949
 THALIDOMIDE – DECLARATION OF
HELSINKI 1964
 BELMONT REPORT 1978 (ETHICAL
PRINCIPLES AND GUIDELINES FOR
THE PROTECTION OF HUMAN
SUBJECTS OF RESEARCH) –
TUSKEGEE SYMPHILIS STUDY
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 1961: Thalidomide tragedy
 Thalidomide was developed by a
German pharmaceutical company
and was known as a wonder drug
that could treat insomnia, anxiety,
gastritis, coughs, colds, headaches,
and morning sickness. Clinical trials
on thalidomide began in November
of 1956. The drug began being
marketed to the public as an OTC
drug under the name Grippex in
November of 1956. It was also
marketed in the United Kingdom
under the name Distava. It had only
been tested on rodents and was not
tested for teratogenic (physiological
abnormality) effects. After its
release to market, thousands of
children were born with
malformation of the limbs
(phocomelia). Additonal defects
included blindness, deafness, and
deformed eyes and hearts. There
were 10,000 cases of phocomelia
due to thalidomide worldwide. Only
5,000 of those children survived. The
United States had only 17 cases.
Thalidomide was taken off the
market as on OTC drug in November
of 1961. However, it is still used
today as a cancer drug.
DECLARATION OF HELSINKI
 THE DECLARATION OF HELSINKI
(DOH) IS, INDISPUTABLY, A
REMARKABLE DOCUMENT. IT IS THE
MISSION OF THE MEDICAL DOCTOR
TO SAFEGUARD THE HEALTH OF THE
PEOPLE.
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  THE BRITISH MEDICAL JOURNAL
ANNOUNCED THE EMERGENCE OF
THE DOH IN ITS 18 JULY 1964
EDITION WITH THE FOLLOWING
WORDS: ‘A DRAFT CODE OF ETHICS
ON HUMAN EXPERIMENTSTION WAS
PUBLISHED IN THE BRITISH MEDICAL
JOURNAL OF 27 OCTOBER 1962.
 The World Medical Association has
developed the Declaration of
Helsinki as a statement of ethical
principles to provide guidance to
physicians and other participants in
medical research involving human
subjects. ... It is the duty of the
physician to promote and safeguard
the health of the people. The
Declaration of Helsinki was heavily
influenced by the Nuremberg Code.
Like the Nuremberg Code, the goal
of the Declaration of Helsinki was to
prevent human subjects from being
mistreated.
1974 - 1979: National Research Act & the
Belmont Report
National Research Act of 1974 –
o As a result of the study of Untreated
Syphilis in 1932, 128 men died, 40 of
their wives contracted the disease,
and 19 children were born with
congenital syphilis.
o As a response to the inadequate
oversight of human research in the
Tuskegee syphilis study, it was
recommended that public
regulations be defined and put into
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place to protect future human
research participants.
o This led to the National Research Act
of 1974.
THE BELMONT REPORT
o In 1974, Congress also created the
National Commission for the
Protection of Human Subjects in
Biomedical and Behavioral Research
to identify guidelines regarding
when human research subjects
should be used and how they should
be treated and to create guidelines
to ensure those new principals were
followed.
o These guidelines and principals were
published by the National
Commission in 1979 as the Belmont
Report.
o The previous post in this series
addressed the start of the Tuskegee
Study of Untreated Syphilis in the
Negro Male in 1932. In the late
1940's, penicillin became the
standard treatment for syphilis.
However, participants in the
Tuskegee study were never given
penicillin. In fact, the Center for
Disease Control (CDC) recommended
that the study continue in 1969,
despite knowing that penicillin had
been effectively treating syphilis
patients for over a decade. Study
participants were also not informed
about the option of penicillin as a
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 treatment, nor were they allowed
access to nearby syphilis treatment
programs. The program finally ended
in 1972, after whistleblower Peter
Buxtun leaked information to the
press. As a result of the study, 128
men died, 40 of their wives
contracted the disease, and 19
children were born with congenital
syphilis. As a response to the
inadequate oversight of human
research in the Tuskegee syphilis
study, it was recommended that
public regulations be defined and
put into place to protect future
human research participants.
The Belmont Report
The three basic principals outlined in
the Belmont Report can be summarized as:
1. Respect for persons: Under this
principal, individuals should be
treated as autonomous agents and
should be entitled to protection if
they have diminished autonomy.
2. Beneficence: Under this principal,
subjects should be protected from
harm and an effort should be made
to secure their well-being.
3. Justice: Subjects should be treated
equally in regards to the distribution
of the burdens and benefits of the
research.
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 The Belmont Report is a critical
document for those involved
in research. However, the report is
also applicable to clinical practice.
 The primary purpose of the Belmont
Report is to protect the rights of
all research subjects or participants.
 The Belmont Report also serves as
an ethical framework for research.
IMPORTANCE OF ETHICAL NORMS IN
RESEARCH
1. To promote the aims of research, such
as knowledge, truth, and avoidance of
error.
Example: prohibitions
against fabricating, falsifying, or
misrepresenting research data promote
the truth and minimize error.
2. To promote the values that are essential
to collaborative work, such as trust,
accountability, mutual respect, and
fairness.
o ethical standards is required
since research often involves a
great deal of cooperation and
coordination among many
different people in different
disciplines and institutions.
Example: Many ethical norms in
research, such as guidelines for authorship,
copyright and patenting policies, data
sharing policies, and confidentiality rules in
peer review, are designed to protect
intellectual property interests while
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encouraging collaboration. Most
researchers want to receive credit for their
contributions and do not want to have
their ideas stolen or disclosed
prematurely.
3. Help to ensure that researchers can be
held accountable to the public.
Example: federal policies on
research misconduct, conflicts of interest,
the human subjects protections,
and animal care and use are necessary in
order to make sure that researchers who
are funded by public money can be held
accountable to the public.
4. Help to build public support for
research.
People are more likely to fund a
research project if they can trust the
quality and integrity of research.
5. To promote a variety of other
important moral and social values such as:
o social responsibility,
o human rights,
o animal welfare,
o compliance with the
law, and
o public health and safety
EMS
Ethical lapses in research can significantly
harm human
and animal subjects, students, and the
public.
Example: a researcher who fabricates data
in a clinical trial may harm or even kill
patients, and a researcher who fails to
abide by regulations and guidelines
relating to radiation or biological safety
may jeopardize his health and safety or the
health and safety of staff and students.
Codes and Policies for Research Ethics
Honesty
Strive for honesty in all scientific
communications. Honestly report data,
results, methods and procedures, and
publication status. Do not fabricate, falsify,
or misrepresent data. Do not deceive
colleagues, research sponsors, or the
public.
Objectivity
Strive to avoid bias in experimental
design, data analysis, data interpretation,
peer review, personnel decisions, grant
writing, expert testimony, and other
aspects of research where objectivity is
expected or required. Avoid or minimize
bias or self-deception. Disclose personal or
financial interests that may affect
research.
Integrity
Keep your promises and agreements; act
with sincerity; strive for consistency of
thought and action.
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 Carefulness
Avoid careless errors and negligence;
carefully and critically examine your own
work and the work of your peers. Keep
good records of research activities, such as
data collection, research design, and
correspondence with agencies or journals.
Openness
Share data, results, ideas, tools, resources.
Be open to criticism and new ideas.
Responsible Mentoring
Help to educate, mentor, and advise
students. Promote their welfare and allow
them to make their own decisions.
Respect for colleagues
Respect your colleagues and treat them
fairly.
Social Responsibility
Strive to promote social good and prevent
or mitigate social harms through research,
public education, and advocacy.
Non-Discrimination
Avoid discrimination against colleagues or
students on the basis of sex, race,
ethnicity, or other factors not related to
scientific competence and integrity.
Competence
Maintain and improve your own
professional competence and expertise
through lifelong education and learning;
take steps to promote competence in
science as a whole.
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Legality
Know and obey relevant laws and
institutional and governmental policies.
Animal Care
Show proper respect and care for animals
when using them in research. Do not
conduct unnecessary or poorly designed
animal experiments.
Human Subjects Protection
1. When conducting research on
human subjects, minimize harms
and risks and maximize benefits;
2. respect human dignity, privacy, and
autonomy;
3. take special precautions with
vulnerable populations;
4. and strive to distribute the benefits
and burdens of research fairly.
Ethical Decision Making in
Research
Case 1:
 The research protocol for a study of
a drug on hypertension requires the
administration of the drug at
different doses to 50 laboratory
mice, with chemical and behavioral
tests to determine toxic effects.
 Tom has almost finished the
experiment for Dr. Q. He has only 5
mice left to test. However, he really
wants to finish his work in time to go
44
 to Florida on spring break with his
friends, who are leaving tonight. He
has injected the drug in all 50 mice
but has not completed all of the
tests. He therefore decides to
extrapolate from the 45 completed
results to produce the 5 additional
results.
 Many different research ethics
policies would hold that Tom has
acted unethically by fabricating data.
If this study were sponsored by a
federal agency, such as the NIH, his
actions would constitute a form of
research misconduct, which the
government defines as "fabrication,
falsification, or plagiarism" (or FFP).
Actions that nearly all researchers
classify as unethical are viewed as
misconduct. It is important to
remember, however, that
misconduct occurs only when
researchers intend to deceive:
honest errors related to sloppiness,
poor record keeping,
miscalculations, bias, self-deception,
and even negligence do not
constitute misconduct. Also,
reasonable disagreements about
research methods, procedures, and
interpretations do not constitute
research misconduct.
EMS
Case 2:
Dr. T has just discovered a mathematical
error in his paper that has been accepted
for publication in a journal. The error does
not affect the overall results of his
research, but it is potentially misleading.
The journal has just gone to press, so it is
too late to catch the error before it
appears in print. In order to avoid
embarrassment, Dr. T decides to ignore the
error.
Dr. T's error is not misconduct nor is his
decision to take no action to correct the
error. Most researchers, as well as many
different policies and codes would say that
Dr. T should tell the journal (and any
coauthors) about the error and consider
publishing a correction or errata. Failing to
publish a correction would be unethical
because it would violate norms relating to
honesty and objectivity in research.
ETHICAL OR MORAL DILEMMA
Case 3:
Dr. Wexford is the principal investigator of
a large, epidemiological study on the
health of 10,000 agricultural workers. She
has an impressive dataset that includes
information on demographics,
environmental exposures, diet, genetics,
and various disease outcomes such as
cancer, Parkinson’s disease (PD), and ALS.
She has just published a paper on the
relationship between pesticide exposure
and PD in a prestigious journal. She is
planning to publish many other papers
from her dataset. She receives a request
from another research team that wants
45
access to her complete dataset. They are
interested in examining the relationship
between pesticide exposures and skin GOOD CLINICAL PRACTICE – GCP
cancer. Dr. Wexford was planning to
conduct a study on this topic.
 GCP – INTERNATIONAL ETHICAL
AND SCIENTIFIC QUALITY
Dr. Wexford faces a difficult choice. STANDARDS FOR DESIGNING,
o On the one hand, the ethical CONDUCTING, RECODRING AND
norm of openness obliges her REPORTING TRIALS THAT
to share data with the other INVOLVE PARTICIPATION OF
research team. Her funding HUMAN SUBJECTA
agency may also have rules
that obligate her to share
data.
 WHY IS IT NEEDED?
o On the other hand, if she
shares data with the other
team, they may publish results o TO ENSURE THAT THE
that she was planning to RIGHTS, SAFETY AND
publish, thus depriving her WELLBEING OF THE TRIAL
(and her team) of recognition SUBJECTA ARE PROTECTED
and priority. o ENSURE THE CREDIBILITY
It seems that there are good arguments on OF CLINICAL TRIAL DATA
both sides of this issue and Dr. Wexford  WHY HAS IT DEVELOPED INTO
needs to take some time to think about FORMAL GUIDELINES?
what she should do. o PUBLIC DISATERS,
o One possible option is to share SERIOUS FRAUD AND
data, provided that the ABUSE OF HUMAN
investigators sign a data use RIGGHTS
agreement. The agreement
could define allowable uses of
the data, publication plans,
authorship, etc.
o Another option would be to
offer to collaborate with the
researchers.

46
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13 GCP PRINCIPLES FOR RESEARCH
“I do the best I know- the very best I can and I
mean to keep doing so until the end.
If the end brings me out all right, what is said
against me won’t amount to anything
If the end brings me out wrong, ten angels
swearing I was right would make no difference.”
- white uniform, but when I speak you
Abraham Lincoln-
LISTEN NURSE
I was hungry and I could not
feed myself, you let my food tray out
of reach on my bedside table, then
you discussed my nutritional needs
during a nursing conference.
I was thirsty and helpless, but
you forgot to ask the attendant to
refill my water pitcher; you later
charted that I refused fluids;
I was lonely and afraid, but
you let me alone because I was so
cooperative and never asked for
anything.
EMS
I was in financial difficulties
and in your mind, I became an object
of annoyance;
I was nursing a problem and
you discussed the theoretical basis
of my illness and you did not even
see me;
I was
thought to be dying, and thinking I
could not hear, you hope I would not
die before it was time to finish your
shift, because you have an
appointment at the beauty parlor
before your evening date;
You seem so well
educated, well- spoken and so very
neat in your spotless unwrinkled
seem to listen, but do not hear me;
Help me care about happens
to me, I am so tired, so lonely, and
so very afraid;
Talk to me…. reach out
to me…… take my hand, let what
happens to me matter to you….
PLEASE NURSE……………………….
FIVE CALLS
BY: FATHER JERRY ORBOS, SVD
• Call to life [Life Line] –
bring people to life, don’t
curtail life.
• Call to be a Person [Personal Life]-
treat others like yourself. Be
sincere.
• Call to be a Christian [Love Line]-
Fill the world with love.
47
 • Call to Serve [Service Line] -
You and I have a mission in
life.

• Call to Eternity [Last Call] -

See you in heaven.
• Bottom Line -
There is nothing perfect in this
world.

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