CHAPTER 1: INTRODUCTORY CONCEPTS ON HEALTH CARE
ETHICS
INTRODUCTION:
 The word ethics is derived from the Greek word “ethos”,
which means custom or guiding beliefs. Ethics
determines the characteristics of a profession and is
also called as a “code of conduct”.
 Nursing ethics provides the professional standards for
nursing activities, which protect the nurses and the
patients from legal and ethical issues.
 Ethics are the determined standard rules or principles
that govern the right conduct and are designed to
protect the rights of a human being. There is a set of
ethics that is used by the nursing profession.
 The code of ethics explains the members of a profession
what kind of conduct is expected from them in their
practice. It states the responsibilities of the members
towards those they serve, their co-workers, the
profession and the society as a whole. When a person
becomes a member of the nursing profession, he/she
should accept the responsibility of living according to
the code of ethics in order to maintain the standards of
the nursing profession.
DESIRED LEARNING OUTCOMES (DLOS)
At the end of the teaching –learning sessions the students are
expected to achieve the following:
 Recognize the need to study Health Care Ethics and the
Importance of the subject to the nursing profession.
 Define philosophy, theory, ethics, law, bioethics,
professional ethics, health ethics, and human nature.
 Apply the concept of the different ethical theories in
specific scenarios
 Demonstrate caring as the core of nursing, love of God,
love of country, and love of people.
 Describe nursing ethics and explain in detail the
involvement of ethics in the various branches of
nursing.
 
Introductory Concepts and Definition of Terms
LEARNING CONTENT:
Definition of Terms:
Philosophy
- comes from the Ancient Greek and traditionally define
as the love of wisdom (pp.1)
- It attempts to explain what is real and what is not real
or what is true and what is false.
- Its discussion based on the capabilities of the human
mind about the nature of reason and reality
Theory
- refers to principle which attempts to describe the truth
about reason and reality.
Ethics
- is that branch of philosophy that implies human mind as
the fundamental means by which action may be judged.
The judgment itself may arise from the nature and
principles of reason (as in Kant,1984)
- It is not the same as moral theology or religious ethics
since ethics use common human experience as its point
of departure.
- Ethics is not to be taken as an attack on religious
founded morality, which for the believer has a superior
validity.
IMPORTANCE OF ETHICS IN NURSING
Ethics is important in the nursing profession for the
following reasons:
- Ethics is used to guide the professional behavior of the
nurses.
- It helps the teachers to identify what needs to be taught
for the nursing students.
- It can be used to prevent a nurse from practicing if
his/her conduct is poor and clearly below the standards
set by the code.
- It can be used to protect a nurse who is falsely accused
of doing something wrong.
- It can also be used as a guide for direction when legal
action must be taken in a lawsuit.
Nor ethics the same as law, although law is an important
expression of social judgment about the rightness and wrongness
of actions that seriously affect the public good.
Law
- is largely concerned with the public good and the
protection of individual rights.
Example: The prohibition and definition of murder, which is an
issue when medical treatment can be terminated or in example of
copyright laws governing file swapping and in sharing music or
videos.
Bioethics
- is concerned with questions about basic human values
such as the rights to life and health, and the rightness or
wrongness of certain developments in healthcare
institutions, life technology, medicine, the health
professions and about society's responsibility for the
life and health of its members.
- Bioethics is multidisciplinary and it blends philosophy,
theology, history, and law with medicine, nursing, health
policy, and the medical humanities.
Examples of topic areas of bioethics are organ donation and
transplantation, genetic research, death and dying, and
environmental concerns.
Professional Ethics
- ethical norms, values, and principles that guide a profes
sion and the ethics of decisions made within the profess
ion.
Nursing ethics
- refers to the professional standards of conduct
practiced by nurses related to or in accordance with
approved moral behaviour in rendering health care
services.
- refers to the moral code of nursing and is based on
obligation to service and respect for human life.
- is the values and ethical principles governing nursing
practice, conduct, and relationships.
NURSING ETHICS
- Nursing ethics provides the professional standards for
nursing activities, which help to protect not only the
nurse but also the patient. In 1973, the International
Council for Nurses (ICN) adopted the code of ethics and
implemented a rule that all nurses must follow this
code. 
The main objectives of the code of ethics as described by the
ICN are as follows:
 Promote health and well-being.
 Prevent illnesses and complications.
 Restore the health and alleviate the suffering of the
patient without any complications.
- The generalized objective of the code of ethics is that
the principles evolved should be made universal and
nursing care should be given irrespective of the race,
caste, creed, religion, age, sex and politics of the patient.
- A nurse should maintain the dignity of the nursing
profession in any situation and should not be influenced
 by the social status of the patient or money and get
involved in corruption. This is possible only by following
nursing ethics.
Nursing Branches Involving Ethical Issues
Ethical issues are involved in the following branches in
nursing:
 Nursing research
 Nursing education
 Nursing administration
 Nursing management
 Intensive care unit
 Operation theatre/surgical nursing
 Medical nursing
 Community health nursing
 Child health nursing
 Mental health nursing
 Maternity nursing
 Nursing procedures
The Code of Ethics
- states the kind of conduct expected from the members
of a profession and the responsibilities of its members
towards those whom they serve, their co-workers, the
profession and the society as a whole. It would be easier
in decision-making if the member understands what the
wrong or right behavior in different situations
- The first such code of ethics, called the International
Code of Nursing Ethics, was adopted by the Grand
Council of the ICN at Sao Paulo, Brazil, in 1953.
- It was later revised in Frankfurt, Germany, in 1965 and
then came to be known as the ICN Code of Ethics.
- The most recent revision was in 1973 and took place in
Mexico City, Mexico, and resulted in the present code for
nurses.
- Each revision of the code has resulted in clearer and
broader standards, which can be applied in any culture.
International Code of Nursing (ICN) Code of Ethics gives a
general description of the following:
 What a nurse does: the fourfold responsibility of
promoting health, preventing illness, restoring health
and alleviating suffering.
 How nursing service should be given: unrestricted by
the considerations of nationality, race, creed, colour, age,
sex, politics or social status; coordinated with related
groups.
 To whom service is given: the individual, the family
and the community.
The body of the code is made up of five sections.
1. Nurses and People
This code is concerned with a nurse’s actions towards
the people. Here, the term “people” refers to the
patients for whom care is provided. A nurse’s
responsibilities based on the ethics are as follows:
- Hold the personal information of patients in
confidence and use judgement in sharing this
information.
- Provide nursing care with prime responsibility
for those who need care.
- Provide care for patients without considering
their caste, creed, etc. and give respect to their
values, customs, and spiritual beliefs.
2. Nurses and Practice
A nurse should adopt standard nursing practices while
providing nursing care and should maintain the highest
quality possible within the reality of the specific
situation. The following are the principles stated in this
code with respect to a nurse’s practice:
- Have a personal interest in updating his/her
knowledge and should ensure it by continual
learning.
- Always provide evidence-based care with the
help of continuous research activities.
- Apply the scientific principles specific for each
nursing procedure as learnt and modify, verify
the same, and act according to the hospital
practices.
- Never ignore any patient while on duty.
- Should commit any malpractice or be
negligent while working.
- Avoid absenteeism in working hours.
- Be physically, mentally, and socially alert at all
times during practice.
- Accept and delegate the responsibilities with
proper judgement and expert guidance.
- Always maintain standards throughout the life
of nursing practice
3. Nurses and Society
This code reflects on the responsibilities of a nurse
towards the society and states the following:
- Educate the public and create awareness about
the various health problems as and when
needed.
- Initiate and support activities to meet the
health and social needs of the public.
- Act as an initiator, supervisor and supporter of
any health program implemented for the
benefit of the society.
- Inform the higher authorities in time about
any abnormalities or contagious diseases
noticed during nursing care.
Health Care Ethics
- Health Care Ethics (a.k.a “medical ethics”) is the
application of the core principles of bioethics
(autonomy, beneficence, non-maleficence, justice) to
medical and health care decisions.
- It is a multidisciplinary lens through which to view
complex issues and make recommendations regarding a
course of action.
International Code of Nursing Ethics
The International Code of Nursing Ethics states the
following:
 The fundamental responsibility of a nurse is to conserve
life and to promote health. Every nurse is a teacher of
health by example.
 A nurse must be adequately prepared to practise
nursing and be willing to continue to learn new ideas by
reading and attending meetings.
 A nurse must learn to respect authority.
 A nurse must carry out the doctor’s orders accurately
and sustain confidence in the doctor and all members of
the health team.
 A nurse should report any unusual condition or
symptom to the doctor or the nurse in charge.
 The religious beliefs of a patient should be respected.
 All information given to a nurse should be held in
confidence.
 When a patient requires continued nursing care, the
nurse must remain with the patient until adequate relief
is available.
  A nurse has the obligation to give conscientious service
and, in return, is entitled to just remuneration.
 A patient should always be called by his full name.
 Punctuality is very important for a nurse.
 Obedience is very important in observing rules and
regulations.
 Every nurse must have respect for authority and for
rules and regulations.
 Manpower, money and material supplies should be
blended fairly as per the hospital needs to meet the
demands of the patients. Any inequality in manpower,
money and material will affect not only the nursing care
but also the entire management process in the hospital.
NURSING ETHICS AND PROFESSIONAL ETIQUETTE
- Etiquette means good manners. We all learn certain
standards of social etiquette in daily life. We know how
to behave with courtesy and respect in our relations
with other people.
- For example, we learn when it is correct to remain
seated or to get up in different kinds of social situations.
We also learn how to make another person feel
welcome, comfortable and at ease. Much of what we do
in these relationships depends upon the social customs
of the community in which we live.
Professional Etiquette
- Professional etiquette means “good manners” in
professional relationships. Just as we learn social
etiquette, we must also learn what etiquette is
acceptable and expected of us in our professional
relationships.
- It is essential for successful working relationships with
those in authority, nursing colleagues, members of other
professions, patients and those in society.
PROFESSIONAL ETIQUETTE FOR NURSES
- Professional etiquette for nurses refers to the ethical
manners and moral behaviour that a nurse should
follow throughout his/her life of nursing. Maintaining
good etiquette reflects good morality in the nurse.
The important qualities that make up good professional
etiquette are as follows:
 Being gentle and polite to all patients, seniors and other
health workers in the hospital.
 Giving respect to the seniors, co-workers and clients.
 Addressing seniors with proper title such as Sir or
Madam.
 Answering politely and humbly to any questions asked
or clarifications sought by the seniors.
 Giving way to the seniors and standing aside and
allowing the senior nurse to pass.
 Maintaining discipline wherever needed such as in the
ward, conference meeting with seniors, classroom and
library.
 Keeping the uniform neat and tidy.
 Not wearing any gold jewelry or applying make-up
while on duty.
 Obeying the rules and regulations of the hospital at all
times.
 Getting proper prior permission from colleagues and
the nurse-in-charge before taking any articles from the
ward.
Ethical Theories
1. Utilitarianism
- sometimes called Consequentialism
- is a form of teleological theory.
- Telos from Greek word meaning end
- Moral theory that holds an action is judged as
good or bad in relation to consequence
rightness and wrongness of an action in terms
of the consequences brought about by the
action.
- These Consequences are generally evaluated
according to the extent to which they serve
some intrinsic good
Most common Consequentialism is utilitarianism or Social
Consequentialism
- one should act so as to do the greatest good for the
greatest number.
- In the 18th century Jeremy Bentham a leading political
philosopher is considered to be the father of modern
utilitarianism.
- According to Bentham theory actions can be considered
to be right when they increase happiness and diminish
misery and can be considered to be wrong when they
have opposite effect.
Following is Bentham theory of the “principle of utility”
- By utility is meant that property in any object, whereby
it tends to produce benefit, advantage, pleasure, good or
happiness or prevent the happening of mischief, pain,
evil or unhappiness to party whose interest is
considered. If the party is a community then the
happiness of the community (Bentham 1948).
Example:
- The good as defined by John Stewart Mill would be the
presence of pleasure and the absence of pain to
determine the proper action involves adding up the
aggregate pleasures and pain suffered by the members
of the community
Contemporary development of Mill’s utilitarianism is the
distinction between:
Act utilitarianism
- an individual is obligated to evaluate each of his or her
actions on utilitarian grounds. There is a great deal of
freedom and responsibility here for what we normal
understand to be moral (such as do not lie).
Rule utilitarianism
- experience based on attempts to maximise utility
generate certain rules which when followed can be
expected to reliably produce and thus ought to be
followed
Case Example: In the application of utilitarianism is the ethical
analysis of contraception. The basic idea of contraception is to
prevent pregnancy is to prevent a pregnancy arising from sexual
intercourse.
Strengths and Weakness of Utilitarianism

Evaluation
Overall, the weakness outweighs strengths because utilitarianism
doesn't take into account the feelings or happiness of the
minority and also how can we measure pleasure, you cannot add
a value towards it.
2. Kantian Deontologism
- expressed by Immanuel Kant as clearly as
mathematical knowledge and a Mathematical
truth that two plus two is four, so is ethical
truth.
- Deontologist considers the rightness or
wrongness of at the acts rather than
consequences.
- Deontology is taken from Greek word for duty,
sometimes called formalism and some writers
refer to this theory as Kantianism
- Kant contented the ethical rules as universal
and that humans can derive certain consistent
principles to guide action.
- The awareness of these moral rules is the
product of pure reason, rather than experience
as the naturalist would maintain.
- Kant asserted moral rules are absolute and
apply to all people.
- Categorical refers top moral rules that do not
admit exceptions imperative denotes a
command that is derived from principle
- Kant said there is only one Categorical
Imperative – Act only according to the maxim
by which you can at the same time will that it
should become a universal law.
- Formal rules are used in judging the rightness
of an act such as “Do unto others as you would
have them do unto you”.
- Act in such a way that you would always treat
humanity whether in your own person or in
the person of any others.
Example of deontological ethics:
- You are duty bound to be faithful to your spouse even if
a more attractive person comes along.
- You are duty bound to always tell the truth, even when it
cost you a job
3. Natural law or Classical or Scholastic Theory
- take as the position that rational reflection on
nature will lead principles of good and bad
that can guide human actions towards human
fulfillment or flourishing.
- Natural law focuses on our ability to recognize
the structured complexity and coherence of
nature
- This was developed by Thomas Aquinas in the
thirteenth century and Natural law became a
central feature of catholic moral thinking.
- Aristotle was the first person to think of the
natural law approach. He lived in the fourth
century BC and was a Greek philosopher. He
began thinking of his theory by distinguishing
between “efficient causes” and “final causes”.
- An efficient cause is what gets things done, a
final cause is the end product.
Example:
- Here is a first example, a child grows up to be an adult
and Aristotle would say that an “efficient cause” of the
child’s growth is food and drink. but the “final cause” is
the adult into which the child is growing.
- Another example would be if I take a piece of wood and
carve it into a statue. The efficient cause is the knife I
used but the final cause is the image that I want to
create – the statue.
- Natural law, everything (object and action) has
some final meaning and purpose – it’s final
cause – and this is what determines it’s “good”.
Therefore, if we understand what that final
cause is, we will know what we need to do in
order to achieve it
- Aquinas further developed all these ideas that
Aristotle first thought about.
- Aquinas argued that the world was created by
God. and that everything should therefore have
God’s ultimate purpose as it’s final “end” or
“good”.
- Humans have reason and freedom so they can
rationally understand God’s final purpose.
- Natural law condemns contraception as
unethical.
4. Virtue Ethics
- involves not only not only the virtues but the
integration of the virtues which is called
practical wisdom or right reason.
- It is the ability to choose patterns of action
made desirable and revealed as desirable by
reasoning that has been informed not only by
habits of emotional experience or virtues
(Baille, 1988).
- The cultural background made the real part of
a person’s life through training to the virtues
of that society is the basis from which action
and thought arise.
Example:
- Virtues, are attitudes, dispositions, or character traits
that enable us to be and to act in ways that develop this
potential. They enable us to pursue the ideals we have
adopted.
- Virtue Ethics considers the moral character of the
person performing the act.
- This approach is not concerned with the consequence
or whether the act is carried out in accordance with
moral duties.
- What matters is whether the person carrying out the act
does so in accordance with qualities that are considered
to be virtuous, in other words good moral intentions.
 - Honesty, courage, compassion, generosity, fidelity,
integrity, fairness, self-control, and prudence are
all examples of virtues.
For example, a nurse might conclude that all terminally ill
patients are naturally depressed. However, no matter how
difficult, the nurse's ethical duty is to advocate for patients. This
requires the virtues of integrity, respect, caring, and courage.
 
Virtue Ethics in Nursing
- Caring is best demonstrated by a nurse's ability to
embody the five core values of professional nursing.
- Core nursing values essential to baccalaureate
education include:
 Human dignity
 Integrity
 Autonomy
 Altruism
 Social justice
- Nursing is a caring profession. Caring
encompasses empathy for and connection with people.
- Teaching and role-modeling caring is a nursing
curriculum challenge.
- The caring professional nurse integrates these values in
clinical practice. Strategies for integrating and teaching
core values are outlined and outcomes of value-based
nursing education are described. Carefully integrated
values education ensures that the legacy of caring
behavior embodied by nurses is strengthened for the
future nursing workforce.
Core Values in Nursing
- Values in Professional Nursing: The American
Association of Colleges of Nursing (AACN, 1998)
identified five values essential for the professional
nurse: altruism, autonomy, human dignity, integrity, and
social justice.
 Altruism: Nurse’s concern for the welfare of
patients, other nurses, and other health care
providers.
- Understands cultures, beliefs, and
perspectives of others.
- Advocates for patients.
- Take risks on behalf of patients and
colleagues.
- Mentors other professionals.
 Autonomy: Nurses respects patient’s right to make
decisions about their health care.
- Plans care in partnership with patients.
- Honors the rights of patients and families
to make decisions.
- Provides information so patients can
make informed choices
 Human dignity: Nurses values and respects the
inherent worth and uniqueness of all patients and
colleagues.
- Provides culturally competent and
sensitive care.
- Protects patient’s privacy.
- Designs care with sensitivity to individual
patient needs.
 Integrity: Nurses acts honestly and provides care
based on an ethical framework.
- Provides honest information to patients
and the public.
- Document care honestly and accurately
- Seeks to remedy errors made by self or
others.
- Demonstrates accountability of own
actions
 Social justice: Nurse upholds moral, legal, and
humanistic principles by ensuring equal treatment
under the law and equal access to quality health
care
- Supports fairness and nondiscrimination
in the delivery of care.
- Promotes universal access to health care.
OTHER CORE VALUES IN NURSING:
The values every nurse should work to, known as the 'six Cs'. The
six Cs
 Care
 Compassion
 Competence
 Communication
 Courage
 Commitment
Core Values of Nurse Advocacy
THREE CORE VALUES HELP FORM THE BASIS OF NURSING
ADVOCACY
 Preserving human dignity
 Patient equality
 Freedom from suffering
Values Clarification:
 It is a process by which people identify, examine and
develop their own individual values.
 A method whereby a person can discover his or her own
values by assessing, exploring, and determining what
those personal values are and how they affect personal
decision making.
 Goal: The goal of "values clarification" is for you to
become fully conscious of their influence, and to explore
and honestly acknowledge what you truly value at this
time in your life. This promotes personal growth by
fostering awareness, empathy and insight.
Clarifying the Client Values
- To plan effective care, nurses need to identify client’s
values as they influence and relate to a particular health
problem. For Eg:- A client with lose of eye sight will
place high value on the ability to see. When clients hold
unclear or conflicting values that are detrimental to
their health, the nurse should use values clarification as
an intervention.
Examples are:
1. List alternatives: make sure that the client is aware all
the alternative actions.
2. Examine possible consequences of choice: make sure
the client has thought about the possible results of each
action.
3. Choose freely: to determine whether the client chose
freely.
4. Feel good about the choice: to determine how the
Professionalism
- Professionalism in health care requires that one strive
for excellence in the following areas which become part
of the attitudes, behaviors and skills
1. Altruism
2. Accountability
3. Excellence
4. Duty
5. Honor and integrity
6. Respect for others

CHAPTER 2: ETHICAL PRINCIPLES - PRINCIPLES OF
AUTONOMY AND INFORMED CONSENT
ETHICAL PRINCIPLES INVOLVED IN NURSING
- In reality, ethical principles control professionalism in
nursing practice much more than the ethical theories.
- Principles are the moral norms that nursing, as a
profession, both demands and strives to implement in
everyday clinical practice.
The ethical principles that a nurse should consider when
making decisions are as follows:
1. Respect for persons
2. Respect for autonomy
3. Respect for freedom
4. Beneficence (doing good)
5. Non-maleficence (avoiding harm to others)
6. Veracity (truth-telling)
7. Justice (fair and equal treatment)
8. Respect for patients' rights
9. Fidelity (fulfilling promises)
10. Confidentiality (protecting privileged information)
ETHICAL RESPONSIBILITIES OF A NURSE
1. Meet the needs of all the patients under care.
2. Be truthful and honest to the patient and maintain
fidelity in all nursing interventions.
3. Keep all the documents confidential and safe.
4. Give care with full respect and caring attitude.
5. Always act for the benefit of the patient and do not
cause physical, social or psychological harm.
6. Maintain a therapeutic relationship with the patient.
7. Always be faithful, punctual and sincere while
performing the duty.
8. Be responsible and accountable for all actions towards
the nursing care.
9. Be aware of all the rights of a patient and try to
implement and respect them.
The ethical principles that a nurse should consider when
making decisions are as follows:
1. Respect for the Patient as a Person
- The basic responsibility of nursing ethics is to
respect the patient or the client as a person or a
human being.
- This is done by allowing the patients to take
decisions based on the choices available in
treatment, addressing them by name and not by
body structure, providing respect for their privacy,
respecting their beliefs and wishes, and striving to
obtain all their rights such as the right to be
informed, the right to get oriented, and the right to
refuse or accept treatment.
2. Respect for Freedom to Make Choices in the Patient
Care
- Many hospitals never allow the patient to choose
the treatments and are very authoritative. However,
it is unethical. The patient has the freedom to make
choices about the treatment, continue the
treatment, withhold or withdraw the treatment,
and get discharged at any time from the hospital.
3. Beneficence
- means doing good to benefit others. Being
beneficial or doing good is the ultimate goal of a
nurse. When a patient gets admitted to a hospital, it
is the duty of the nurse to alleviate his/her
suffering and discomfort, whether it is physical,
psychological, or social, and to do only good to the
patient throughout the period of his/her
hospitalization. Learning procedures while on duty
should be avoided, for example, learning to inject a
patient. In procedures such as the insertion of
intravenous cannula in the patient's vein, in which
the nurse pierces the patient's skin, if he/she
follows the correct standards of practice and
inserts the needle as per the procedure, he/she is
doing good. Instead, if he/she is learning to
puncture the vein and tries repeated venipuncture
in the same vein, it will harm the patient and
should not be done.
4. Non-maleficence
- Nonmaleficence is the principle used to
communicate the obligation to do no harm.
Emphasizing the importance of this principle is as
old as an organized medical practice. Healthcare
professionals have historically been encouraged to
do good (beneficence), but if for some reason they
cannot do good, they are required to at least do no
harm. Because of the two sides of the same coin
connotation between these two principles, some
people consider them to be essentially one and
the same.
- A nurse should know about and anticipate the
problems that may occur to the patient during
treatment. For example, the position of a bed-
ridden and paralyzed patient should be changed
frequently and all the necessary comfort devices
should be provided to him/her.
- Otherwise, it leads to the formation of bedsores in
the patient, which is difficult to cure. If the nurse
never changes the position, it amounts to doing
harm knowingly. Therefore, all the nursing activity
should be directed towards not doing harm to the
patient.
5. Veracity
- Veracity means telling the truth. A nurse should
never lie in any situation and should be honest and
truthful not only to the institution and patient but
also to the profession. For example, a nurse should
never lie about the diagnosis details. Once the
diagnosis is confirmed, he/she nurse has to reveal
the actual diagnosis made and should not lie for
anybody's sake or favor.
6. Justice in Providing Nursing Care
- Justice means being fair to all the patients,
providing care to everyone, and trusting them
equally, irrespective of their caste, creed, religion,
sex, age, education, race, socio-economic status,
and marital status. A nurse should not show any
cultural or language preference in patient care.
7. Respect for Patients' Rights
- A nurse should always give respect to the rights of a
patient, such as the right to get respect, the right to
be informed, the right to be oriented, the right to
take decisions, and the right to refuse or accept any
treatment. A nurse should be aware of all the rights
of the patient and treat him/her accordingly.
8. Fidelity
- Fidelity means maintaining promises and being
more trustworthy and fruitful towards the
profession. A nurse should be dedicated and work
with full commitment, keep all the details of a
patient safe, and create a truthful and trustworthy
relationship with patient.
9. Confidentiality
 - It is the most important ethical principle in the
nursing profession. It is the duty of a nurse to keep
all the details of a patient and the relevant
documents safe and not reveal anything to other
patients, nurses, or anybody unknown.
10. Respect for Autonomy
- This is a very important ethical principle, according
to which a nurse should give complete respect to
the patient and allow him/her to take decisions on
his/her own. A nurse should never interfere in any
part of decision-making regarding the treatment
unless the patient asks for it. Moreover, he/she
should never force the patient to choose a
treatment method. Even when the patient asks for
help, a nurse should suggest the best options
available, explain the risks and benefits associated
with the treatment, and provide alternatives if
available. While obtaining informed consent, a
nurse should explain the pros and cons of the
procedure and make sure that the patient has
understood the details clearly before getting the
signature.
Patient Autonomy: Informed Consent
AUTONOMY
- precisely as a human person does not have authority
and should not have power over another person.
- This means that an individual should not coerce others
or impose their will on others.
- Principles of autonomy in health care states that an
institution cannot treat a patient without inform
consent of the patient or her lawful surrogate exception
narrowly defined emergencies.
- This principle implies the meaning of respect for the
person for his/her freedom in the context of health care.
PATIENT'S RIGHTS
- The term patient is derived from a Latin verb meaning
“to suffer” and has traditionally been used to describe
those who are recipients of care, whereas the term
client is derived from a Latin verb meaning “to lean”
connoting alliance and independence.
- A patient has two types of rights—the moral and ethical
rights such as the right to privacy and the legal rights
such as the right to treatment.
PURPOSES OF EXECUTING PATIENT'S BILL OF RIGHTS
 To make aware of the patient's rights and to use them
appropriately when needed.
 To ensure the patient's dignity and respect and to
improve the self-esteem.
 To gain the patient's cooperation and willingness to
participate in the health care system.
 To legally protect the patient and the health care
providers by adopting the patients' bill of rights.
 To improve the patient's trust, faith, and confidence
towards the health care providers.
 To help the patient in decision-making regarding the
treatment provided.
 To keep the records of the patient's confidential and
exercise privacy while performing any procedure for the
clients.
 To help coordinate with hospital rules and regulations.
 To help ensure and continue the treatment as per the
patients in and beliefs.
 To help the patient analyze the available health
resources and their utilization.
PATIENTS BILL OF RIGHTS DURING HOSPITALIZATION
 Right to Admission
- A patient has the right to know about the
admission details in the out-patient department
(OPD). If the patient wants to know about the
procedure of the OPD, the nurse should clearly
explain the details and make him/her feel
comfortable. The patient should be free from stress
throughout his/her hospitalization.
 In-patient Department
- When a patient is admitted in the ward, he/she
should be informed about the details of care to be
given to him/her, as a checklist for patient's
verification. The patient should be informed in
advance regarding the nursing procedures, who
will be the nurse, etc, Informed consent is an
important legal documentation of the patient's
rights, wherein the patient is informed clearly both
orally and in writing about the procedure to be
performed and the signature obtained from the
patient or his/her spouse, parents, or family
members.
 Privacy
- A patient has the right to privacy, which is a right
that extends to all aspects of his/her care, including
care for his/her personal needs, screens should be
provided during physical examination and the body
should not be exposed unnecessarily.
- Moral Privacy. This is the right to take decisions on
his/her own without the interference of others.
- Legal Privacy. This is the right to check on his/her
own case sheet and reports and the right to choose
the treatment methods.
- Violating Privacy. The patient's privacy rights
should never be violated. Details of patients should
not be overheard or discussed in front of others.
 Right to Get the Bills on Time
- A patient obviously pays for the care provided to
him/her during hospitalization. Hence, he/she has
the right to know about the related charges, but
some health institutions delay the settlement of
bills. The amount should be informed prior, so that
the patient can be prepared to pay at the time of
discharge.
 Right to Complain
- A patient has the rights to express a complaint to
the concerned hospital authorities about problems
faced regarding treatment or care or regarding
issues such as lack of respect. Every hospital should
have an opinion box, which is used to obtain the
patient's feedback about the hospital procedures
and the nursing care.
 Right to Get Discharged at Any Time
- A patient has the right to get discharged from the
hospital at any time he/she wishes before the end
of the treatment. He/she cannot be compelled to
stay in the hospital. The expected length of stay for
the illness should be explained clearly to the
patient, but the patient has the right to decide
whether to continue treatment or get discharged
from the hospital.
 Right to Access the Available Resources from the
Hospital
- A patient should be informed about the available
resources and their importance, for example,
availability of the doctors, specialists, their arrival
 time, treatment details, etc. The patient should be
informed about these details before he/she asks for
it.
 Right to Access the Emergency Services
- A patient has the right to access the emergency
services when needed.
ROLE OF NURSES IN IMPLEMENTING THE PATIENT'S BILL OF
RIGHTS
 Help the patient to understand about the Patient's Bill
of Rights and its importance.
 Provide care equally to all patients without any
discrimination based on race, colour, religion, sex,
nationality, disability, socioeconomical status or age.
 Provide respectful care in a safe and hygienic
environment to all the patients.
 Be always alert and prepared to attend to any kind of
emergency. A patient in emergency should be treated
immediately without any delay.
 Provide adequate needed information about the health
care providers to the patient and orient the patient as to
the details regarding the physicians, the health care
professionals. and the hospital departments in advance,
since the right of the patient to be informed should be
understood and respected by a nurse.
 Inform the patient about the procedures, ward routines,
names of health care providers, and the rights of the
patient to choose the physicians who provide care and
to refuse care.
 Provide complete information about the patient's
assessment details, treatment and progress.
 Explain the details of informed consent and the benefits
and risks before getting the patient's signature.
 Explain to the patient about his/her right to choose
treatment modalities and to decide whether or not to
continue treatment.
 Explain to the patient about his/her right to refuse to
get involved in
research activities.
 Explain to the patient about his/her right to be present
while taking decisions regarding patient care.
 Explain to the patient about his/her right to get a copy
of medical summary regarding all aspects of treatment
from the hospital.
 Explain to the patient about his/her right to get bill
details in advance.
 Inform the patient that he/she can lodge a complaint or
give feedback if he/she is not satisfied with the care
provided by the hospital.
 Explain to the patient about his/her right to provide
authority to his/her family members and spouse to visit
him/her.
 Explain to the patient about his/her right to donate the
organs after death and record his/her wish in the donor
card that should be provided by the hospital to the
patient.
BILL OF RIGHTS
The following are the rights mentioned in the Patient's Bill of
Rights:
1. Right to get needed assistance from the hospital about
using the patient's rights.
2. Right to get treatment irrespective of the patient's sex,
race, colour, nationality, religion, disability,
socioeconomic status and age.
3. Right to get respectful care under a safe and hygienic
environment.
4. Right to get immediate care in emergency situations.
5. Right to get informed about the details of health care
providers of the hospital.
6. Right to decide the treatment modalities planned for the
patient.
7. Right to know and be oriented to the ward routines and
procedures of the hospital.
8. Right to know about the patient's diagnosis,
observation, reports and treatment.
9. Right to get the needed information before signing in
the informed consent.
10. Right to refuse any treatment provided to the patient.
11. Right to participate or refuse in research and to
withdraw at any stage of the research.
12. Right to get copies of medical reports and summary
documents of the patient's details.
13. Right to get bill details of the patient in advance before
discharge.
14. Right to keep the reports and details of the patient
confidential.
15. Right to get and provide privacy for the patient
throughout hospitalization
16. Right to complain regarding patient care to the hospital
management.
17. Right to donate organs and get donor card from the
hospital.
18. Right to provide authority for the close family
members/spouse to visit the patient and they should be
given priority in all aspects to visit the patient during
visiting hours.
INFORMED CONSENT
- Hippocrates the ancient Greek physician did not
believe that he needed the consent of patients
when being treated under his care.
- It was only in the second half of the 20th century
the development of informed consent in the United
States was formed into law.
- Inform consent was done most especially for any
invasive procedures such as those involving
surgery or treatment with considerable risk
involve.
- To disregard inform consent means a lawsuit.
- In 1960 the law has tended to say that the role of
the health care professional requires respect for
the freedom of the client and it demands inform
consent.
- Informed consent in regard to a patient's treatment
is a legal, and ethical issue of autonomy.
- At the heart of informed consent is respecting a
person's autonomy to make personal choices based
on the appropriate appraisal of information about
the actual or potential circumstances of a situation.
ELEMENTS OF INFORMED CONSENT
I. Threshold elements (preconditions)
1. Competence (to understand and decide)
2. Voluntariness (in deciding)
II. Information elements
3. Disclosure (of material information)
4. Recommendation (of a plan)
5. Understanding (of 3 and 4)
III. Consent elements
6. Decision (in favor of a plan)
7. Authorization (of the chosen plan)
Dempski (2009) presented three basic elements that are
necessary for informed consent to occur
1. Receipt of information
 - This includes receiving a description of the
procedure, information about the risks and benefits
of having or not having the treatment, reasonable
alternatives to the treatment, probabilities about
outcomes, and the credentials of the person who
will perform the treatment (Dempski, 2009, p. 78).
Because it is too demanding to inform a patient of
every possible risk or benefit involved with every
treatment or procedure, the obligation is to inform
the person about the information a reasonable
person would want and need to know. Information
should be tailored specifically to a person's
personal circumstances, including providing
information in the person's spoken language.
2. Consent for the treatment must be voluntary
- A person should not be under any influence or be
coerced to provide consent. This means patients
should not be asked to sign a consent form when
they are under the influence of mind-altering
medications, such as narcotics. Depending on the
circumstances, consent may be verbalized, written,
or implied by behavior. Silence does not convey
consent when a reasonable person would normally
offer another sign of agreement.
3. Persons must be competent
- Persons must be able to communicate consent and
to understand the information provided to them. If
a person's condition warrants transferring
decision-making authority to a surrogate, informed
consent obligation must be met with the surrogate.
KEY CONCEPT OF INFORM CONSENT
- The patient or appropriate surrogate must be
competent or have decision making capacity.
- Be capable of understanding the consequences of
the consent and be free from coercion and undue
influence that would substantially diminish
freedom.
- The health care professional within the demands of
his or her particular role must provide the
necessary information and make sure that it is
understood.
- Consent is the written document about any surgical
procedure that is explained by the nurse or
surgeon to the patient, and patient's family
members.
TYPES OF CONSENT
1. General Consent
- This is the kind of formal consent signed by the
patient at the time of admission, where if the
patient is conscious signs, witness signed by the
parents or legal guardian, their consent legally
authorizes that the patient should get standardized
care from the physician, the nurse and the entire
perioperative health care team. This consent is to
perform general ward routine activities, not for any
specific invasive procedure.
2. Special Informed Consent
- The entire health care team members are directly
responsible in getting the informed consent signed,
since the duty is delegated to the perioperative
nurse practitioner and also the surgeon, any
negligence to deliver the details of informed
consent is considered as branch of duty and
responsibilities, getting the document signed is not
enough, but explaining clearly in a understandable
manner about the surgical procedure, the risks,
benefits, alternatives and any extension procedure
that can be done along with the stated one,
especially about the anesthetic agent given by
anesthesia specialist should speak about the risk,
benefits, care given, alternatives if the circulatory
nurse found that doctor does any extended
procedure without consent immediately she should
inform it to the supervisor or administrative
authority about discrepancy.
PRINCIPLES OF BIOETHICS
INTRODUCTION
 Bioethics represents a particular branch of ethics within
the field of health care. Bioethics narrows the ethical
enquiry of moral thought of those who work as
professionals in clinical practice, basic research, or any
professional education institutions. It affects all the
health professionals who seek knowledge to improve
their skills, at times, they are trapped in legal and
ethical issues and their minds are in an ethical dilemma
regarding taking any decisions concerning the ethical
issues involved in the bioethics. Therefore, it is
important for a nurse to learn and practise bioethical
issues and management. Stewardship in Nursing
requires new models of delivery of care, and we need to
address the ever-changing nature of the work of a
nurse.
 With evolving new roles in the nursing profession,
collaboration with nursing research colleagues will be
required to develop mechanisms of evaluation and
assessment which further refine evidence that supports
the essential and exclusive contributions of the
professional nurse in outcomes of care and prevention.
PRINCIPLES OF BIOETHICS
*Murphy and Murphy (1976) Approach to Ethical Problem
Solving
1. Identify the problem.
2. Identify why the problem is an ethical problem.
3. Identify the people involved in the ultimate decision.
4. Identify the role of the decision maker.
5. Consider the short and long-term consequences of each
alternative.
6. Make the decision.
7. Compare the decision with the decision makers.
8. Follow up on the results of the decision to establish a
baseline for future decision making.
PRINCIPLE OF DOUBLE EFFECT
 Thomas Aquinas established the Principle of Double
Effect by which states that an act is permissible even
though it has a bad effect as long as it is not
intentionally done, or the intent of doing the act is to
produce something good and even if it had caused
something bad.
 Aquinas mentioned in Summa Theologica that
homicidal self-defense can be a permissible act.
 He justified that killing the attacker is allowed if the act
is unintentional, stating that “this act, since one's
intention is to save one's own life, is not unlawful,
seeing that it is natural to keep itself in being as far as
possible." but also mentioned that the act is not
unconditional, “thought proceeding from a good
intention, and can may be rendered unlawful if it be out
of proportion to the end.
 Wherefore, if a man in self-defense uses more than
necessary violence, it will be unlawful, whereas, if he
repels force with moderation, his defense will be lawful.
  This principle will help us in deciding on what action to
take during a moral dilemma that can happen in our life.
 The nurse should provide interventions to relieve pain
and other symptoms in the dying patient consistent
with palliative care practice standards and may not act
with the sole intent to end life (American Nurses
Association (ANA).
 The principle of double effect aims to provide specific
guidelines for determining when it is ethically
permissible for a human being to engage in conduct in
pursuit of a good end with full knowledge that the
conduct will also bring about bad results.
 Although there has been much substantive
disagreement concerning the precise formulation of this
principle, the principle of double effect generally states
that, in cases where an agent contemplates conduct that
has both good effects and bad effects, the course of
conduct selected is ethically permissible only if it is not
wrong in itself and if it does not require that one
directly intend the bad result.
 Requirements:
1. What you perform must be good or indifferent.
2. Intention of the agent- Beneficial effect or
harmful effect
3. The beneficial effect must be equal or better
and greater than the harmful effect, if not the
principle of double effect is illegitimate.
4. Order of time Beneficial effect, harmful effect,
it could happen in the same time.
Examples:
 As individuals you have trouble deciding some of our
choices in life, probably because those choices are not
equally good, or the consequence might cause harm.
This is where the principle of double effect takes on
how you are going to decide. A patient who had a car
accident and has been comatose for about a year. He
was declared brain dead and the family, who is
currently in a financial crisis, are now asking to pull the
plug. The family though, doesn't want to pull it and
insist that you, the nurse, should do it. Now, is it ethical
to pull the plug?
 As a nurse you are always taught to preserve the
patient's life, but in this case, the family agreed on the
euthanasia for the patient, since the patient can't give
consent, it is the family who can. Think of the act you
are about to make. Can it be labelled as a double effect?
 Using a set of criteria, we can help label if euthanasia
can be permissible.
1) The nature of the act is good and morally neutral, is
the nature of the act good? Maybe, one, because it stops
the patient's suffering once and for all. Two, his family
who's in a financial crisis, can now be relieved from
paying continuous hospital bills.
2) The person doing the act intends the good effect and
not the bad effect; the act done intends to have a good
effect. Even if the patient has died by pulling the plugs
from his life-support, it helped in taking out some
burden on the family and as well as the suffering of the
patient, who might not even wake up anymore from
being brain dead.
3) The good effect outweighs the bad effect in situations
that are serious that can justify the bad effect or the
person doing the act did it to prevent some more harm
to happen. It's the same reason as the second criteria. It
is to relieve the burden of both the family and the
patient.
THE PRINCIPLE OF LEGITIMATE COOPERATION
There are two types of cooperation that differentiates the action
of the assailant from the action of the co-operator through two
major distinctions.
 The first distinction is the formal and material
cooperation which is when the co-operator intends in
helping the act of the assailant then the cooperation is
formal of course morally wrong but if it is unintentional
then the cooperation is material
 In a health care setting, usually Doctors and Nurses help
hand in hand with each other. What if the doctor plotted
a crime to a patient just because he had a grudge against
that patient and so he asked for the nurse to do inject
high dose of potassium to the patients IV to be killed,
then, it is formal cooperation if the nurse did it with the
intention, but if the doctor did prescribed that kind of
those without telling the nurse the intent and the nurse
was oblivious and naïve and still gave the medication
without the intention of actually killing the patient is
material cooperation.
 Cooperation may be similar with partnership,
accordingly there are three principles to evaluate
partnership.
 One is that the cooperation should be mediated material
never formal or immediate material.
 Second is in a partnership, you must agree that the
decisions that you are going to do together are actually
appropriate. Cooperation with appropriate acts can
eventually help in the society.
 Lastly, everything should be straightforward. The
partnership must be open and must be honest. It
shouldn't contain any malice and doing anything behind
the back.
PRINCIPLES OF INTEGRITY AND TOTALITY
 These principles dictate that the well-being of the whole
person must be taken into account in deciding about
any therapeutic intervention or use of technology.
 Therapeutic procedures that are likely to cause harm or
undesirable side effects can be justified only by a
proportionate benefit to the patient.
 This principle is grounded in the presupposition that
God has absolute Dominion over creation, and that,
insofar as human beings are made in God's image and
likeness (Imago Dei), we have been given a limited
Dominion over creation and are responsible for its care.
 INTEGRITY refers to each individual's duty to "preserve
a view of the whole human person in which the values
of the intellect, will, conscience and fraternity are
preeminent''.
 TOTALITY refers to the duty to preserve intact the
physical component of the integrated bodily and
spiritual nature of human life, whereby every part of the
human body exists for the sake of the whole as the
imperfect for the sake of the perfect.
Example: A man's foot is gangrenous, should he consent to an
amputation? Since the amputation will save the patient's life and
he can still walk through the aid of crutches or artificial limbs, he
can consent to an operation.
 Future nurse leaders or stewards will be directly
centered on working with nurse practitioners and nurse
educators to transform the practice environments in
which they work. The intended outcome is to make
practice environments more positive, healthy and
engaging.
 Areas for dialogue may be within:
o patient-population centeredness
o safety for patients and health care personnel
o the needs of an ageing workforce
 o increased autonomy for advanced nurse
practitioners
o increased respect for the contributions made
by professional nurses
o clarification of the caring work of the nurse,
and
o enhancement of the collaborative practice of
the multidisciplinary health care team.
THE PRINCIPLE OF COMMON GOOD AND SUBSIDIARITY
 Common good refers to a standard of moral values that
is the most ideal. An individual must follow this
principle to know what the best option in making
decisions is.
 It helps to analyze problems with an optimistic point of
view since individuals are actually looking for a
common goal that will benefit people.
Example: 10 families need a school, but none of them is rich
enough to build one, and they all want the school to be in their
backyard. Some "superior society" has to collect money from all
those families, buy some land, build a school and administer it. It
could be an association founded by those 10 families, but it must
be something above" them, and something "one", that is not as
divided as those families.
 If there are 10 oil refineries in a country and 9 of them
decide to make investments to reduce pollution. This
means their prices will rise. If one refinery decides to
just pollute the atmosphere and keep its prices low, it
will be able to put the 9 other refineries out of business,
while simultaneously destroying everybody's health. If
some "superior society" has the authority to punish
refineries that don't comply, they will all have to
decrease pollution and increase their prices, so none of
them will lose any business (and we will all breathe
cleaner air). In situations like this we all actually need to
find common ground or common goal. If one cannot
decide on how to resolve a problem, we all resort to
solidarity which helps us search for a choice that we can
contribute to and will also benefit everyone who
contributes for it. This principle also helps us balance
situations that will have the same treatment for
everyone who is involved.
 Subsidiarity is actually giving power to the minority.
 It guarantees independence for lower authority which is
in relation to a higher authority.
Example: If a mother gives the freedom to her daughter on what
to wear to a party. It shows that the parent is giving the child the
freedom to choose in a health care setting, subsidiarity can
happen too.
Example: A doctor (which is considered as a higher authority)
prescribed a drug to a patient but the nurse (the lower authority)
knew that it can be harmful on the patient since the nurse
learned that the patient had allergies on the specific medication.
So, the nurse did not give it to the patient. The nurse showed that
she can also decide on her own. She might have discarded the
medication and also informed the doctor about it. Since the nurse
has her own knowledge, she is also capable of knowing what is
good or bad for the patient. It doesn't necessarily need to follow
the doctor's orders immediately when given but it is important to
inform the attending doctor on the case of the patient.
PRINCIPLE OF STEWARDSHIP AND ROLE OF NURSES AS
STEWARD
Stewardship
 A steward may be defined or characterized as a person
who preserves and promotes the intrinsic value of a
situation, as well as one who engage(s) others in
solutions and actions (Haase-Herrick, 2005).
 This principle is grounded in the presupposition that
God has absolute Dominion over creation, and that,
insofar as human beings are made in God's image and
likeness (Imago Dei). we have been given a limited
dominion over creation and are responsible for its care.
 The principle requires that the gifts of human life and
its natural environment be used with profound respect
for their intrinsic ends. Accordingly, simply because
something can be done does not necessarily mean that
it should be done (the fallacy of the technological
imperative).
PRINCIPLE OF STEWARDSHIP
 Requires us to appreciate the two great gifts that a wise
and loving God has given the earth, with all its natural
resources and our own human nature, with its
biological, psychological, social, and spiritual capacities.
 This principle is grounded in the presupposition that
God has absolute Dominion over creation, and that,
insofar as human beings are made in God's image and
likeness (Imago Dei). We have been given a limited
Dominion over creation and are responsible for its care.
 As applied to Catholic-sponsored health care, the
principle of stewardship includes but is not reducible to
concern for scarce resources; rather, it also implies a
responsibility to see that the mission of Catholic health
care is carried out as a ministry with its particular
commitment to human dignity and the common good.
THE PRIMARY ROLE OF A NURSE
 The primary role of a nurse is to advocate and care for
individuals of all ethnic origins and religious
backgrounds and support them through health and
illness. There are various other responsibilities of a
nurse that form a part of the role of a nurse, including
to:
o Record medical history and symptoms
o Collaborate with team to plan for patient care
o Advocate for health and wellbeing of patient
o Monitor patient health and record signs
o Administer medications and treatments
o Operate medical equipment
o Perform diagnostic tests
o Educate patients about management of
illnesses
o Provide support and advice to patients
FUTURE NURSE LEADERS OR STEWARDS
 Future nurse leaders or stewards will be directly
centered on working with nurse practitioners and nurse
educators to transform the practice environments in
which they work. The intended outcome is to make
practice environments more positive, healthy and
engaging Areas for dialogue may be within:
o patient-population centeredness
o safety for patients and healthcare personnel
o the needs of an ageing workforce
o increased autonomy for advanced nurse
practitioners
o increased respect for the contributions made
by professional nurses
o clarification of the caring work of the nurse,
and
o enhancement of the collaborative practice of
the multidisciplinary health care team
  Others promote the view that a steward provides
leadership through individual and collective reasoning
and the articulation of shared value priorities while
preserving and promoting the intrinsic values of
nursing, including equity and fairness (Murphy &
Roberts, 2008).
 These notions may be appealing to nurse leaders who
are willing to choose and exercise stewardship through
the notion of a virtue-based ethic. At the same time,
these authors note that the articulation of shared value
priorities is a complex process with multiple tensions.
 Making decisions based upon what is known or
described as the common good has given way to a
dominant view of managerial decision-making. Thus,
the sharing of community values may be put aside in
favor of choices that are of instrumental, economical
good that is intended for society. Members of healthcare
disciplines, and especially the discipline of nursing,
should discern the value priorities for which it will
practice and display the conduct of stewardship in the
discipline, while serving as leaders and scholars who
will preserve and protect the values of the discipline for
future generations.
 Stewardship is a metaphor or expression used to
describe the ethical responsibilities and obligations of a
discipline. Nurse scholars can be fruitfully imagined as
stewards, who hold in trust and care for the vigor,
quality, and integrity of the discipline.
 The Carnegie Foundation has proposed that a steward
of a discipline is a person who is a scholar first and
foremost, someone who will creatively generate new
knowledge, critically conserve valuable ideas, and
responsibly transform new understandings through
writing, teaching, and application (Golde & Walker.
2006).
 The concept or metaphor of stewardship may be
illuminated as potential ethical convictions that are
necessary to be understood as responsible scholars of
the discipline of nursing grapple with discerning the
knowledge base that will guide research, practice, and
education for future generations. Scholars and leaders
of the discipline of nursing should be faithful stewards
in preserving nursing knowledge and skills.
STEWARD
 A steward may be defined or characterized as a person
who preserves and promotes the intrinsic value of a
situation, as well as one who engage(s) others in
solutions and actions (Haase-Herrick,2005).
 But is not reducible to concern for scarce resources.
 It also implies a responsibility to see that the mission of
Catholic health care is carried out as a ministry with its
particular commitment to human dignity and the
common good.
CHAPTER 5: BIOETHICS AND ITS APPLICATION IN VARIOUS
HEALTH CARE SITUATION
Introduction
 In characterizing society, whether ancient or modern,
there are two elements rather closely interconnected
which are of prime importance like one is the economic
system, the other the family system. The sexual orals of
the community will be found to consist of several layers.
 There are positive institutions embodied in law like
monogamy in some countries and polygamy in others.
The effects of sexual ethics are the most diverse kinds:
personal, conjugal, familial, national and international.
The primary motive of sexual ethics as they have
existed in Western civilization since pre-Christian times
has been to secure that degree of female virtue without
which patriarchal family becomes impossible since
paternity is uncertain Marriages may be decided by the
parties themselves or by their parents.
DESIRED LEARNING OUTCOMES (DLOS)
At the end of the teaching-learning sessions the students are
expected to achieve the following:
 Need, purpose and scope of bioethics on Sexuality and
Human reproduction
 Principles of bioethics
 Analyze and discuss different Bioethical issues in
medical practice
 Relate the importance of Bioethics to different
bioethical issues
LEARNING Content
Sexuality and Human Reproduction
 Human sexuality is a part of our total personality. It
involves the interrelationship of biological,
psychological and sociocultural dimensions.
 The Sexuality Information and Education Council of the
United States encompassing the sexual knowledge,
beliefs attitudes values and behaviors of individuals. Its
various dimensions include anatomy physiology and
biochemistry of sexual response system identity, roles
personality and thoughts, feeling and relationships.
 The expression of sexuality is influenced by ethical,
spiritual, cultural and moral concerns (SEICUS 2012).
 Sexuality – talks about who we are than about what we
can do.
 Human sexuality is a part of our total personality It
involves the interrelationship of biological,
psychological and sociocultural dimensions.
Interactive Nature of Social dimensions
A. Biological dimensions of our sexuality involve our physical
appearance especially the development of physical sexual
characteristics: our responses to sexual stimulation: our ability to
reproduce or control fertility and our growth and development in
general.
 Example: A model of sexual response cycle published by
a well-known researchers Masters and Johnson in
1966.focused mainly on physiology.
 Fisher (1992) emphasizes the genetic aspects of
behavior in her view humans have a common nature a
set of unconscious tendencies that are encoded in our
genes.
 She recognizes that culture plays a role in one's
sexuality she also seems to support essentialism, the
belief that the essence of biological dimensions.
 Example: the sexual double standard in which men are
expected to be promiscuous and women are not is a
belief held by many people in the US.
B. Psychological Dimensions
 Sexual activity is also psychology our sense of being.
Sexuality is probably the clearest example of learned
aspects of sexuality.
 Our attitudes and feeling toward ourselves and other
people begin to develop very early in life.
 From the time we are born, we get signals from all
around us how to think and act we learn that some
words are wrong or dirty and that certain parts of our
body are unmentionable.
Reason to Study Sexuality
A. Obtaining accurate sexual knowledge.
B. Clarifying personal values.
C. Improving sexual decision making.
 D. Learning the relationship between human sexuality and o Group Marriage
personal well-being. Arguments against Non-Monogamous Marriages
E. Exploring how the varied dimensions of human 1. Bible advocates marriage.
sexuality influence one's sexuality. 2. Tradition
Major Aspects of Human Sexuality 3. Exclusivity required by law.
A. Public aspect – adversely affects others not directly 4. Social diseases and AIDS eliminated (or greatly
involved. reduced).
B. Private aspect – directly affects consenting adults only. 5. Better for children
Meaning and Purpose of Human Sexuality Argument for Non-Monogamous Marriage
1. Procreation 1. Encourages alternative lifestyles and arrangements
2. Pleasure where all enter freely and willingly into.
3. Expression of love Homosexual marriage – purpose of sex as an expression of love.
4. Expression of friendship/liking Arguments against Homosexuality
1. 'Unnatural' and 'perverse
C. Sociocultural Dimensions of sexuality is the sum of the 2. Against laws of God
cultural and social influences that affect our thought and actions. 3. Sets bad example for children.
 Tiefer (1995) promotes the idea of social 4. Homosexuals regarded as main cause of AIDS
constructionism which proposes that sexual identifies 5. Offensive to 'family values'
and experiences are acquired from the people around Arguments for Homosexuality
them, and influenced and modified by an ever-changing 1. Non conclusive 'proof of natural laws or God's law
social environment. 2. Private issue (recent Supreme Court decision striking
 People acquire social meanings skills and values from down Texas sodomy laws)
the people around them. 3. No link between homosexuality and inclination to child
 These dimensions of sexuality are the sum of the abuse
cultural influences that affect our thoughts and actions 4. Non incompatibility between homosexuality and family
both historical and contemporary. values
 Example: Historical influences become evident when Arguments against Adultery
one considers roles of males and females as well as 1. Violation of most personal and intimate human contract
certain customs 2. Bad consequences for all affected
 Among sources of influence are religion, Arguments for Adultery
multiculturalism, socioeconomic status, ethics, the 1. Private sexual freedom
media and the politics. 2. Need not be bad consequences if affairs conducted
Moral issues and the public aspect of human sexuality discreetly
1. Rape, child molestation and sadism considered harmful Arguments against Masturbation
to the public and controlled by law. 1. Religious - abusing oneself
2. Pornography, homosexuality, sex outside marriage, 2. Domino argument
prostitution, masturbation, non-monogamous marriage Arguments for Masturbation
and ‘unnatural’ or 'perverted' sex are all activities 1. Natural and harmless and safe.
considered by some to be against public interest. Arguments against Pornography
Arguments against sexual freedom 1. Degrading to human beings
1. Violation of tradition and family values. 2. Criminal – causes harm
2. Domino argument. 3. Degrading to women
3. Offense to public taste. 4. Encourages “perversions”
4. Social diseases and AIDS. Arguments for Pornography
Arguments for sexual freedom 1. Individual discretion.
1. Individual freedom. 2. No proof of degradation.
2. Traditions seen as irrelevant. 3. Help to eliminate repression.
3. Reputation of the Domino argument. 4. Crimes covered by other laws.
4. Offensive to public taste (don't do, look, buy, etc. of??) 5. Exploitation is matter of opinion.
5. Social diseases and AIDS promote responsibility Arguments against Prostitution
without restricting choice. 1. Extramarital and commercialized sex is immoral
Premarital sex (Arguments against) 2. Causes crime
1. The undermining of traditional morality and family 3. Social diseases and AIDS
values. Arguments for Prostitution
2. The encouragement of promiscuity. 1. Safe sexual release
3. Social diseases and AIDS. 2. Victimless crime
4. Fostering of guilt and ostracism. 3. Social acceptance and governmental control sexual
5. Having children perversion or 'unnatural' sexual activity.
6. The compatibility and experience
 Sex in marriage – type relationships (including Marriage
nonlegal) continuous and lasting Purpose of Fundamentals of Marriage
sex in this relationship.  Marriage can refer to a legal contract and civil status, a
o Intimate expression of love religious rite, and a social practice all of which vary by
o Procreation legal jurisdiction religious doctrine and culture.
 Various types of marriage relationships  St. Thomas Aquinas (ca. 1225-1274) grounded
o Monogamy concurring judgments about sexual morality in natural
o Polygamy law, explicating marriage in terms of basic human
 goods. including procreation and fidelity between
spouses.
 (Finnis 1997). Monogamous marriage, as the
arrangement fit for the rearing of children, "belong(s) to
the natural law.
 Monogamous marriage secures paternal guidance,
which a child needs, fornication is thus a mortal sin
because it tends to injure the life of the offspring
(Aquinas rejects polygamy on similar grounds while,
like Augustine, arguing that it was once permitted to
populate the earth.)
 Marital sex employs the body for its purpose of
preserving the species, and pleasure may be a divinely
ordained part of this.
 The idea that marriage has a special moral status and
entails fixed moral obligations is widespread and
philosophically controversial.
 Marriage is a legal contract, although an anomalous one:
as the idea of it as a contract has taken hold, questions
have arisen as to how far its obligations should be
subject to individual choice.
 The contractual view of marriage implies that spouses
can choose marital obligations to suit their interests.
 However, to some, the value of marriage consists
precisely in the limitations it sets on individual choice in
the service of a greater good: thus, Hegel commented
that arranged marriage is the most ethical form of
marriage because it subordinates personal choice to the
institution.
 The institutional view holds that the purpose of the
institution defines its obligations, taking precedence
over spouses' desires, either, in the two most prominent
forms, in the service of a procreative union, or to
protect spousal love.
 These theories have implications for the moral status of
extra-marital sex and divorce, as well as the point and
purpose of marriage.
Contractual Views
 On the contractual view, the moral terms and
obligations of marriage are taken as a set of promises
between spouses. Their content is supplied by
surrounding social and legal practices, but their
promissory nature implies that parties to the promise
can negotiate the terms and release each other from
marital obligations.
1. Marriage
Fundamentals of Marriage
▪ Marriage’ can refer to a legal contract and civil
status, a religious rite, and a social practice, all of
which vary by legal jurisdiction, religious doctrine,
and culture.
▪ St. Thomas Aquinas (ca. 1225–1274) grounded
concurring judgments about sexual morality in
natural law, explicating marriage in terms of basic
human goods, including procreation and fidelity
between spouses (Finnis 1997). Monogamous
marriage, as the arrangement fit for the rearing of
children, “belong[s] to the natural law.”
▪ Monogamous marriage secures paternal guidance,
which a child needs; fornication is thus a mortal sin
because it “tends to injure the life of the offspring.”
(Aquinas rejects polygamy on similar grounds
while, like Augustine, arguing that it was once
permitted to populate the earth.)
▪ Marital sex employs the body for its purpose of
preserving the species, and pleasure may be a
divinely ordained part of this.
▪ The idea that marriage has a special moral status
and entails fixed moral obligations is widespread—
and philosophically controversial.
▪ Marriage is a legal contract, although an anomalous
one; as the idea of it as a contract has taken hold,
questions have arisen as to how far its obligations
should be subject to individual choice.
▪ The contractual view of marriage implies that
spouses can choose marital obligations to suit their
interests.
▪ However, to some, the value of marriage consists
precisely in the limitations it sets on individual
choice in the service of a greater good: thus, Hegel
commented that arranged marriage is the most
ethical form of marriage because it subordinates
personal choice to the institution.
▪ The institutional view holds that the purpose of the
institution defines its obligations, taking
precedence over spouses' desires, either, in the two
most prominent forms, in the service of a
procreative union, or to protect spousal love.
▪ These theories have implications for the moral
status of extra-marital sex and divorce, as well as
the point and purpose of marriage.
3.1 Contractual Views
▪ On the contractual view, the moral terms and
obligations of marriage are taken as a set of promises
between spouses. Their content is supplied by
surrounding social and legal practices, but their
promissory nature implies that parties to the promise
can negotiate the terms and release each other from
marital obligations.
▪ One rationale for treating marital obligations as such
promises might be thought to be the voluntaristic
account of obligation. On this view, all special
obligations (as opposed to general duties) are the result
of voluntary undertakings; promises are then the
paradigm of special obligations (see entry on Special
Obligations). Thus, whatever special obligations
spouses have to one another must originate in
voluntary agreement, best understood as promise. We
will return to this below. A second rationale is the
assumption that existing marriage practices are morally
arbitrary, in the sense that there is no special moral
reason for their structure. Further, there are diverse
social understandings of marriage. If the choice
between them is morally arbitrary, there is no moral
reason for spouses to adopt one specific set of marital
obligations; it is left up to spouses to choose their terms.
Thus, the contractual account depends upon the
assumption that there is no decisive moral reason for a
particular marital structure.
Issues on Sex Outside Marriage and homosexuality
Kant’s sexual pessimism:
▪ Because sexuality is not an inclination which one human
being has for another as such, but is an inclination for the
sex of another, it is a principle of the degradation of
human nature, in that it gives rise to the preference of
one sex to the other, and to the dishonouring of that sex
through the satisfaction of desire
▪ St. Aquinas and other Natural Law theorists would say
that our sexual faculties have one true end
 — procreation. True, sex is pleasurable but it is
pleasurable in order to fulfil this end. If this is correct
then sexual activity is good if, and only if, it is consistent
with procreation and bad in so far as it  frustrates that
end. It is important to understand that the outcome is
independent of desires, wants, reasons, hopes, fears etc.
and that for the Natural Law Theorist (NLT) it is simply
an  objective fact whether a sexual act is wrong or right,
something which is not affected by culture, religion, etc.
This means that for the NLT there are objective moral
truths regarding how we ought, and ought not, to
behave sexually
▪ Premarital sex is wrong because children would be
brought into the world outside the safe confines of
marriage.
▪ Sexual intercourse before marriage with the sexual
PARTNER.
▪ Premarital Relationship – period for 2 different people
who do not know each other, to know and understand
each other and create bonds of love which are
necessary to live together before they take the decision
to marry.
▪ Homosexual acts have no tendency towards procreation
at all; contraception frustrates procreative ends;
masturbation and pornography focus the sexual
acts inwards towards oneself, frustrating procreative
ends. However, it is vital to make a number of
clarifications as people often misunderstand NLT
▪ The NLT is  not claiming that anything that frustrates
natural ends is wrong but rather only human acts. So,
according to the NLT, the fact that, for instance, the
Bonobo monkeys engage in “rape”, “masturbation” and
“homosexual” acts does not mean that they are doing
something morally wrong.
▪ Furthermore, there is a difference between using
something wrongly and  not using it at all. We use a
knife wrongly if we try to use it as a violin bow but not
by leaving it in the knife drawer. So, not using sexual
faculties (celibacy)  is morally acceptable for the NLT.
▪ However, on the face of it NLT does seem to have a lot
of counter examples; there are lots of things that we
agree are not wrong but do seem to frustrate natural
ends. For example, imagine I regularly walk on my
hands, or I am fed through a tube rather than using my
perfectly good mouth, both these seem to be frustrating
the natural ends of my hands and mouth, but surely
such things are not  morally wrong?
▪ In 1991 the neuroanatomist Simon LeVay published a
report showing that some brain structures in
homosexual men are statistically smaller than the same
structures in heterosexual men. But because the size of
these structures does not correspond exactly with
sexual orientation, this study could not establish any
definitive link between neuroanatomy and sexual
interests. In 1993 the geneticist Dean Hamer and
colleagues published a study showing that homosexual
men are more likely than others to have male
homosexual relatives, and the pattern of distribution of
these male homosexual relatives suggests a genetic
inheritance passed through mothers. The study also
showed that male homosexual brothers are more likely
to share a genetic region in common than
nonhomosexual brothers, which also suggests there is a
genetic contribution to sexual orientation. Again,
however, because this shared genetic region does not
correspond exactly with sexual orientation, these
patterns do not prove that there is a "gay gene."
▪ But an NLT would agree because these sorts of
examples are  not cases of the faculty being used to
“frustrate” the natural end of the hands or mouth. If on
the other hand we wired someone’s jaw shut so they
could not eat through the mouth, or if
someone  always walked on their hands even though
they had perfectly good legs, then this might be
different.5 But as it stands simply using a faculty for
something other than what it is for is not the same as
using that faculty to  frustrate its end.
▪ Furthermore, the claim is not that if you use a
faculty with the knowledge that it will be frustrated then
it is wrong; it is that if you  intend to use it to be
frustrated. So, for example, sex between a man and
women when the woman is pregnant is not wrong for
the NLT.
▪ Also, the claim is not that if something is “unnatural” it
is wrong. Deciding whether something is right or wrong
is not the same as asking whether something is “man-
made or not”. If this was the case, wearing glasses and
taking medication would be wrong and the NLT is not
committed to this. So the use of sex toys, or various
medications such as Viagra is not wrong even though
they are unnatural.
▪ We might think that linking sex to procreation in this
way would take all the fun out of sex but this is not the
case. Just as one can eat a dish in many different ways
whilst always fulfilling the natural function of eating,
one can be involved in different forms of sexual act,
fantasy, etc. as long as it is part of the  long term
function of the sexual organs (so, for example, oral sex is
not necessarily ruled out as long as it is, overall, part of
a sex act that is intended for procreation).
▪ As noted, the NLT does, though, rule out homosexual
sex and all forms of contraception because having sex
whilst using contraception is to use the sexual faculties
whilst  intending to frustrate their end.
Philosophy of Love, Sex, and Marriage
▪ Morality divides actions into right and wrong, and
subdivides right actions into permissible and obligatory.
Wrong actions are ones we should not do, permissible
actions are ones we may do, and obligatory actions are
ones we must do. To which category does romantic love
belong? And does this question even make sense since
love is an emotion, not an action? Suppose that envy is a
bad emotion. Suppose also that Rajiv is an envious
person and that Sanjay is neither envious nor not
envious. Sanjay should take steps to ensure that he
won’t become an envious person, and Rajiv should take
steps to expunge envy in him. Morality requires them to
act in these ways. So morality prohibiting or permitting
an emotion makes sense, including the emotion of
romantic love. If morality prohibits it, we should act to
either expunge or not cultivate it. If morality permits
love but does not consider it obligatory, we may have
the emotion and act on it. If morality considers love
obligatory, we must take steps to cultivate it in
ourselves.
CONTROVERSIES OVER SAME-SEX MARRIAGE
SEXUAL ACTIVITY AND MARRIAGE
▪ Some 15% of adolescent Filipino women in 2013
reported ever having had sex.
▪ Among women aged 18–24, 19% said they had had sex
before age 18. This proportion was far higher than
average among the poorest women (36%) and slightly
 higher than average among those living in rural areas
(22%).[5]
▪ One in 10 adolescent Filipino women reported ever
marrying or entering into consensual union. Teenage
unions were more than four times as common among
women living in the poorest households (17%) as
among those in the wealthiest (4%).
USE OF REPRODUCTIVE HEALTH CARE
▪ As of 2013, 37% of married adolescent women used
some method of contraception. This level of overall use
represents an encouraging 11 percentage-point
increase from the 2003 and 2008 surveys.[3,4]
▪ However, married adolescents in the Philippines relied
on traditional methods almost as much as they did on
modern methods (17% and 19%, respectively).[5]
Adolescents were far more likely than all women of
reproductive age to be using such methods, which have
far higher failure rates than most modern methods.[6]
▪ Twenty-nine percent of married adolescents had an
unmet need for contraception, meaning that they
wanted to avoid pregnancy but were not using any
contraceptive method; this proportion is much higher
than that among married women of any other age-
group (15–22%).
▪ Although adolescents’ level of unmet need appears to
have declined slightly since 2003 (when it was at 34%),
it has fluctuated within a narrow range.
Issues on Artificial Reproduction, its Morality and Ethico
moral Responsibility of Nurses
Artificial Insemination
▪ When the husband’s sperm has poor quality or motility,
several semen samples are collected from him. The
samples consist of split ejaculates, that is, the sperm-
rich first portion only is collected for freezing and later
pooling for therapeutic intrauterine insemination.
Donor semen may also be used for this purpose.
▪ This method again raises the problem of acceptance of
male partner for the donated sperm, who will be the
father, and confidentiality.
▪ Nurses are required to deal with these issues very
carefully while protecting the values of the parents.
In-vitro Fertilization
▪ There have been remarkable developments in
reproductive medicine.
▪ Assisted reproductive therapies (ARTs) include in vitro
fertilization and embryo transfer (IVF–ET), gamete
intra-fallopian transfer (GIFT), zygote intra-fallopian
transfer (ZIFT), ovum transfer (oocyte donation),
embryo adoption and embryo hosting.
▪ The lack of information or misleading information
about the success rates and the risks and benefits of
treatment alternatives prevents couples from making
informed decisions. Some of the questions that need to
be answered regarding these procedures are as follows:
Should IVF be available only to married couples? Should
the embryo be frozen for later use? Who has the
ownership—the woman, the man or both? Who are the
parents—the biological or adoptive parents? Is
compensation for egg donors acceptable? Should the
donor be anonymous? What are the long-term effects of
the medications and treatments on the women and their
children and families?
▪ Issues arise regarding the right to reproduce,
ownership of embryo, parenthood and parent–child
bonding, rights of research subjects and research
initiatives, truth telling and confidentiality, and
intergenerational responsibilities.
▪ Nurses can provide information so that the couples
have an accurate understanding of their chances for a
successful pregnancy and live birth. They can also
provide anticipatory guidance about the moral and
ethical dilemmas regarding the use of ARTs. Nurses
must remember that they are to act in the client’s best
interests and not their own.
Surrogate Motherhood
▪ Surrogate childbearing occurs when a woman agrees to
become pregnant for a childless couple. She is
artificially inseminated with the male partner’s sperm.
If fertilization occurs, the woman carries the fetus to
term and then releases the infant to the couple after
birth.
▪ This method of resolving infertility raises many ethical
questions including the problem of religious objections
to conception, and financial and moral responsibility for
a child born with a congenital defect. The issue of
candidate selection and the rights of the surrogate
mother must also be considered.
▪ Surrogate childbearing occurs when a woman agrees to
become pregnant for a childless couple. She is
artificially inseminated with the male partner’s sperm.
If fertilization occurs, the woman carries the fetus to
term and then releases the infant to the couple after
birth.
▪ This method of resolving infertility raises many ethical
questions including the problem of religious objections
to conception, and financial and moral responsibility for
a child born with a congenital defect. The issue of
candidate selection and the rights of the surrogate
mother must also be considered.
Need for surrogate mother
▪ The need for a surrogate mother arises because of the
inability of married couples to conceive after
unprotected coitus.
Indication
▪ Either male or female or both are found to be infertile;
sperm count is less, female uterus is weak, or congenital
abnormality such as small uterus or bicornate uterus
because of which the female cannot bear the child
normally. In such cases, the couple opts for surrogate
mother.
Procedure
The following is the procedure to opt for a surrogate mother:
1. Informed consent from the couple and surrogate
mother is to be obtained to start this procedure.
2. Agreement form is signed by surrogate mother
declaring that the child will be handed over to the
couple immediately after birth. All expenses towards
maintaining the health of the fetus during the
pregnancy period will be borne by the couple and
money will be paid after the birth of the child. The
pregnant woman should pay attention to the growth
and development of the fetus.
3. Semen analysis of male is done and drugs are given to
promote semen count and strength. Healthy sperms are
taken from the male and the zygote is obtained from the
ovum of the female. Through the process of in vitro
fertilization, the zygote is injected or placed into the
fundus of the uterus after a series of injections of HCG,
estrogen, and progesterone to prepare the
endometrium for the arrival of the zygote and to
facilitate its implantation.
4. After zygote implantation is successfully performed by
the doctors, the mother is kept in the hospital for
observation to check the growth of the embryo into
fetus.
 5. A series of scanning is done to confirm the fetal
heartbeat and the surrogate mother is discharged
though she is kept under the control of the couple or the
hospital until term.
6. The baby is delivered and is handed over to the couple
without allowing the newborn to breastfeed, since
breast feeding will break the agreement.
7. The surrogate mother is treated in the post-partum
period, money is settled as per the agreement and the
communication between the couple and the surrogate
mother is stopped.
MORALIY OF ABORTION, RAPE AND OTHER PROBLEMS
RELATED TO DESTRUCTION OF LIFE
DEFINITION OF ABORTION
▪ Abortion is defined by the World Health Organization
(WHO) as the expulsion or extraction from its mother of
an embryo or fetus weighing 500 gm or less when it is
not capable of independent survival. It is simply
termination of pregnancy, which begins at the moment
of conception, when the sperm fertilizes the egg and
ends the birth of the child.
Kinds of Abortion
1. Spontaneous Abortion
▪ This is defined as the involuntary loss of the product of
conception prior to 28 weeks of gestation, with the
weight of the fetus being less than 1000 gm or less.
▪ A. Complete – That is all the content in the uterus are
expelled. No treatment, except bed rest usually needed.
▪ B. Incomplete – part or the entire placenta is retained in
the uterus. (Bleeding occurs when part of the placenta
adheres to the wall of the uterus and the uterus does
not contract to seal the blood vessels that feed the
placenta.
▪ C. Missed abortion – when the fetus is retained in the
uterus for a period of time after its death.
2. Direct or Induced Abortion
▪ Induced abortion means deliberate termination of
pregnancy either by medical or by surgical method
before the fetus becomes viable.
3. Legalized Abortion:  Legal abortions are performed in India
after the MTP Act of 1971 (revised in 1975) was passed; it is
a deliberate induction of abortion prior to 20 weeks of
gestation by a registered medical practitioner in order to
save the life of the mother that is at risk due to the growing
fetus in the mother’s womb.
4. Illegal Abortion:  An illegal abortion may be self-induced,
induced by someone who is not a physician or not acting
under his/her supervision, or induced by a physician under
conditions that violate the state laws governing abortions.
Illegal abortions are often associated with life-threatening
complications.
Directed to the use of the following procedures:
1. 1. Vacuum Aspiration –suctioning of the lining of the
uterus through the use of thin and flexible tube through
the opening of the cervix
2. Dilation and Evacuation and Curretage (D & C) use of
suction tube to remove the fetus and placenta.
3. Prostaglandin and Saline Injection –is administered into
the amniotic sac through the wall of the uterus to
induce abortion
4. Hysterectomy –Removal of the uterus.
1. Indirect Abortion
▪ termination of pregnancy is not directly intended but
becomes only the necessary result of another medical
procedure
ISSUES IN ABORTION
There are various issues that surround the topic of abortion. The
following rights of the fetus are not protected:
1. Right of the fetus to survive
2. Right of the fetus to be respected
3. Right of fetus not to be harmed
4. Right of the fetus to get treatment for survival
5. Right of the fetus to get nutrition, safety and comfort
Sociological Indications
The absolute sociological indications are as follows:
1. Pregnancy by rape or sexual abuse
2. Failure of contraceptive use
Illegal or Unsafe Abortion
The following points have been observed about illegal abortion:
1. It is usually performed by a person who is untrained in
doing abortions.
2. It involves using unnatural and unsafe devices to
remove the fetus.
3. The persons who perform illegal abortion are not
registered in the Medical Council and are not
recognized by the state government; if caught, they are
liable to be sued under law and can be imprisoned.
4. An illegal abortion may be called a “back-alley”,
“backstreet” or “backyard” abortion. India records a
whopping 5.7 million illegal abortions every year and
over 80 percent of the pregnant women do not get
hygienic antenatal care or are left uncared. Every year
6.7 million abortions take place in India but the sad part
is that of this 5.7 million are illegal.
ETHICAL PRINCIPLES OF ABORTION
National Abortion Federation (NAP)
▪ This is the professional association of abortion
providers in North America. The board of NAP has
developed a document of ethical principles as a guide
for practitioners. These principles help the care
providers in a challenging situation.
▪ A care provider is expected to practise higher
professional conduct with compassion and respect the
dignity of each affected individual. The following are the
guidelines recommended by the NAP:
1. Maintain mutual, healthy physician–nurse–
patient relationship.
2. Ensure that informed consent is signed not by
force but of the own free will of the mother.
3. In case of incompetent patients such as a
minor girl below 18 years of age or a woman
with psychiatric illness, informed consent
must be obtained from the parents or
guardian.
4. While getting the informed consent signed,
there are certain principles to be followed
such as providing complete details about the
abortion procedure, treatment method, and
alternatives that are appropriate for the
patient.
Reporting of Sexual Abuse in Minor or Incompetent Patients
The appropriate guidelines for reporting of sexual abuse in case
of minor or incompetent patients are as follows:
1. The nurse should understand the situation that has its
own legal obligation and should immediately report the
abuse to the concerned authorities as per the
jurisdiction.
 2. The nurse should report to the concerned authorities if
the minor or incompetent patient is not capable of
giving the informed consent.
3. The nurse should report to the government about the
ongoing risks of abuse and neglect of minors and
incompetent patients.
4. Before reporting to the government, the nurse has to
communicate clearly with the minor or incompetent
patient with good faith and effort. These details about
the client will not be revealed by the nurse.
5. Once judgment is obtained from the court, the surrogate
is decided.
Avoiding Misconduct and Malpractice
A nurse should adhere to the following guidelines while
providing care:
1. A nurse should not do abortion for money nor do
abortion service in a misleading manner.
2. A nurse should not verbally or physically abuse the
client.
3. A nurse should not make sexual comments or sexual
approaches to the patient.
4. A nurse should not provide care if he/she is addicted to
drug or alcohol.
5. A nurse should not practise abortion with unpermitted
drugs or use drugs beyond their expiry date. If a nurse
is found to indulge in misconduct or malpractice,
he/she is liable for punishment.
HISTORICAL BELIEFS ON ABORTION
There were many beliefs regarding abortion in the
ancient period. It was not accepted by the Greeks and Romans.
The Old Testament states that persons causing miscarriage
leading to abortion in a woman must pay a fine to the husband of
the woman; but, if they cause the woman to die, then they are
liable to be killed. The various beliefs and practices regarding
abortion in the various countries are as follows:
England
▪ The English Common Law did not accept abortion,
which was considered to be a crime. An English law
enforced in the 1803 states that abortion after
quickening is a criminal offence that requires death
penalty, but is less punishable if it is before quickening.
However, in 1837, the law considering abortion to be a
crime along with the death penalty for abortion was
abolished. In 1920, a law was enforced that states that
abortion can be done if the mother’s life is at risk and is
done with good faith.
The USA
▪ In the USA, performing abortion was common, but it
was kept secret because of the strict laws against
unmarried sexual relationship and activity. By the
second half of 1800s, laws against abortion were
enacted. By the 1900s, performing abortion became
illegal in every part of the USA, except when it was done
to save the mother’s life. In 1967, an Abortion Act was
passed in England that states that abortion can be done
by a doctor, with an approval of another two doctors,
only for the following reasons:
1. The growth of the fetus will be a risk to the
mother’s life and can cause physical and
mental harm.
2. The mother is mentally unsound.
3. The fetus is known to have mental or physical
abnormalities, for example, any handicap or
congenital disease, such that the child might
not survive after birth.
a. By 1970s, abortion was legalized in
most of the European countries and
Japan, Abortion was permitted until
six months of pregnancy in the USA
under a law passed by the Supreme
Court in 1973.
The UK
▪ An Abortion Act was passed in 1967 stating that
abortion can be done up to 28 weeks of pregnancy. The
declaration of Oslo, by the World Medical Association, in
1970 made it clear that therapeutic abortion can be
done only to save the mother’s life; a competent
physician permitted by an appropriate authority can
perform the abortion.
India
▪ Abortion was not allowed in India unless medically
indicated, until the MTP Act was passed. In mid-1960s,
the government of India appointed an abortion
committee under the leadership of Dr. Shantilal Shah to
provide the statistics of abortions done illegally. The
report was submitted on 30th December, 1966. On the
basis of the ultimate needs, in order to avoid illegal
abortion and to safeguard the mother’s life, the MTP Act
was enacted in 1972 and revised in 1975.
Philippines
▪ Abortion It shall equally protect the life of the mother
and the life of the unborn from conception." The act is
criminalized by Philippine law. Articles 256, 258 and
259 of the Revised Penal Code of
the Philippines mandate imprisonments for women
who undergo abortion, as well as for any person who
assists in the procedure.
RELIGIOUS BELIEFS CONCERNING ABORTION
▪ There are many religious beliefs that influence the
performing of an abortion. A nurse should be oriented
towards such religion beliefs.
Roman Catholic Christians
▪ The Catholic Church strictly prohibits abortion.
According to its beliefs, life has begun once the
fertilization is over. The fetus is independent and
unique and has its own genetic code, and nobody has
the right to kill the fetus mercilessly. Doing abortion is
considered to be a sin, and even now many hospitals of
the Catholic missions never do MTR or even tubectomy.
Hinduism
▪ Hinduism is based on the principle of ahimsa, which
means non-violence, and therefore, the beliefs of
Hinduism are strongly against abortion. Hindus believe
that all lives are holy and sacred and should be
respected. Therefore, killing a fetus is considered to be
evil. However, abortion is practised by certain groups of
Hindus in India because of their preference for male
child. Female feticide has become common in certain
places in India.
Islam
▪ Muslims were never allowed abortion after 120 days of
pregnancy, but Islam allows abortion to save the life of
the mother and it is justified with the following reasons:
1. Mother is the one who gives origin to the fetus
2. Mother’s life is only important
3. Mother has duties and responsibilities
4. Mother is a part of the family
5. If the mother’s life is at risk, allowing the
mother to die will also kill the fetus.
▪ Thus, abortion is permitted only if the life of the mother
is at risk. These Muslim laws are known as Sharia laws.
Sikhism
▪ In Sikhism, abortion is forbidden. According to their
holy text, Guru Granth Sahib, the practice of abortion is
forbidden and is a sin. Though the religion is against
 abortion, there is a practice of aborting the female
embryo to get male children in the family.
Judaism
▪ Jewish law permits abortion in the first 40 days of
pregnancy. The life of the embryo at that stage is
considered to be of little value, but the religion does not
permit abortion on demand. Again, Judaism permits
abortion only if the growing fetus risks the life of the
mother. Apart from that, the religion says killing the
fetus is breaking the God’s command and image and is
destroying a part of the God’s creation. It is an
unjustifiable act of wounding and it is wrong to injure
the fetus.
Learning about all these religious beliefs will help a nurse to react
appropriately when she/he provides care for a patient of a
particular religion.
Abortions are legal throughout much of the world, but laws vary.
● 61 countries, including much of Europe, allow abortions
without any restrictions.
● 26 countries ban abortions altogether, with no
exceptions.
● The remaining countries allow abortions with
restrictions, such as to save the mother’s life or protect
her health.
Abortion is legal in the United States during the first and second
trimesters of pregnancy. Most abortions are done during the first
trimester of pregnancy. The first trimester refers to the first 12
weeks of pregnancy.
Some states allow abortions until the 24th week, which is at the
very end of the second trimester. Others prohibit it after 20
weeks.
Third-trimester abortions are often done only if the mother’s or
the baby’s life is in danger.
ABORTION TYPE BY TRIMESTER
Medical abortion
▪ A medical abortion is performed through taking two
medications in pill-form: mifepristone (Mifeprex) and
misoprostol (Cytotec). These two drugs work together
to end a pregnancy.
▪ You can use this method until your 10th week of
pregnancy.
▪ A medical abortion isn’t for everyone. Your doctor
might suggest that you avoid this method if:
● your pregnancy has implanted outside of the
uterus (ectopic pregnancy)
● you’re allergic to mifepristone or misoprostol
● you have a bleeding disorder or you take
blood thinners
● you have severe liver, kidney, or lung disease
● you have an intrauterine device (IUD)
● you’ve been taking corticosteroid drugs for a
long time
Procedure
▪ A doctor or nurse will give you mifepristone in the
office or clinic. This drug blocks the hormone
progesterone, which the embryo needs to implant in
your uterus and grow.
▪ You’ll get misoprostol to take home with you. You take
it a few hours or up to 4 days after the first pill. You can
either take the medicine by mouth or by placing the
pills into your vagina. Misoprostol makes your uterus
contract to push out the pregnancy tissue.
▪ You’ll start to cramp and bleed heavily 1 to 4 hours after
taking misoprostol.
▪ Other symptoms after taking the pills include:
● passing small blood clots
● nausea and vomiting
● diarrhea
● tiredness
● headache
● sweating
● dizziness
Recovery
▪ Most people pass the pregnancy within 4 to 5 hours
after taking the pills. Others take up to 2 days. You
might want to take a couple of days off from work
because of the discomfort.
▪ Your periods should restart about 4 to 6 weeks after
your abortion.
▪ You’ll start to ovulate about 3 weeks after you take the
medicine. Once you ovulate, you can get pregnant again.
Your doctor might recommend that you wait to have sex
for a week or two after your abortion.
▪ A medical abortion shouldn’t affect your ability to get
pregnant in the future.
Cost
▪
The cost of the abortion pill varies from clinic to clinic.
Expect to pay between $300 and $800. Some insurance
companies will cover the cost.
METHOTREXATE AND MISOPROSTOL
▪ Methotrexate and misoprostol (MTX) is an abortion
method you can use in your first 7 weeks of pregnancy.
▪ Methotrexate is a cancer drug. Just as it stops cancer
cells from multiplying, it stops cells in the embryo from
multiplying. Misoprostol then contracts the uterus to
release its contents.
▪ This method takes longer than mifepristone and
misoprostol, and it’s rarely used for planned abortions.
Doctors mainly use it for women who have a pregnancy
outside their uterus, an ectopic pregnancy. An ectopic
pregnancy can be life-threatening if it continues.
▪ You shouldn’t use this method if:
● you have liver, kidney, or inflammatory bowel
disease
● you get seizures more than once a week
● you take blood thinners
● you’re allergic to methotrexate or misoprostol
● you have a blood clotting problem
● you have severe anemia
● you have an IUD
Procedure
▪ You get methotrexate in your doctor’s office. It comes as
a shot or a pill that you take by mouth. You’ll take the
misoprostol pills 4 to 6 days later at home, either by
mouth or by inserting them into your vagina.
▪ The abortion will start within 1 to 12 hours after you
take the medicine. You’ll have cramps and bleeding. The
bleeding may be heavy for 4 to 8 hours.
▪ You may want to take a few days off from work because
of the discomfort.
Recovery
 ▪ It can take a few days or weeks for the abortion to
finish. Some people take up to a month. In 1 to 2
percent of people, the medicine won’t work. If it doesn’t
work, you’ll need to have a surgical abortion.
▪ Side effects from methotrexate and misoprostol include:
● nausea and vomiting
● diarrhea
● headache
● dizziness
● low-grade fever
● chills
▪ Your periods should restart a month or two after your
abortion.
▪ The abortion shouldn’t affect your ability to get
pregnant in the future. Your doctor might advise you to
wait a week or two before having sex again.
Cost
▪
The cost of methotrexate and misoprostol can range
from $300 to $1,000. Some insurance companies will
cover it.
VACUUM ASPIRATION
▪ Vacuum aspiration is done during the first trimester
(first 12 weeks) or early second trimester (12 to 16
weeks) of pregnancy. It’s also called suction aspiration.
▪ Some people choose vacuum aspiration as the main
method for having an abortion. Others need it after a
medical abortion fails to end their pregnancy.
▪ This method might not be right for you if you have:
● an abnormally shaped or functioning uterus
● blood clotting disorders
● a pelvic infection
● serious health problem
Procedure
▪ Vacuum aspiration uses gentle suction to pull the fetus
and placenta out of the uterus. You’ll have this
procedure at a clinic, doctor’s office, or hospital.
▪ Vacuum aspiration isn’t painful, but you may feel some
cramping because your uterus will contract as the tissue
is removed.
▪ The procedure only lasts 5 to 10 minutes. You may need
to stay at the clinic for a few hours afterward to make
sure the abortion is complete. Some clinics will do your
procedure on the same day as your first appointment.
▪ Side effects after a vacuum aspiration procedure can
include:
● bleeding or spotting
● cramps
● nausea
● sweating
● dizziness
Recovery
▪ You might need to take a day or two off from work
because of the discomfort.
▪ Avoid sex for at least a week after the procedure. Your
periods should return about 4 to 6 weeks afterward.
▪ Having this type of abortion shouldn’t affect your ability
to get pregnant in the future. Your doctor might advise
you to use birth control to prevent a pregnancy in the
first few weeks after your abortion.
Cost
▪
A vacuum abortion costs between $600 and $1,000.
▪
The further along you are in your pregnancy, the more
the procedure will cost. Some insurance companies will
cover part or all of the cost.
DILATION AND EVACUATION
▪ Dilation and evacuation (D&E) is an abortion procedure
that’s used in the second trimester, usually after the
14th week of pregnancy.
▪ It’s usually recommended for someone who’s delayed
getting an abortion, or for someone who chooses to end
a pregnancy because the fetus has a severe abnormality
or medical problem.
Procedure
▪ D&E uses a combination of vacuum aspiration, forceps,
and dilation and curettage (D and C). The procedure
may be done over a two-day period.
▪ On the first day, the doctor dilates (or widens) your
cervix to make it easier to remove the pregnancy tissue.
On the second day, the doctor uses forceps to remove
the fetus and placenta, a tube to suction out the uterus,
and a scoop-like instrument called a curette to scrape
out the uterine lining.
▪ You’ll have this procedure in a hospital or a clinic. A
D&E can be painful, but your doctor can give you a
numbing medicine to prevent discomfort.
▪ The procedure takes less than 30 minutes. You can go
home on the same day.
▪ Side effects from a D&E include:
● bleeding
● cramping
● nausea
Recovery
▪ Side effects can last for two weeks after the procedure.
You may need to take off a few days from work due to
discomfort.
▪ You’ll need to wait for about two weeks to have sex
after the procedure. Avoid heavy exercise for one week.
▪ Your periods should restart 4 to 8 weeks after the
procedure. Having a D&E shouldn’t affect your chances
of getting pregnant in the future. Ask your doctor how
long to wait before trying to conceive afterward.
Cost
▪
A D&E can cost more than $1,500. The price depends on
where you have it done and how far along in your
pregnancy you are.
▪ Some health insurance plans will cover part or all of the
cost.
INDUCTION ABORTION
▪ An induction abortion is done in the second trimester of
pregnancy. It may be an option if you’re past the 24th
week of pregnancy and can no longer get a D&E
procedure.
▪ This method is rarely used in the United States.
Procedure
 ▪ You’ll get medicine that puts you into labor. Your uterus
will contract to release the pregnancy. Your provider
might also use suction or a spoon-like instrument called
a curette to clean out your uterus.
▪ This procedure is done in a hospital or specialized
clinic. You’ll feel intense cramps as your uterus
contracts. Your healthcare provider will give you
sedatives or an epidural to relieve the pain.
▪ It can take several hours or more than a day to complete
the procedure.
▪ Side effects from an induction abortion can include:
● pain
● bleeding
● cramping
● nausea and vomiting
● diarrhea
● chills
● headache
Recovery
▪ You may need to take a day or two off from work to
recover afterward.
▪ You’ll need to avoid sex for 2 to 6 weeks after your
procedure. Ask your doctor how long to wait. You
should be able to go back to your regular activities
within a couple of weeks.
▪ Your period should restart within a month or two after
the procedure. Having an induction abortion shouldn’t
affect your ability to get pregnant in the future. Ask your
doctor how long to wait before trying to conceive again.
Cost
▪ Because this procedure is performed late in the
pregnancy, it can cost $3,000 or more. Some health
insurance companies may cover the cost.
LATE-TERM ABORTIONS
▪ A late-term abortion can have different meanings.
▪ Some consider an abortion ‘late-term’ if it’s done after
the 20th week of pregnancy. Others say it’s when it’s
done in the third trimester. Still others consider it late
when the fetus is viable, meaning it could survive
outside the womb.
▪ Late-term abortions are rare in the United States. Most
states ban or restrict them, except in cases where the
mother’s life is at risk.
▪ You may have a late abortion if:
● you had trouble deciding whether to have an
abortion
● financial reasons kept you from having the
procedure earlier
● you’re underage and afraid to tell your parents
● the fetus isn’t viable or has a serious medical
condition
● the pregnancy jeopardizes your health
▪ Procedures that can be done in the third trimester
include:
● induction abortion
● D&E
▪ Complications are rare for late-term abortions. But the
risks increase the further along you are in your
pregnancy.
▪ Even if an abortion is performed late in your pregnancy,
it shouldn’t affect your ability to conceive in the future.
Is emergency contraception a type of abortion?
▪ Plan B and other morning-after pills are emergency
contraception. Taking these pills within 5 days after
having unprotected sex can prevent you from getting
pregnant.
▪ Emergency contraception isn’t an abortion pill. If you’re
already pregnant, it won’t end the pregnancy.
▪ You can buy emergency contraception without a
prescription at a drugstore. You don’t need to be a
certain age to buy it.
CONTRACEPTION AFTER AN ABORTION
▪ Having an abortion will end your current pregnancy. If
you’re sexually active and don’t desire another
pregnancy, you should talk with your doctor about
contraception options.
▪ This is important to do before you begin having sex
after the abortion. There are many options available,
many of which don’t require a daily pill.
▪ Talk with your doctor to see which method would be
best for you and how soon you can start it after the
abortion.
Abortion resources
▪ You can get an abortion from a specialized clinic,
hospital, or, if you’re in the United States, a Planned
Parenthood health center. Not all doctors offer this
service.
▪ Although abortion is legal in every state, it’s not always
easy to find a provider. Some states have fewer abortion
providers than others. A few states, like Kentucky, have
only one clinic.
▪ To find a qualified abortion provider in your area, visit
these resources:
● Abortion Care Network
● Abortion Clinics Online
● National Abortion Federation
● Planned Parenthood
▪ If an abortion clinic isn’t available where you live, you
might have to travel to another state.
▪ Some providers now offer medical abortions over the
phone or computer through telemedicine. Yet 19 states
require the doctor who performs the abortion to be in
the room during the procedure.
Mental health resources
▪ It’s normal to feel a range of emotions after an abortion.
You might feel regret, relief, guilt, or shame. Some
people may become depressed afterward. Each person
reacts differently.
ETHICAL DILEMMAS IN ABORTION
There are many ethical dilemmas against and favouring abortion.
Ethical Dilemmas Against Abortion
There are certain issues in abortion that are in dilemma or under
debate. A nurse must have knowledge about such issues and
handle them carefully. Some of the issues are as follows:
1. Killing an innocent life is wrong. As human life begins at
conception, the fetus is a living being, which is very
innocent. Therefore, doing abortion is wrong and is a
merciless act.
 2. Fetus is a person. People consider the fetus as a unique
genetic code and a unique individual, and therefore, it
should not be destroyed.
3. If not killed, the fetus would also grow into a human
being and have a future similar to others; therefore, it is
wrong to kill the fetus and destroy its future.
4. It is wrong to cause pain and discomfort to the fetus.
Since the fetus can feel pain by 18 weeks, carrying out
abortion after 18 weeks of pregnancy will cause pain to
the fetus.
5. Legalized killing of fetus is wrong as legal killing
reduces or decreases the respect for life. It is bad for the
society and contributes to mercy killing called
euthanasia and genocide, and increases the mortality
rate of children. Therefore, abortion is always
considered to be wrong.
Ethical Delimitation Favour of Abortion
Though there are arguments against abortion, there are certain
cases where abortion is done with scientific rationale such as the
following:
1. A pregnant woman has the right to survive. In certain
cases, if abortion is not done, the fetus will harm the life
of the mother. In such cases, the mother has the right to
abort the fetus; she has the right to the ownership of her
own body, right to decide her own future, and right to
take decisions without any moral or legal intervention.
2. Fetus is only a potential human being and hence does
not have the rights similar to human beings.
3. Fetus is not necessarily considered as a ‘person’ with
the right to live. A collection of human cells does not
have any ‘right’ to live though it belongs to a human. In
case of a patient with diabetic ulcer wound in the leg
that is gangrenous, the doctor will advise to amputate
the leg in order to save the patient’s life. Similarly, if the
growth of the fetus is harmful to the mother, the doctor
will advise abortion. A fetus never attains the stage of
development that makes a person a moral human being
and hence can be aborted.
4. It is not always wrong to end the life of an innocent
person. For example, in the case of conjoint twins, that
is, thoracopagus, where two fetuses are joined together,
effort is made to separate the twins. Sometimes, only
one child can be saved and the separating process may
lead to the death of the other child.
5. There are cases where abortion is done since there is a
serious medical problem to mother or the fetus such as
the following:
▪ Pregnancy that might lead to the mother’s
death, for example, eclampsia, uncontrolled
convulsion, untreatable hyperemesis that risks
the mothers.
▪ Presence of too many fetuses in the uterus,
where it is difficult for all of them to survive.
▪ Defective fetus that will die if pregnancy is
continued.
▪ Defective fetus such that the baby will not be
able to survive after birth.
1. In some cases, abortion is done because the child will be
not be normal and healthy to be able to survive. The
child might suffer from serious structural or mental
abnormality, which makes its survival difficult, for
example, down syndrome or mental retardation.
2. There are cases where abortion is done since the
pregnancy was totally unintentional such as the
following:
▪ Pregnancy because of rape.
▪ Pregnancy that happened due to the failure of
the contraception.
▪ Pregnancy that resulted because of
unsuccessful vasectomy.
▪ Pregnancy in a mentally incapable woman, for
example, pregnant woman with psychiatric
illness such as psychosis who is not of a sound
mind to take care of the fetus.
1. Abortion is also done in cases where the pregnancy was
unintentional, but the risk was taken by the parent. The
reasons are as follows:
▪ Pregnancy due to usage of failed
contraceptives, even after knowing all the
advantages and disadvantages of the
contraceptive before using it.
▪ Pregnancy resulted because of careless use of
contraception.
▪ Pregnancy resulted because of not using
contraception.
1. In some cases, abortion is done because the pregnancy
affects the lifestyle of the mother such as follows:
▪ Coping up with a disabled child is difficult for a
pregnant mother
● Difficulty in bringing up the child
because of poverty
Thus, the arguments, debates, and ethical dilemma still continue.
However, a nurse should support and go with legalized abortion,
at the same time enquiring and ensuring that the reasons for
abortion are legal
CONCLUSION
Abortion, of course, is a serious issue that deals with
two lives, namely, the mother and fetus. Killing any life is wrong
and is against the ethical principles. However, legalized abortion
is done only to save the life of the mother or to prevent the birth
of a child whose survival will be very difficult. A nurse should be
aware of all the laws concerning abortion and the ethical issues,
dilemmas, and principles associated with it. They help the nurse
to guide the behaviour and provide guidelines for reacting
towards abortion. The nurse should provide good care to the
mother who has undergone abortion, create awareness about the
illegal or unsafe abortion practices, and prevent the feticides and
save the life of the mother and the child.
Organ Donation
Ethics of Transplants
▪ In organ transplants, there should be ethical decisions
involve like determination of death
▪ An Individual who has sustained either:
1. Irreversible cessation of circulatory and
respiratory functions
2. Irreversible cessation of all functions of the
entire brain stem, is dead.
▪ A determination of death must be made in accordance
with accepted medical standards.
Organ donation
▪ Organ donation is the process when a person allows
an organ of their own to be removed and transplanted
to another person, legally, either by consent while
the donor is alive or dead with the assent of the next of
kin.
▪ Republic Act No. 7170, otherwise known as the Organ
Donation Act of 1991, as amended by Republic Act No.
7885, organ and tissue donations from donors who
have been declared brain dead has been allowed.
Authored by Senator Richard Gordon, the “Organ Donor
Act of 2018” states that the internal organs of 'brain
dead' patients will automatically be harvested for
transplant to patients in need. “We have to educate all
the Filipinos that there is such a thing as deceased
organ donation.”

The Ethics of Organ Donation from the Patients perspective
▪ The ethics of human donor are influenced by the
question of whether the donation involves a renewable
resource such as blood or bone marrow or paired
nonrenewable organs such as the corneas, kidneys or
non-paired nonrenewable organs such as the liver and
the heart.
▪ The donation of the organs inter vivos between living
persons would be unethical except in rare cases unless
approves of altruistic suicide like when a living donor
gives his heart as the donor simultaneously about to
receive the heart or lungs from the third party
▪ Donor must have inform consent
▪ Surrogate decision making is more complex whether for
an incompetent adult or a child
Examples: Parents conceiving a child in the hope if
providing bone marrow donor for older sibling. Parents
here are surrogate and must give permission for such
blood a donation and must operate in the best interest
of the donor.
ETHICAL CONSIDERATIONS
1. Informed Consent
▪ Ethically justifiable living organ donation presupposes
the competent donor’s voluntary informed consent.
Competence or capacity in this context refers to the
prospective donor’s ability to understand the relevant
information in relation to his or her personal values and
interests and, on that basis, to make a thoughtful
decision about donation. When the individual being
evaluated for living donation lacks the capacity to make
such a decision, he or she cannot, strictly speaking, be a
“donor,” that is, one who competently decides to donate
2. Voluntary Consent
▪ General ethical concerns focus on a potential donor’s
competence, level of understanding, and voluntary
choice, whatever the relationship between the donor
and the recipient. When the prospective donor is
related to the recipient, which usually involves close
affective ties as well as the genetic relationship, specific
concerns focus on the dangers of undue influence,
pressure, and coercion, even if he or she is competent,
has received adequate information, and appears to
understand that information.
3. Donations, Not Sales
▪ An ethical concern about living unrelated donation that
frequently arises is that the organ is actually being sold
or, at least, that financial incentives partially motivate
the donation. For example, such concerns have arisen
with regard to solicitations on the Internet (Steinbrook,
2005). Money may be a factor in living related
donations too. Whatever the context, compensation for
organs is illegal under Section 301 of the National Organ
Transplant Act: “It shall be unlawful for any person to
knowingly acquire, receive, or otherwise transfer any
human organ for valuable consideration” (Public Law
98-507). Compensating living donors opens up the
possibility of exploiting poor and underprivileged
people and also increases the risk that potential donors
will withhold relevant medical information.
4. Independent Donor Advocate Team
▪ In determining which potential living donors will be
accepted, transplantation teams serve as ethical
gatekeepers, with less societal oversight than occurs in
much of transplantation. Additionally, they may have an
inherent conflict of interest because they seek to obtain
an organ for patients on the waiting list while assuming
major responsibilities to potential and actual donors.
5. Living Donor Follow-Up
▪ Living donation developed on an ad hoc basis in various
transplant centers and has never had the central
oversight and supervision that has marked practices of
donation by deceased individuals. As a result, there is
no national infrastructure for gathering information and
for ensuring accountability as there is for donation by
deceased individuals.
The Ethics of Cadaver Organ Donation
▪ When dealing with the cadaver donation the harvest
and transplant the organ as quickly as possible.
▪ The philosophical ambiguity regarding the nature of
death is clearly seen as disputes about whether death is
the end of all existence, a reentry into another life on
earth. Even as generalized definition of death as the
irreversible loss of functions essentially significant to it
or death as irreversible loss of capacity or social
interaction does not solve the problem.
The Uniform Definition of Death Act (UDDA) has been
adopted by many and provides as follows:
An individual who has sustained either
1. irreversible cessation of circulatory and respiratory
functions
2. irreversible cessation of all functions of the entire brain
including the brain stem is dead.
The Harvard Criterion of Irreversible Coma (Beuchamp and
Perlin 1978) is an example of one set of medical standards. These
Criteria call first to the elimination of the possibility of
hypothermia and coma induced by barbiturates and then the
application of the following four tests:
1. Unreceptivity and unresponsitivity even to intensely
painful stimuli
2. No movement or breathing during an hour-long period
of observation
3. No reflexes
4. A flat electroencephalogram
Cardiac death
▪ The United Network for organ sharing (UNOS )
http.//.unos .org/)lists a daily update of waiting list
candidates which on March 9, 2012 was
122,950 .Seventy five percent comes from a deceased
patient and the most rapid rise was is those who had a
medical situation that did not result in brain death but
left the patient terminal and usually supported by a
ventilator without hope of recovery .Many had injuries
or illnesses that did not affect other organs leaving
these ideal for transplantation .These procedure
involves withdrawing life support using all comfort
measures and there has been total arrest of circulation
for 5 minutes ,the organs are procured.
BIOETHICS AND RESEARCH
DESIRED LEARNING OUTCOMES (DLOS)
At the end of the teaching – learning sessions the students are
expected to achieve the following
1. History of ethical concern in research
2. Importance of ethics in nursing research
3. Human rights and consideration in research
4. The Nuremberg Code (1947)
5. Ethical principles concerned with nursing research
6. Causes of unethical behavior
INTRODUCTION:
▪ Ethics is concerned with the conduct of a human being.
All scientific activities, including those by social
 scientists, are conducted with the participation of
human beings or have an impact on human beings and
on the wider society and environment. For making an
ethical judgment, the researcher relies upon various
standards of ethics, which could be universal or specific
to the cultures or localities. A researcher should have
deep concern for human welfare and sensitivity for the
rights of the research subjects. Sometimes, the ethical
responsibility to safeguard the subject’s rights conflicts
with the efficiency with which one progresses with the
research; it may affect the ultimate quality of the
results.
LEARNING CONTENT
Principles of Ethics in Research
HISTORY OF ETHICAL CONCERN IN RESEARCH
▪ The period during the origin of ethical research is
known as the dark ages of ethics. Slaves, prisoners,
criminals, children and poor people were forcibly used
as samples or experimentation subjects for the research
activities. They were treated like animals and there was
no consideration for their rights, consent, wishes, or
values. This dark period of ethical concern is considered
to be a big unhealed wound in the initial period of
development of ethical research.
▪ Between 1932 and 1972, there was a drastic and
contagious spread of a sexually transmitted disease
called syphilis. This disease was studied by researchers
as a kind of retrospective cohort study to know the
natural history of the disease, which has pre-
pathogenesis, pathogenesis, recovery from acute
disease or chronic existence of disease leading to
terminal illness with disability or death. The research
study titled “The Tuskegee Study of Untreated Syphilis
in Negro Male” done in Macon County, Alabama, used
400 Black males as subjects. The main aim of the study
was to determine the damage caused in the patients
affected by syphilis if it was left untreated. The
spirochete treponema palladium, which caused the
disease, was injected into the subjects without their
consent and they were left untreated. They were not
given any information regarding the disease and were
left to die or experience the course of illness, even
though a proven cure was available for the disease.
▪ There were other ethical issues during the Second
World War period. Many prisoners in the German
concentration camps were forced to participate in
research studies, in which most of the subjects died or
were permanently crippled. It included deliberate
breaking of bones until no healing was possible,
sterilization of women without anaesthesia, and, in case
of twin children, using one child as control while the
other was used as a sample for the medical
experiments. We need to empathize with those patients
who were forced to undergo such pain and suffering as
a result of those research activities. Such examples
stress the need for ethical principles and guidelines for
research activities, especially on humans and animals.
The research study should get the approval of an ethical
team or organization before conducting the research.
The American Psychological Association (APA) and the
U.S. Department of Health and Human Services have
established standard guidelines that should be followed
in all kinds of research in the USA.
▪ The Nuremberg trials in 1947 helped bring forth many
hidden details regarding the ethical issues in the Second
World War and paved way for the establishment of the
Nuremberg Code. It became the foundation for future
ethical guidelines regarding the use of human samples
in the research study.
PRINCIPLES OF ETHICAL ISSUES AND CONCERNS IN
RESEARCH
The following are the principles of ethical issues and concerns in
research:
1. Following accurate ethical norms helps to promote
the research objectives, that is, both horizontal and
vertical widening of broad and in-depth knowledge.
The ethical norms to be followed include adopting
truth and honesty in conducting the research as per
the principles and avoiding mistakes and errors, for
example, copying the thesis of others without
conducting actual research and misinterpreting
research data.
2. An important task in research activity is
collaboration and coordination, which can be
achieved only by strictly adopting the ethical
principles such as accountability, trust, mutual
respect and fairness, because they favour unity.
Coordination and combined efforts are needed to
achieve the objectives of any research activity. For
example, a researcher should go through the
guidelines for authorship while reviewing the quality
of a book, and if any copyright is needed, the
required formalities must be completed properly.
When information is taken from published books
and journals, permission needs to be obtained from
the concerned authors. Confidentiality must be
maintained while doing the literature review. Such
measures will protect the researcher from legal
problems while doing any research activity.
3. Ethical norms also help the public. They ensure that
the research is done in a safe manner. The norms are
formed in such a way that the researcher is made
answerable and accountable for any of his/her
research activity towards public. The activities are
legalized, licensed and securitized; the financial
resources used for research work should be
transparent and should be used fruitfully for the
benefit of the study, which should ultimately give
good outcomes to the public.
4. The scientific knowledge and educational
background of the people today is so wide and deep
that there is a lot of awareness about health. Any
new research activity creates curiosity among the
public and is generally supported by the public
because they anticipate good outcomes, which
depend upon the quality and integrity of the
research activity. Innovations through research for
health problems and their benefits through
evidence-based practice will be supported by the
people, provided the research work binds to ethical
norms.
5. Ethical norms help to protect the public from any
kind of harm because of fake results published, since
the norms framed are so strong that they give
importance to moral and social values, such as social
responsibilities, basic human rights, animal welfare,
compliance with law, health, and safety. The data
that is obtained through the research should be
collected ethically, relevantly, and accurately. Strictly
following the research methodology and openly
agreeing to the limitations will help to promote the
health of the people.
CONSIDERATION OF HUMAN RIGHTS IN RESEARCH
▪ Nurses are always present with patients and are under
pressure to deal with all kinds of problems and issues
during patient care. There is a need for each nurse to be
well acquainted with the ethical principles and norms,
so that they act as a shield and protect him/her from all
the legal and ethical issues concerning patient care.
Therefore, the nurse should update his/her knowledge
about the new technology as well as the ethical issues
affecting it.
▪ The ethical considerations safeguarding the subject’s
rights must always be given the highest priority. Among
human subjects, the rights that must be taken into
consideration are as follows:
1. The right to choose whether or not to
participate in the research and the option
to withdraw without being penalized, in
other words, freedom from coercion
2. The right to full information about the
research, that is, what is to be expected,
and the right to raise questions about the
research as it progresses
3. The right for protection from unnecessary
risk or harm as a result of participating in
the research project
4. The right to be informed of any potential
risk or harm that might be incurred as a
result of participating in the research
5. The right for privacy, dignity and
confidentiality
6. The right to be informed about the results
of the research
ETHICAL ISSUES IN RESEARCH PROCESS
▪ Ethical and legal issues play an important role
throughout the process of research activity, right from
the selection of the problem until its application. Always
the boundaries rotate from input, throughput and
output, and throughout the entire research process, the
legal and ethical issues will be kept hidden. Similar to
the weapon used by the stone sculptors to carve the
statue from the stone, the ethical principles in research
process must remove the unwanted ethical issues and
ensure a safe and harmless research process. The
sculpting process is done in the following areas:
1. Identification and selection of the research
problems and conceptual models
2. Determination of the research methodology
and data collection
3. Publication of the research reports
4. Application of the research outcomes
Selection of Research Problems and Conceptual Models:  This
is a crucial period during the research process. Initially, it is not
possible for the researcher to accurately estimate the expense for
the research process when selecting a research statement.
He/she should select a problem that is free from ethical issues, is
affordable, is reasonable, has widely implementable outcomes
and has more benefits to the public. Adequate time and expert
guidance are needed to select the conceptual model for the
research.
Ethical Research Concerning Research Methodology:  There
should be truth, honesty, and sincerity in collecting the data for
the research process. Faking or fabricating the data is against
ethical principles and becomes an ethical issue. The researcher
should be evaluated at each step by the guide and co-guide.
Duplicating the results may help the researcher to complete the
project easily, but if the research data is found to be fabricated, it
will ruin his/her future. Methodology means the design of
research. The core of research should be clear, the methods
should be enjoyable, and the subjects as well as the investigator
should have full interest in the research.
Ethical Issues in Publishing Research Reports:  The reports
should be original, clear, and verified by the experts. The report
should be relevant to the research statement and should be made
known to the public.
Ethical Issues in Application of Research Outcomes:  It should
be possible to apply the findings of a research project in practice.
For example, it was proved with evidence that changing the
position of an unconscious or bedridden patient every two hours
reduces the incidence of pressure sores. Thus, the finding should
be constructive, creative, innovative, and useful. It should benefit
the patient and be widely implementable. It should be ensured
that the findings published in the report are not fake or duplicate,
because implementing fake findings in nursing care may prove
harmful.
THE NUREMBERG CODE (1947)
▪ It is a code of research-related principles for doing
human experimentation, which has been framed based
on the Nuremberg trials that happened subsequent to
the Second World War. This code is framed to protect
the humans from being forcibly used as experimental
subjects and to prevent them from being harmed or
injured through human experimental research.
Origin of Nuremberg Code
▪ In December 1946, an American military tribunal
opened criminal proceedings against 23 German
physicians and administrators who participated in war
crimes and crimes against humanity. They had
conducted experiments on thousands of prisoners
without their consent and most of the subjects died due
to the human experimentation. As a result of the trial,
the Nuremberg Code was established in 1947, which
stated that voluntary consent of the human subject used
for experimentation is absolutely essential. All the
participants in the research have to be informed about
the advantages and disadvantages before participating
in the study. The medical experiments conducted under
the disguise of scientific research by the German
doctors fall under the following categories:
1. Medico-military research
2. Ad hoc experiments
3. Racially motivated experiments
▪ The Nuremberg code is the first international document
that advocated voluntary participation and informed
consent and was framed based on the transcript given
in the Doctor’s trial. It has acted has a guide to ethical
issues in research over the past seven decades.
Nuremberg Trials
▪ After the Second World War, an international military
tribunal was set up with judges from different countries
such as United States, Britain, France and former Soviet
Union, with a view to solving the emerging issues in
human experimentation. Subsequent to this trial, the
following three important physicians were involved in
framing the medical ethics:
1. Leo Alexander, an American neuropsychiatrist
2. Werner Leibbrand, a German psychiatrist and
medical historian
3. Andrew Ivy, an American physiologist
Contribution of Leo Alexander
▪ Leo Alexander, an American physician who was born in
Vienna, worked in the US Army Medical Corps in 1942.
He worked for an intelligence organization called
Combined Intelligence Objectives Subcommittee. It sent
him to gather the evidence needed for the Nuremberg
 trials. He submitted a report titled “Ethical and Non-
Ethical Experimentation on Human Beings” in which he
postulated three important ethical, legal, and scientific
requirements for conducting human experimentation.
They are as follows:
1. To give the subject the right to get informed
consent and the right to participate or refuse
2. Not to injure the subjects or to conduct research
that might harm humans, based on the Hippocratic
Oath
3. To follow good research practices
Contribution of Werner Leibbrand
▪ In January 1947, Werner Leibbrand, a German
psychiatrist and medical historian, explained to the
court that German physicians had adopted biological
thinking and treated patients as objects and not as
humans. German doctors had no morality and respect
for human life. He strongly condemned doctors who
conducted experiments on patients without getting
their consent.
Contribution of Andrew Ivy
▪ Andrew Ivy presented three important research
principles on research practices in his document titled
“Principles of Ethics Concerning Experimentation with
Human Beings”, which was adopted by the American
Medical Association House of Delegates in December
1946. They are as follows:
1. The consent of the subject should be obtained
with full explanation about problems. Small
rewards in various forms have been provided
as a rule.
2. Before performing on human subjects, the
experiment should be first done on animals,
with the knowledge of the natural history of
the disease. It must be so designed that the
anticipated results will justify the performance
of the experiments, which will be for the good
of the society.
The Ten Points of Nuremberg Code
The ten points of the code (all from United States National
Institutes of Health) are as follows:
1. Voluntary Informed Consent:  The voluntary consent
of the human subject is absolutely essential. This means
that the participant should give consent wholeheartedly
to participate in the study, and not by force or
compulsion. The researcher should give complete
details about the research to be conducted, such as the
nature, duration, purpose, advantages, and problems
that participants may have to face in the research.
2. Beneficial Results:  The research should yield results
that benefit the society and should not be random or
uncertain in nature. The researcher should anticipate
the benefits and ensure that the experiment does not
harm the humans or society.
3. Prior Experimentation on Animals and Prior
Knowledge of Problem:  The experiments should not
be performed on humans without tests to determine
their safety on animals, and the researchers should
determine from prior knowledge the likely effects of the
experiment. Thus, the problem under the study will
justify the conduct of the experiment on humans.
4. Avoidance of Physical and Mental Harm:  The
experiment conducted on humans should ensure that it
does not harm or injure them physically or
psychologically. The researcher should justify and prove
that the subjects are not made to suffer any harm, injury
or insult during the research study.
5. Avoidance of Lethal or Disabling
Experiments:  Experiments should not be performed if
there is an a priori reason to believe that death or
disabling injury will occur. The exception to this rule is
if the physicians performing the experiment also serve
as subjects.
6. Limitation of Risk in Study:  There should no increase
in the degree of risk mentioned. The degree of risk
should not be more than the benefits caused by solving
the problem through the research.
7. Protection and Facilities for the Subjects Involved in
Research:  Adequate physical facilities should be
provided for each participant to safeguard him/her
from any possible injury, disability or death.
8. Performance of Experiment by Qualified and
Experienced Persons:  It is important that the research
is conducted by a qualified as well as experienced
researcher with good skill and knowledge about the
research study through all the phases of the research
process.
9. Freedom or Liberty for the Subjects to Withdraw:  The
participants of the study must have the freedom to
withdraw from the study at any time if they feel
physically or mentally unable to continue. This allows
the subjects to choose what happens to them and to
protect their rights.
10. Termination of Study at any Stage:  During the course
of the experimentation, the researcher must be
prepared to terminate the study if there is a cause to
believe, after careful judgement, that the continuation of
the experiment might cause injury, disability, or death
to the subjects.
ETHICAL PRINCIPLES CONCERNED WITH RESEARCH
The code of conduct and the ethical principles for research as
published by the APA 1992 are as follows:
▪ Planning Research in Use of Humans as Research
Subjects:
▪ Step 1:  The entire blueprint of the research
process should be planned in advance under
expert guidance; it must be cleared without
any harmful drawbacks.
▪ Step 2:  The researcher should submit the
synopsis of the study and the possible ethical
issues/problems and benefits arising out of it
to the members of an ethical review
board/committee and should get a clearance
and approval to conduct the study.
▪ Step 3:  Human rights, values, respect and
dignity of participants should be ensured.
Confidentiality must be maintained
throughout the research process.
▪ Responsibility:  The entire research content should be
thoroughly analysed by the guide, co-guide and
psychologist; the investigator has to get their full
guidance. The psychologist has to scrutinize the tool
used and determine whether it will harm the subjects
physically, socially, or psychologically, which might
affect their self-esteem and dignity. The psychologist
should also ensure that the values and rights of the
participants are respected throughout the research
process and should anticipate any potential harm and
guide the researcher accordingly.
▪ State and Federal Law:  All members involved in the
research to be conducted such as the investigator,
supportive researcher, the guide, co-guide, and
psychologist should be familiar with the state and
federal law and regulations. For example, if a research is
 conducted using any sedative drugs that cannot be
experimented on children or old people as the state law
prohibits it, the researcher and his/her team should
follow and abide by the rules.
▪ Provision of Any Benefit or Money to the
Subjects:  Even if the participants are provided any
reward such as money for participating in the study,
they should not be ill-treated. Irrespective of the
provision of benefit, the participants must be ensured
security and safety and must be given full information
about the subject and its benefits and risks.
▪ No Plagiarism in Reporting the Results of the
Research:  If the results of the research are erroneous,
it will be the researcher’s responsibility to correct it and
publish the correct results. He/she should not fail to
credit the citations for the work of other authors and
should not resort to plagiarism.
▪ Approval from the Institutional Ethics Review Board
(IERB):  A person involved in conducting research for a
doctoral degree in an institution or for any other
purpose should present a research proposal to the
IERB. This organization has experts from all the areas
such as medicine, surgery, pharmacology, pathology,
microbiology, nursing, psychology and psychiatry, and
specialized doctors from the field of obstetrics,
orthopedics, neurology and neurosurgery, nephrology,
dermatology, ENT, ophthalmology, etc. They will assess
the entire proposal. The researcher has to present the
ethical issues present in the research and the ways to
solve them. The proposal should have a format of the
informed consent and its details should be present.
Once the IERB approval is obtained, the researcher can
start the study ensuring that the subjects involved in
the study are free from all injuries and risks and that
their safety, values, dignity and human rights are
respected and valued.
▪ Use of Informed Consent in Research:  The informed
consent is a legal document. All participants are clearly
informed about their role in the research and any
potential harm/injury if present. They are assured of
safety and confidentiality throughout the research
process and are free to withdraw from the study
whenever they want. The participants must also be
allowed to view the results of the study. Many
researchers do not give complete details to the
participants as they are afraid of not getting samples.
They just get the signature, take videograph, and give
some money to the subjects so that they silently accept
to participate. Nowadays, the informed consent form is
available in the e-format in the World Wide Web. The
subjects can click on the accept button and proceed to
participate in the study or can click on the default
button to withdraw from the study.
LIMITATIONS IN APPLYING ETHICS AND ETHICAL
PRINCIPLES IN NURSING RESEARCH
The following are the disadvantages of ethics in research:
1. If the participants of the research are the workers of an
institution, there are chances of them being
psychologically harmed by the management when it
comes to know about their performance through the
results of the research.
2. All activities regarding the work might be revealed
through the research on the work performance and a
worker may lose job or promotion if he/she is found to
indulge in malpractice or negligence through the
research study.
3. Certain projects may reveal the sexual orientation of the
subject, which is supposed to be kept confidential
during the study. The researcher may disclose the
sexual orientation of the subject and violate the
principle of ethics.
4. Wrong information can be given by the participants if
they are afraid of the management.
5. All ethical principles cannot be followed by all hospitals.
Nursing care must always be practised with ethical
principles but the policies of all hospitals are not the
same, which will hinder following certain ethical
principles.
6. The researcher may provide money to the subject to
cooperate in the study, if the research is conducted
among people of high status. The respect and safety
during the research will be followed by the researcher
in such cases because the money and status is valued.
However, if people of low status or poor people who are
admitted in government hospital are involved, the
researcher may violate the ethical principles of non-
maleficence, accountability and responsibility. There is
no money offered by the researcher to such patients
and the experiment is conducted for free on them as a
part of treatment.
CONCLUSION
Research is searching something that is unknown.
Nursing research is the stepping stone for quality care. Following
ethical principles and gaining knowledge about ethical issues in
the nursing research are essential and will ensure that the
outcome of the research is good and valid. This chapter deals
with the many ethical issues in research that have been observed
until now. It is the responsibility of a nurse to follow ethics in
research and apply the relevant principles wherever needed, so
that he/she is able to bring out an excellent nursing research
activity, which leads to quality care.
PPT FROM THE VIDEO
Codes of Ethics
Nuremburg Code 1947
● Evolved from the Nuremberg trials of Nazis involved in
atrocities during WWII
● Addresses voluntary participation, protection of
subjects from harm, right to withdraw, affirmation of
researcher's credentials
Declaration of Helsinki 1964
● Developed by the World Medical Association and is
directed specifically toward medical research.
● Affirms principles of Nuremberg Code
● Categorizes research into two major categories
o direct value to subjects
o no therapeutic value
● Recommendation of written consent
● Legal guardians allowed to grant permission for subject
participation - vulnerable populations
ANA Guidelines
● Affirms the rights of individuals to privacy and dignity
and to freedom from injury.
● Considers the following:
o Risk-benefit ratio
o Anonymity and confidentiality
o Freedom from coercion and deception
o Voluntary participation
● Informed consent
● Institutional Review Board
Ethical Principles
Codes of ethics are comprised of ethical principles o anonymity
● Beneficence Ethical Dilemmas
● Respect for Human Dignity ● Occur when there are ethical conflicts
● Justice o Risk vs. Benefit
Principle of Beneficence ▪ Example: Use of physical or chemical
● Ensures freedom from physical and psychological harm restraints vs. fall prevention
- do good, avoid harm o Decisions based on generally accepted moral
o Studies that pose a danger must be terminated principles (tell the truth vs. withholding truth)
o Provides for debriefing and referral in cases of ▪ Example: Family wishes vs. patient
psychological discomfort or harm wishes in disclosure
● Ensures freedom from exploitation o Decisions based on the greatest good for the
o Information given cannot be used against the whole
participant. ▪ Example: Mandatory vaccination
o Provides for an explicit agreement about the programs
scope of the study. ● Individual vs. collective rights
o Nurses cannot exploit their position to gain o Everyone is entitled to equal rights and
information that would not otherwise have treatment
been forthcoming. o All entitled to equal access to goods and
● Considers the Risk/Benefit Ratio services
o Do the benefits to individuals or humanity ▪ government distribution
outweigh the risks? ▪ distributive justice
o Does the benefit gained outweigh the costs? o Right to private property is most important;
o Guards against superfluous research limited government interference.
Principle of Respect for Human Dignity ▪ Example: Ebola epidemic
● Right to Self-Determination
o Voluntary participation/voluntary withdrawal
without penalty
o Incentive/Reward for participation is not
excessive (coercion)
● Right to Full Disclosure
o description of the nature of the study
o participant and researcher responsibilities
o risk/benefit
Internal Review Board
● Selected agency committee that reviews all proposed
research activity.
● Depending on type of research
o Expedited process
o Intensive review
Informed Consent
● Consent form requirements
o Study involves research
o Purpose/duration
o Procedures
o Risks/benefits
o Alternative procedures
o Contact person
o Right to withdraw without penalty
● Implied consent (anonymous return of questionnaire)
Problems
o Vulnerable populations – who gets to consent?
o Research bias (volunteers are only those who are
interested and will not include those who refuse to
participate)
o Can use concealment only if minimal risk (ethnographic
study); avoid deception

Principle of Justice
● Right to Fair Treatment
o Selection of sample is not discriminatory
o Honoring all agreements
o Sensitivity to culture and values of others
o Access to the researcher
o Follow-up assistance if appropriate
● Right to Privacy
o confidentiality;