Health Care Ethics division of ethics that relates to human health.

Deals with the conduct and moral issues that arise in the practice of health care professionals.
Resides in the realm of human values, morals, customs, personal beliefs, and faith.
What is Health Care Ethics for? Strives to resolve ethical issues that confront health care professionals.

History of Bioethics born out of the rapidly expanding technical environment of 1900, is a specific domain of ethics
focused on moral issues in health care.
During World War II, President Franklin D. Roosevelt assembled a committee to improve medical scientists’
coordination in addressing the medical needs of the military.
• Between 1945 and 1965, antibiotic, antihypertensive, antipsychotic drugs came into common medical use; surgery
entered the heart and the brain; organ transplantation was initiated; and life-sustaining mechanical devices, the
dialysis machine, the pacemaker, and the ventilator were invented.
• During the 1950s, scientists and medical professionals began meeting to discuss these confusing problems.
• A new field of study was developed called Bioethics, a term that first appeared in the literature in 1969.

Bioethics means ethics of life, the application of ethics in the field of medicine and healthcare.
Deal with study of morality of human conduct concerning human life in all aspect from conception to its natural end.
A specific discipline as a result of life and death dilemmas faced by health care practitioners.
A continuous process of decision-making in order to save lives or enhance quality of lives at all times as possible.

Hippocratic Oath: oath of physician - relieve pain - reduce violence of disease - refrain from trying to cure whom the
disease has conquered.
Nightingale Pledge named after Florence Nightingale → considered the founder of modern nursing.
Nurses promise to uphold the Hippocratic oath, do no harm, practice discretion, be dedicated to their work as nurse.
Ethical Principles
1. Autonomy refersto the right to make one’s own decisions.
Inward autonomy: one can make choices; Outward autonomy: if their choices arent limited or imposed by other.
Honoring the principle of autonomy means that the nurse respects a client’s right to make decisions even when
those choices seem to the nurse not to be in the client’s best interest.
Respect for autonomy means that people should not be treated as impersonal sources of knowledge or training.

2. Nonmaleficence the duty to do no harm.

Harm can mean intentionally causing harm, placing someone at risk - unintentionally causing harm.
intentional harm is never acceptable. Unintentional harm occurs when the risk could not have been anticipated.
Caregivers dont always agree on the degree of risk morally permissible to attempt the beneficial result.
-Futility violating the principle of nonmaleficence may involve issues of medical futility.
Futile treatments are treatments a healthcare provider, when using good clinical judgment, does not believe will
provide a beneficial outcome for a patient.
-Rule of double effect: attributed to the Medieval Saint Thomas Aquinas (1124-1274) from his book Summa Theologica.
Basic premise for justifying killing in self-defense is that act can have two effects:
intended effect (selfdefense) and other effect beside the intention (killing another person during selfdefense action).
In healthcare, performing some actions may have two potential outcomes:
intended good outcome, but to achieve good outcome, a second, less acceptable outcome might be foreseen to occur.

3. Beneficence doing good. nurse obligated to do good, to implement action benefit client and their support person.
However, doing good can also pose a risk of harm.
-Paternalism deliberately overriding patient opportunity to exercise autonomy bec of perceiv obligation of beneficence.
the word reflects its roots in fatherly or male (paternal) hierarchical relationships, governance, and care.
-Second victim phenomenon situation when principle of beneficence is needed, which may not often be recognized
but should be discussed more often. In 2000, Albert Wu coined the second victim.
Ex: medical resident who made serious error in interpreting patient electrocardiogram, was labeled incompetent.
Physicians are the victims of an “expectation of perfection”.
He proposed that health care professionals nurse and pharmacist who make mistake are “second victim” along with
patients who “first and obvious victims of medical mistake”.
second victim need help from their colleague to navigate “grieving proces” that occur after make a serious mistake.

4. Justice frequently referred to as fairness. Nurses often face decisions in which a sense of justice should prevail.
Distributive justice refers to the fair allocation of resources.
Social justice represents the position that benefits and burdens should be distributed fairly among members of a
society, ideally, that all people in a society should have the same rights, benefits, and opportunities.

5. Fidelity means to be faithful to agreements and promises.

6. Veracity refers to telling the truth.

Accountability means answerable to oneself and others for one’s actions.
Responsibility refer to specific accountability or liability associated with the performance of dutie of particular role.

7.Confidentiality is the state of keeping or being kept secret or private.

Nondisclosure of private or secret information with which one is entrusted. Duty to respect privilege information.
Confidential Communication is privilege communication or professional secrecy because it is given based on trust.
It is both a legal and moral obligation of health care providers. Confidentiality builds trust.

Informed consent is a method that promotes: Autonomy

The client on renal dialysis inform nurse that he want to stop the series of dialysis. the nurse should appropriately do
which action in response to the client’s decision? Respect the client’s decision and provide comfort measures.
Nurse Aiman avoids deliberate harm, risk of harm and harm that occurs during her performance of nursing actions.
The nurse is promoting which ethical principle? Nonmaleficence
The nurse in a unit is caring for several clients. To distribute nursing care the nurse utilized the principle of triage due
to the limited availability of resources. The nurse is promoting which ethical principle? Justice
The duty to respect privileged information is called: Confidentiality
Professional-Patient Relationship
-Unavoidable trust create asymmetrical or even power structure in relationship between professional,patient,family.
According to Zaner, healthcare professionals must promise “not only to take care of, but to care for the patients and
families - to be candid, sensitive, attentive, and never to abandon them.”
-Human Dignity nurses protect a person’s dignity during all nursing care, and often a patient is a nurse is a primary
person who guards a patient’s dignity during medical procedures.
MacIntyre (1999) virtues of acknowledge dependence:
Just generosity form of giving generously without keeping score of who gives or receives the most.
Misericordia Latin word that signifies giving without prejudice based on the urgent need.
Truthfulness involves not being deceptive.
-Patient Advocacy nurses moving from patient to healthcare system. Advice from the nurse’s values to the patient.
The concept of advocacy has been part of the ethics of the international council of nurses (ICN) and ANA since 1970s.
• In the code of ethics or nurses with Interpretive statements, the ANA (2015) continues to support patient advocacy
by elaborating on the “primacy of patient’s interest” and requiring nurses to work collaboratively with others to
attain the goal of addressing the health care needs of patients and public.
• Nurses are called upon to ensure that all appropriate parties are involved in patient care decisions, patients are
provided with the information needed to make informed decisions, and collaboration is used to increase the
accessibility and availability of health care to all needed patients.
• The ICN (2012), in its Code of Ethics for Nurses, affirms that nurse must share “with society the responsibility for
initiating and supporting action to meet health and social needs of public, particularly those vulnerable populations.

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to
determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is
the nurse practicing patient advocacy? Assessing the patient’s point of view and preparing to articulate it.
The nurse’s obligations to the client least like: Work toward securing and maintaining conditions of employment
that satisfy the goals of nursing.
When caring for terminally ill client its important for nurse maintain client’s dignity. this can be facilitated by: placing
the client in a private room to provide privacy at all times.

Moral suffering disquieting feeling of anguish, uneasiness, angst experienced by healthcare professional.
Situations when moral suffering occurs:
• When nurses sort out their emotions, they find themselves in imperfect situation that morally unsatisfactory, force
beyond their control prevent them from positively influencing or changing unsatisfactory moral situations.
• Moral suffering may arise from disagreements with imperfect institutional policies.
• Nurses disagre with physician order that believe arent in patients best interest, they disagree with way family treat
patient or makes patient care decisions.
• When nurse with patient receive terminal diagnosis, when nurse caring for severely impaired neonate or elder who
is suffering, and life-sustaining care is either prolonged or withdrawn.
• Nurse freely choose to act in way they wouldnt defend as being morally condemnable in action honestly analyzed.
• When nurses act virtuously and courageously by doing what they believe is morally right despite consequences.

ethical dilemma situation in which individual is compelled to choose between two action it will affect welfare of a
sentient being, and both actions are reasonably justified as being good, neither action is readily justified as being
good, or the goodness of the actions is uncertain period one action must be chosen, thereby generating a quandary
of the person or group who is burdened with the choic.
the heart of ethical dilemmas It is the ethics of right versus right. (Kidder, 1995).
How can we judge wrong choices: violation of the law - departure from truth - deviation from moral restitute period
When person facing real ethical dilemma, often, none of the available option feel right. Both choices may feel wrong.
Critical Thinking Socrates’s method of teaching and questioning is one of the oldest systems of critical thinking.
• John Dewey (1952) is one of early proponents of critical thinking.
He summarized reflective thought as “active, persistent, careful consideration of any belief or supposed form of
knowledge in light of the grounds that support it, and further conclusion to which it tends, once it is conscious and
voluntary effect, they establish belief upon a firm basis of reasons.”
• Fisher (2001)
described the fundamental way to develop critical thinking skills as simply “thinking about one’s thinking”.
• Paul and Elder (2006)
directors of the Foundation for Critical Thinking.
defined critical thinking as “the art of analyzing and evaluating thinking to improve it.”
Paul summarizes the process of critical thinking.
Elder as “self-directed, self-discipline, self-monitored, self-corrective thinking that requires rigorous standards of
excellence and mindful command of their use.”
Characteristics of a Critical Thinkers (Paul and Elder):
• Asks straightforward, pertinent questions and identify fundamental problems.
• Analyze and interpret relevant information by using abstract thinking.
• Can generate reasonable conclusions and solutions tested according to sensible criteria and standards.
• Remains open-minded and consider alternative thought systems.
• Solves complex problems by effectively communicating with other people.

Ethical Decision Making

Ethical reasoning process of thinking through what one ought to do in orderly, systematic manner to provide
justification of actions based on principles.
Ethical decision making is used in situations in which the right decision isnt clear or in which there are conflicts of
rights and duties. Ethical decisions cant be based entirely on intuition or emotions.
Framework For Ethical Decision Making:
which theory involve? which principle involve? who will be affected? what consequence of alternative (ethical option)?

Procesing ethical dilemma resolving ethical dilemma similar to nursing proces in it methodical approach to clinical issue.
But it differs from the nursing process in that it requires negotiation of differences of opinion.
What make resolution of conflicting opinion work best: presumption of goodwill on the part of all participant -
strict adherence to confidentiality - patientcenter decision make - welcom participat of family and primary caregiver.
How do we know if the issue is ethical one: you are unable to resolve it solely through a review of scientific data - It
is perplexing - the answer to the problem will have a profound relevance for areas of human concern. (Curtin, 2004)

Key Steps in the resolution of an ethical dilemma:

1 ask question, is this ethical dilemma - 2 gather information relevant to case - 3 clarify values - 4 verbalize problem -
5 Identify possible courses of action - 6 negotiate a plan - 7 evaluate the plan over time.
• SITUATION: You are caring for a patient with a terminal illness. The patient has discussed with you her desire to
explore DNR orders. However,she expresses conflicting sentiments to the admitting physician, and you are
challenged with how to proceed.

The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the
chances of success are unclear. In helping the parents to decide and resolve this ethical conflict, the nurse knows
that the first thing to do: Collecting all available information about the situation.
In most ethical dilemma, the solution to the dilemma requires negotiation among members of the health care team.
The nurse’s point of view is significant because: Nurses develop a relationship with the client that is unique among
all professional health care providers.
Nurses aim to make decisions in line with a code of ethics. In this manner, nurses used the process of evaluating and
choosing among alternatives in a way consistent with ethical principles. Which of the following that describe the
best action of the nurses? Ethical Decision-making
When health care is in a complex situation that often involves an apparent mental conflict between moral
imperatives, in which to obey one would result in conflict with another, this refers to: Ethical dilemma
A health care issue often become ethical dilemma because: choices involve dont appear tobe clearly right or wrong
Moral Imagination is a way of seeing and feeling things as they compose an integral whole. Dewey (1934).
Moral imagination is moral decision-making through reflection involving empathetic projection and creatively
tapping a situation’s possibilities.
It involve moral awareness, decision-making beyond merely applying standardized ethical meaning, decision-making
models, bioethical principles to real-life situations.
Opinion shouldnt be form hastily, nor should action be taken without nurse cultivating and using moral imagination.
Reflective Practice distinguished reflection-on-action from reflection-in-action. Schon (1987).
-Reflection-on-action involves looking back on one’s actions.
-Reflection-in-action involves stopping to think about what one chooses and does before and during one’s actions.

Ethical Committee consists of physicians, nurses, staff chaplains, social worker, representative of the organization’s
administrative staff, a legal representative, local community representatives, and another drafted by the team.
Also, the involved patient, patient family, surrogate decision maker may meet with one or more committee member.
Ethical Committee question the decision-making capacity of the patient or family, and the patient’s or family’s
decisions may conflict with the physician’s or healthcare team’s recommendation regarding treatment.
Team approach to decision-making helpful under IOM‘s call for health care professionals to work in interdisciplinary
teams by cooperating, collaborating, communicating, integrating care to ensure that care is continuous and reliable.
What if nurse disagrees with physician or family’s decision? It is within the rights and duties of nurses to seek help
and advice from professional when experience moral uncertainty or witness unethical conduct in their work setting.

Islamic medical ethics extension of Shari’ah (Islamic law), which is itself based on 2 foundations: Quran – Sunna.
What happened when there is no clear rule found in the Quran or Sunna? Ijtihad or Qiyas is contemplated.
Fatwas translates as explanation or clarification, Legal opinion or decree handed down by an Islamic religious leader.
Objectives and Aims of Islamic Rules:
preservation of faith - of life - of mind (intellect, reason) - of progeny (alnasl) - of honor (al-irdh) - of property.
Do all nations have common principles in morality and ethics? YES
Source of these Moral and Ethical Attitudes in Islam Intuitive Reasoning or alfitra (innate nature) Faculty of
Reasoning or al- ‘Aql Divine Revelation or (Al-wahy, Tanzil).

Fitra refers to the innate nature of a human being; encompassing the good and the bad qualities.
Aql (Reason, Intellect) a guide used to think critically and distinguish right from wrong.
god endowed humanity ability to use reason to differentiate between right and wrong, discern proper course of action.
Wahy (revelations and guidance of God, carried by prophets to people):
The Oneness of God is the doctrine that states that there is one God, a singular divine being.
In Islamic belief revelation or inspiration is god word delivere by his chosen individual known as messenger prophet.
It traditionally thought that god send these prophet to people who carry revelation that are used to direct their live.

Autonomy means self-rule. The Quran clearly declared that “there is no compulsion in religion” (Quran 2:256) and that
each person has the full will to accept Islam or refuse it.
Personal choices are only accepted if they are the right ones.
Non-maleficence If action results in both good and harm, it is preferable to prevent causing harm.
Furthermore, if good outcome outweighs the harm in a situation, the action can be completed and accepted. The
Prophet Muhammad said “La Dharar wa la Dhirar” (There should be neither harming nor reciprocating harm).
In his book, (Qawaid Alahkam - Basics of Rulings) Alizz ibn Abdulsalam, an Islamic jurist, stated that the aim of medicine
is to preserve health and to provide a cure when it is needed.
Beneficence so intimate to principle of nonmaleficence. implies act of mercy,kindness,charity,altruism,love,humanity.
There are many verses in Quran that orders Muslims to “enjoin the right and forbid the wrong” when considering
that the true nature of man (al-fitra) is to be good.
Justice synonymous with fairness. A great importance is paid to justice by the Holy Quran.
The main purpose of sending the prophets was to establish justice in the world.
Quran say: (Indeed we have sent our messenger with clear proofs, and revealed with them the scripture and balance (justice) that mankind may keep up justice).
Justice is not only a supreme virtue but also a command from God.
Quran say (God commands justice (principle of Justice), doing of good (principle of beneficence), giving to kith and kin, and forbids all indecent deeds, and evil
(principle of non -maleficence) and rebellion: He instructs you that may receive admonition)