HEALTH CARE ETHICS

MODULE 2

PRINCIPLES OF HEALTH ETHICS

2.1 PATIENT’S BILL OF RIGHTS

1. The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from physicians and
other direct caregivers relevant, current, and understandable information
concerning diagnosis, treatment and prognosis. Except in emergencies when the
patient lacks decision-making capacity and the need for treatment is urgent, the
patient is entitled to the opportunity to discuss and request information related to
the specific procedures and/or treatments, the crisis involved, the possible length
of recuperation, and the medically reasonable alternatives and their
accompanying risks and benefits. The patient has the right to know the identity of
physicians, nurses, and others involved in his/her care, as well as when those
involved are students, residents, or trainees. The patient also has the right to
know the immediate and long-term financial implications of treatment choices, in
so far as they are known.
3. The patient has the right to make decisions about the plan of care prior to and
during the course of treatment and to refuse a recommended treatment or plan
of care to the extent permitted by law and hospital policy and to be informed of
the medical consequences of this action. In case of such refusal, the patient is
entitled to other appropriate care and services the hospital provides or transfer to
another hospital. The hospital should notify patients of any policy that might
affect patient choice within the institution.
4. The patient has the right to have an advance directive (such as a living will,
health care) concerning treatment or designating a surrogate decision maker
with the expectation that the hospital will honor the intent of that directive to the
extent permitted by law and hospital policy. Health care institutions must advise
patients of their rights under state law and hospital policy to make informed
medical choices, ask if the patient has an advance directive, and include that
information in patient records. The patient has the right to timely information
about hospital policy that may limit its ability to implement fully a legally valid
advance directive.
5. The patient has the right to every consideration of his privacy. Case discussion,
consultation, examination, and treatment should be conducted so as to protect
each patient’s privacy.
6. The patient has the right to expect that all communications and records
pertaining to his/her care should be treated as confidential by the hospital,
except in cases such as suspected public health hazards where reporting is
permitted or required by law. The patient has the right to expect that the hospital
will emphasize the confidentiality of this information when it releases it to any
other parties entitled to review information in these records.
7. The patient has the right to review the records pertaining to his/her medical care
and to have the information explained or interpreted as necessary except when
restricted by law.
8. The patient has the right to expect that, within its capacity and policies, a hospital
will make reasonable response to the request of a patient for appropriate and
medically indicated care and services. The hospital must provide evaluation,
service, and /or referral as indicated by the urgency of the case. When medically
appropriate and legally permissible, or when a patient has so requested, a
patient may be transferred to another facility. The institution to which the patient
is to be transferred must first have accepted the patient for transfer. The patient
 must also have the benefit of complete information and explanation concerning
the need for, risks, benefits, and alternatives to such a transfer.
9. The patient has the right to ask and be informed of the existence of business
relationships among the hospital, educational institutions, other health care
providers, or players that may influence the patient’s treatment and care.
10. The patient has the right to consent to or decline to participate in proposed
research studies or human experimentation affecting his care and treatment or
requiring direct patient involvement, and to have those studies fully explained
prior to consent. A patient who declines to participate in research or
experimentation is entitled to the most effective care that the hospital can
otherwise provide.
11. The patient has the right to expect reasonable continuity of care when
appropriate and to be informed by physicians and other caregivers available and
realistic patient care options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and practices that
relate to patient care, treatment, and responsibilities. The patient has the right to
be informed of available resources for resolving disputes, grievances, and
conflicts, such as ethics committees, patient representatives, or other
mechanisms available in the institution. The patient has the right to be informed
of the hospital’s charges for services and available payment methods.

RIGHTS OF A PATIENT
 PATIENT’S RIGHT – means the moral and inviolable power vested in him as a
person to do, hold, or demand something as his own.
 Every right in one individual involves a corresponding duty in others to respect
this right and not to violate it.

TYPES OF PATIENT’S RIGHTS

1. Right to be treated with respect.
2. Right to obtain medical records.
3. Right to privacy of medical records.
4. Right to make a treatment of choice.
5. Right to informed consent.
6. Right to refuse treatment.
7. Right to make decision about end-of-life care.

PATIENT’S BILL OF RIGHTS

1. Considerate and respectful care.
2. Relevant current and understandable information concerning diagnosis,
treatment prognosis, specific procedures, treatment, risks involved, medically
reasonable alternative benefits needed to make informed consent.
3. Make decisions regarding his plan of care; in case of refusal, he is entitled to
other appropriate care and service or be transferred to another hospital.
4. Have an advance directive (such as living will) concerning treatment or
designating a surrogate decision maker.
5. Every consideration of his privacy such as in case discussion, consultation and
treatment.
6. Confidentiality of communications and records.
7. Review his records concerning his medical care and have these explained to him
except when restricted by law.
8. Be informed of business relationship among the hospital, educational institution,
health care providers that may influence the patient's treatment and care.
9. Consent or decline to participate in experimental research affecting his care.
10. Reasonable continuity of care when appropriate and be informed of other care
options when hospital care is no longer appropriate.
11. Be informed of hospital policies and practices that relate to patient care.

PATIENT’S RESPONSIBILITIES
1. Maintaining rights as a patient.
2. Maintaining health habits.
3. Being respectful to providers.
4. Being honest with providers.
5. Complying with treatment plans.
6. Preparing for emergencies.
7. Reading behind the lines.
8. Making decisions responsibly.
9. Understanding prescription drugs and their possible effects.
10. Meeting financial obligations.
11. Avoiding putting others at risk.

LIMITATIONS OF A PATIENT’S RIGHTS

1. Patient’s right do not include the right to be allowed to die.
2. A person in a moribund condition does not possess the necessary mental
capacity or emotional stability to make an informed choice. The attending
physician, in such a situation, may perform a paternalistic act for the well-being
of the patient.
3. Patient’s rights are not absolute.

INFORMED CONSENT
 Every person is primarily responsible for his own body – to protect patient’s
personal integrity and enhance his active role in his own care.
 Main Functions:
1. Protective
2. Participative
 Elements
1. Knowledge
‒ Information disclosure by healthcare giver.
‒ Comprehension by the subject
2. Consent
‒ Subject competence
‒ Subject freedom /voluntariness
 ENLIGHTENED CONSENT
‒ It is embodied in a document called “CONSENT FORM” which is needed
before any invasive procedure or any research is done.
‒ It is said to be informed or enlightened because of the following:
a. Full disclosure of the procedure or research was given.
b. All possible effect, risks and alternative management have been
honestly discussed.
c. Free decision and agreement of the patient.
d. Person concerned affixes his/her signature voluntarily.
 PROXY CONSENT
‒ The field of Bioethics as promoted by the Institute of Ethics and Human
Rights in Houston, Texas (1993) specifies the following:
1. When the patient is in a coma, unconscious or incapable of making a
decision - those closest to him or her such as the family or relatives may
decide for the best benefit of the patient.
2. In instances when there is no close relatives and decisions must be
made - the health professionals with honest desires and intentions to
give the best strategy or intervention to the patient may decide for the
 patient. They are expected to execute their ADVOCACY ROLE to the
best outcome of the patient.
3. In case of minors – parents and the family of the patient will assume the
patient’s autonomy and make the decision which should always be the
best for the patient
‒ What does a health professional do when the patient is not in his or her right
sense when obtaining the informed consent?
‒ Who serves as the patient’s advocate when a patient is in coma?
‒ What about minors, who makes the decision for them?

2.2 ETHICAL PRINCIPLES

Ethical principles are the basis of all nursing practice and provide a framework to
help the nurse in ethical decision-making. The primary ethical principles include:
1. BENEFICENCE: Acting for the good and welfare of others and including such
attributes as kindness and charity.
2. NON-MALEFICENCE: Acting in such a way as to prevent harm to others or to
inflict the minimal harm possible.
3. AUTONOMY: Recognizing the individual’s right to self-determination and
decision-making.
4. JUSTICE: Acting in fairness to all individuals, treating others equally and
showing all individuals the same degree of respect and concern.
5. VERACITY: Being truthful, trustworthy, and accurate in all interactions with
others.
6. FIDELITY: Being loyal and faithful to individuals who place trust in the nurse.
7. INTEGRITY: Acting consistently with honesty and basing actions of moral
standards.
8. CONFIDENTIALITY: It encompasses the obligation of discretion on the part of
the health professional regarding any information afforded by the patient.

AUTONOMY – Patient’s rights; Patient’s Bill of Rights; Informed consent; Proxy

consent; Privacy
 The word autonomy is derived from the Greek words "autos" meaning "self" and
"nomos" meaning "rule," "governance" or "law." The original usage of this word
was for the self-rule-rule or self-governance of the independent Hellenic city
states. Since then, the term has been extended to individuals and has acquired
diverse meanings and interpretations. There is independence or autonomy in the
sense that one is able to see, judge, and decide what is logical and best for the
person to survive and enjoy living. In autonomy, the individual is free from
threats or any type of force. or coercion This means that the individual is in full
control of self, totally aware of what is the issue, and in a capacity to make
appropriate moves and decisions for the best outcome.
 However, autonomy can be studied in many aspects. For instance, some
theories on autonomy have featured the traits of an autonomous person. An
autonomous person must have the capacity for self-governance. To govern
one's self, one must have these capacities to understand the issue and what the
situation is all about; to reason out and give one's own opinion; to deliberate by
weighting the pros and cons of the issue, and then eventually to make an
independent choice. Basic to making an independent choice is one's capacity to
make decisions.
 Beauchamp and Childress (1994:121) agree that even autonomous persons with
self-governing capacities often fail to govern themselves in their choice because
of temporary constraints imposed by illness, depression, extreme fatigue, or
because of ignorance, coercion or conditions that restrict options. These authors
continue to state that an autonomous person who signs a consent form without
reading or understanding the form has failed to act autonomously because of
 failure to read and understand what the consent demanded. On the other hand,
some individuals who are not generally autonomous can at times make
autonomous choices. As an example, some patients who are confined in mental
institutions may be unable to care for themselves and are declare legally
incompetent. However, they may still be able to make autonomous decisions
such as stating preferences for meals, refusing some medications and
interventions, or making choosing to talk to certain relatives and friends.
 Some contemporary writers on ethical theory such as Dworkin (1988) contend
that autonomy is largely a matter of having the capacity to reflectively control and
identify with one's own basic or so-called first-order desires or preferences
through higher level desires or preferences. To make this clearer, let us take the
example of an alcoholic who may have a desire to stop drinking or a smoker who
desires cigarettes but at the same time also wants to quit smoking. An
autonomous person in this situation is one who has the capacity to rationally
identify with, accept, or repudiate a basic order desire or preference in a manner
that is independent of the manifestation of the desires. Such acceptance or
repudiation of the lower level in favor of the higher level, demonstrating the
individual's capacity to change his or her preference structure, constitute
autonomy. However, when we consider the Filipino people in general, there is a
common tendency to consider hierarchy and family authority in making decisions,
even decisions for the self. Many of our decision s and actions are influenced by
people in authority such as the family. In order to practice autonomy, there is a
need to fully inform or educate the individual so he or she can reach a decision
that we can call appropriate self-governance. For an action to be autonomous,
requirements should touch mainly on a substantial degree of understanding and
freedom from constraint.
 Autonomy of the client must be respected because this is a person's right to
exercise freedom of decision and choices. As health care providers, there is a
need for each of us to keep this in mind so that the client is assured of his / her
practice of autonomy.
 Now let us pause and see how much we remember. Challenge yourself with the
following questions. The answers can be found at the end of this chapter, but
answer the questions first to test yourself. Here we go!
 Summing up the principle of autonomy brings us to the corollary principle of
respect for autonomy. Respect for autonomy means we acknowledge the
individual's right to hold views and opinions, to make choices, and to take action
based on personal values, traditions, and beliefs. Respect is concretized through
action, reaction and attitude. It means allowing the person to act on his or her
own, in other words, autonomously; and accepting •the person positively for what
he or she is to. us. Disrespect for autonomy involves attitudes and actions that
ignore, insult, belittle, despise, or demean a person.
 Why respect an individual's autonomy? Because all persons have unconditional
worth and each one has the capacity to determine his or her own destiny.
Philosophers Immanuel Kant and John Stuart Mill have strong contentions on
their statement of personal destiny. To violate a person's autonomy is to treat
that person merely as a means, that is, in accordance with another's goals with
no regard to that person's own goals. Such treatment is a fundamental moral
violation because autonomous persons are ends in themselves capable of
determining their destinies. We must also consider the individuality of persons in
shaping their own lives because each individual has the capacity to develop the
self according to personal convictions. This is as long as their development does
not interfere with the freedom of others. There should be an effort in each one of
us to respect and recognize what the person is worth without prejudice and
prejudgments.
CONFIDENTIALITY
 Keeping in confidence all that one has learned in the course of caring for the
patient and the family, is a very strong basis for an effective and working
professional-patient relationship. To confide in someone like a physician or nurse,
one has to feel secure that secrets are securely guarded and kept in confidence.
Confidentiality often does not apply to families because each member knows or
will try to know about each other.
 Let us make the distinction between infringement on privacy and infringement on
confidentiality. The difference is this: An infringement of X's right to confidentiality
occurs only if the person to whom X discloses the information in confidence fails
to protect the information, or deliberately discloses it to someone without X's
consent. In contrast, a person who, without authorization, enters a hospital
records room or computer data bank, violates the right to privacy rather than
confidentiality. In sum, only the person or institution to whom information is given
in a confidential relationship can be charged with violating rights of confidentiality.
 Nurses, physicians, and guidance counselors are some of the professionals
among whom confidentiality must be observed, respected, and guarded because
many confidences are revealed to them in the course of the exercise of their
profession. These professionals must have keep ears to listen, big hearts to
understand, and very small mouths to talk. Once secrets are confided, they
should be sealed with much respect because with confidentiality, there is trust.
 In health care, truth-telling and confidentiality are essential components that
must always be respected. Smooth professionalpatient relationships happen
when truth telling and confidentiality along with the other components of a
relationship such as privacy, veracity, and fidelity, are honestly kept and
respected al all times. Hence, we need constant discernment of our words and
critiques so that we are reminded of the magnitude of our responsibilities in all
our relationships with others.

VERACITY – Truth Telling & Right To Information

 Veracity in its basic meaning is truthfulness. To be true is to accept one's self as
one is. To respect veracity in relationships is to deal honestly with patients and
colleagues as they are. With veracity goes virtues of candor and truthfulness,
and these are the widely praised character traits of health professionals in
contemporary biomedical ethics.
 Veracity is necessary in professional-patient relationships for three reasons:
1. The obligation of veracity is based on respect owed to others. In asking
patients their consent for any deemed necessary intervention, the validity of
the consent depends on the thorough information, full disclosure, and
enlightenment given to the patient regarding the procedures or intervention
to be done. According to Allan Donagan (1978), the "respect owned to other
human beings includes respect for their liberty."
2. Veracity has a close connection to obligations of fidelity and promise-keeping.
When we communicate with others, we implicitly promise that we will speak
truthfully and that we will not deceive our listeners. Voluntary participation in
these social conventions engenders an obligation of veracity, of truthfulness.
An example that I could think of is when a relationship is entered into a
contract, thereby gaining a right to the truth regarding diagnosis, prognosis
and all other pertinent information. The professional gains a right to truthful
disclosure of information from patients and research subjects.
3. Relationship of trust between persons are necessary for fruitful .intervention
and cooperation. At the core of these relationships is confidence in and
reliance on others to be truthful. Relationships between health care
professionals and their patients and between researchers and their subjects
 ultimately depend on trust and adherence to rules of veracity. These are all
necessary to foster trust. On the other hand, lying and inadequate disclosure
show disrespect for persons, violate implicit contracts, and threaten
relationships.

FIDELITY
 By fidelity, we mean the obligation to act in good faith and to keep vows and
promises, fulfill agreements, maintain relationships and fiduciary responsibilities.
Fiduciary responsibility refers to the contract of relationship we enter into with the
Patient. The model for fidelity is keeping one's word of honor, loyalty to
commitments and oaths, and reliability. Why so? Because the model of fidelity
leans on the values of loyalty and trust as well as standing true to one's word. In
popular Spanish Parlance, this is known as palabra de honor With fidelity goes
the traits of maturity and commitment of the person.
 Fiduciary relationships bank on trust and confidence. This means that once the
physician or nurse enters a relationship with the patient, these professionals
become the trustees of the patient's health and welfare. Hence, both the
physician and the nurse are obligated to maintain the contract of care. They
cannot withdraw their care without giving notice to the patient, the relatives or
responsible friends, who need enough time to look for their replacement
attendants. (Ramsey, 1970).
 The Council on Ethical and Judicial Affairs on Health Care (1992) specifies that
"abandonment is a breach of fidelity, and infidelity amounting to disloyalty."
Whether or not a promise was made, such infidelity undermines trustworthiness,
honesty, and loyalty.
 According to Benjamin and Curtis (1987), "traditionally, nurses have been
discouraged from developing and acting on their own ethical judgments.
Although the institutions of nursing and medicine developed separately until the
late eighteenth century, the increasing importance of the hospital in health care
brought nursing under the dual command of physicians and hospital
administrators.
 Recent codes of nursing ethics define the moral responsibility of nurses in
sharply different ways from the codes of two or three decades ago. In America,
for example, in 1950, the American Nurses Association stressed the nurse's
obligation to carry out the physician's orders, but the 1976 revision stressed the
nurse's obligation to protect the reputation of associates, the later code
emphasized the obligation to safeguard the client and the public from the
"incompetent, unethical or illegal" practices of any person (Hasting Report, 1984).
 In the same manner, the Philippine Nursing Law, particularly RA 7164, passed,
promulgated and executed in 1992, emphasizes the role of the nurse as the
client advocate or patient advocate who can do independent nursing measures.
In brief, the nursing profession acts on ethical guidelines, independent of the
command of physicians or hospital administrators.
 This demands keen assessment, competence, and fidelity to the patient and to
the profession for every nurse who cares for patients regardless of creed, race,
or age. Fidelity is possible when one knows what is beneficent to others and
when one respects the autonomy of others, because these lead to honesty and
trust.

JUSTICE
 The terms fairness, deserts (what is deserved) and entitlement (that to which
one is entitled) have been mentioned by various philosophers in an attempt to
explain the term justice. Justice is giving each one his or her due. Let's take an
example. Someone who has been working hard on the
 Job does not get the needed promotion while another one who gets promoted
without merit. The one who worked hard is entitled to something; in this case, a
promotion. An injustice therefore involves a wrongful act or omission that denies
people benefits to which they have a right to.
 There are many types of justice according to Beauchamp and Childress (1994):
1. DISTRIBUTIVE JUSTICE – refers to fair, equitable, and appropriate
distribution of responsibilities, or share of rights and roles.
2. CRIMINAL JUSTICE – refers to the just infliction of punishment, or penalty
proportionate to the crime committed.
3. RECTIFICATORY JUSTICE – refers to just compensation for
transactional problems such as breaches of contract and practice based
on civil law.
 Problems of distributive justice arise under conditions of scarcity and competition.
When the supply is limited, distributive justice requires that more should be given
to the one who needs most and to the one who will be most benefited to attain
quality life. When fairness is observed with honest justification in allotting shares
of limited goods, distributive justice flows without much problem. When the
available supply is too limited, and there are just too many who desire to avail of
the limited supply, sometimes it is resolved by lottery, giving each one a fair
probability of being selected.
 Engelhardt, Keusch, Wildes (1995) and others have suggested the following
principles as valid material principles of distributive justice:
 There is no obvious barrier to the acceptance of more than one principle, and
some theories of justice accept all six as valid. A plausible moral theme is that
each of these material principles identifies a prima facie obligation whose weight
cannot be a assessed independently of particular circumstances in which they
are especially applicable. Additional specification may also establish the
relevance of these principles to a circumstance in which they formerly had not
been judged applicable.
 Theories of distributive justice have been developed to specify and unite our
diverse principles rules, and judgments. A theory attempts to connect the
characteristics of persons with morally justifiable distribution of benefits and
burdens. For example, a person's service, effort, or misfortune might be the
basis of distribution. Several systematic theories have been proposed to
determine how social burdens, including health care goods and services, should
be distributed or redistributed. Some influential theories that go with the principle
of justice are the following:
1. UTILITARIAN – emphasizes a mixture of criteria for the purpose of
maximizing public utility
2. LIBERTARIAN – emphasizes rights to social and economic liberty,
invoking fair procedures rather than substantive outcome
3. COMMUNITARIAN – stresses the principles and practices of justice that
evolve through traditions in a community
4. EGALITARIAN – emphasizes equal access to goods in life that every
rational person values. The acceptability of any theory of justice is
determined by the strength of its moral argument. B ut we must all seek to
provide the best possible health care for all citizens and promote public
interest

BENEFICENCE AND NON-MALEFICENCE

 Beneficence as a primary principle of bioethics includes non-maleficence (doing
no harm to anyone), attentiveness, prevenance (anticipating one's needs),
positive reinforcement, helpfulness, positive paternalism, sharing, and also truth-
telling in beneficence, all persons should be treated autonomously No harm
should be done to anyone and we should contribute to their welfare and growth
 The role of others to take positive steps to help others is emphasized in the
principles of beneficence
 The term beneficence connotes blessings, acts of mercy, kindness, charity,
altruism, love, humanity and kindness. Broadly, beneficence stands for all forms
of action done for the benefit of others In this context, benevolence refers to the
character trait or virtue of being disposed to act for the benefit of others; and the
principle of beneficence refers to the moral obligation to act for the benefit of
others Many acts of beneficence are not obligatory, but a principle of
beneficence asserts an obligation to help others achieve their important and
legitimate interests as well as help them attain full growth and development of
their personhood
 Beneficence refers to action done for the good of others. Non-maleficence refers
to prevention of harm and the removal of harmful conditions. In line with these
principles, we shall discuss guidelines on the use of extraordinary means in
critically injured individuals and for those whose clinical conditions are
irreversible. The field of Bioethics has evolved fast because of the continuously
changing economics and lifestyles of people all over the world. We have now
classified extraordinary measures as proportionate or disproportionate means
depending on the pathologic conditions of the sick as well as on their
socioeconomic capabilities.
 Our morality dictates that not only do we respect a person's autonomy but also
that we contribute to their welfare. Let us keep in mind that each person by
nature, is good. Everyone possesses kindness in the depths of their hearts and
beings. Let us study together the significance of beneficence in our dealings with
ourselves and with others.
 As you go through the text, you will see that beneficence goes hand in hand with
our benevolence and provenance. Benevolence is goodness in each
personhood. Provenance on the other hand, is the attentiveness dictated by
kindness to anticipate what one needs. In each one of us, there is that inner
goodness that pushes us to alleviate the pain and discomforts of other people.

BENEFICENCE
 Beauchamp and Childress (1994), Pesche (1990), and other bioethicists
associate beneficence with acts of mercy, kindness, and charity. Humanity,
altruism, and love are also sometimes considered forms of beneficence.
Benevolence refers to the character trait or virtue of being inclined to do good
and act for the benefit of others. Many acts of beneficence are not obligatory, but
there are instances when one is obliged to do emergency care to one who is
hovering between life and death.
 Some ethical theories like utilitarianism are based on the principle of beneficence
This means goodness and kind deeds form the backbone of the utilitarian theory.
Utilitarianism is defined as the moral and political rightness of an action and is
determined by its contribution to the greatest good of the greatest number.
 Later thoughts on beneficence touch on obligatory beneficence and ideal
beneficence. Different philosophers like Bentham and 'Ross ehployed the term
beneficence to identify positive obligations to others Many critics though are
suspicious of the claim that we have these positive obligations. Bentham and
Ross hold that beneficence is purely a virtuous ideal or an act of charity, thus
persons are not morally deficient if they fail to act beneficently. These concerns
rightly point to a need to clarify and specify beneficence, taking care to note the
limits of our obligations and the point at which beneficence is optional rather than
obligatory.
 An example of beneficence is found in the New Testament in the Parable of the
Good Samaritan, which illustrates several problems in interpreting beneficence.
As the parable goes, a man traveling from Jerusalem to Jericho was beaten by
 robbers who left him "half dead." After two other travelers passed by the injured
man without rendering help, a Samaritan saw him, "had compassion, went to him
and bound up his wounds, brought him to an inn, and took care of him." In
having compassion and showing mercy, the Good Samaritan expressed an
attitude of caring for the injured man. Both his motives and actions were
beneficent.
 The parable, however, suggests that positive beneficence is more an ideal than
an obligation because the Samaritan's act serves to exceed ordinary morality.
Furthermore, suppose that the injured rnan, when encountered by the Samaritan
gives an advance directive indicating that he wants to die. The Samaritan then
would face a dilemma: should he respect the injured man's wishes or will he take
care of him his wishes?
 Beneficence, then, is sometimes an admirable ideal of action that exceeds
obligations, and at other times is appropriately linked to other moral obligations.
Beauchamp and Childress (1994) and others ask: Are we ever obligated to act
beneficently? Does Oui moral obligation stem from our feelings and duties to do
good to our neighbor?
 The questions can be initially addressed by noting that acts of beneficence play
a vital role in moral life quite apart from the principle of obligatory beneficence.
No one denies that many beneficent acts, such as the donation of a kidney to a
stranger, are morally praiseworthy and not obligatory. In organ donation, we are
cautious because under the beneficent act of giving one's organ to another, we
also touch the principle of stewardship. This principle of stewardship reminds us
that we are care takers or stewards of our body and that we cannot just give any
part of our body without due cause or the utmost benefit of another person in
need.
 Virtually everyone agrees that the common morality does not contain a principle
of beneficence that requires severe sacrifice and extreme altruism. Only ideal
beneficence incorporates such extreme generosity. We are likewise not morally
required to give benefits to persons on all occasions, even if we are in a position
to do so. For example, We are not morally required to perform all possible acts
of generosity or charity that would benefit others. We can readily grant then, that
ideal beneficence means going out of one's way in order to do good to others.
Beneficence is plain goodness to others without going out of one's ways.
 Nonetheless, several rules on obligatory beneficence form an important part of
morality. Because of the wide range of types of benefits, the principle of
beneficence supports an array of more specific moral rules, including some that
are already noted without referring to them as rules. What we have to keep in
mind are the following beneficent rules taken from Principles of Biomedical
Ethics (1994).
1. Protect and defend the rights of others
2. Prevent harm from occurring to others
3. Remove conditions that will cause harm to others
4. Help persons with disabilities
5. Rescue persons in danger
 Beneficence and Non-maleficence and their Implications on Certain Situations
 The principle of non-maleficence asserts an obligation not to inflict harm
intentionally. The maxim of medical ethics is Primum non nocere, which means,
"above all, do no harm to anyone." An obligation of non-maleficence and an
obligation of beneficence are both expressed in the Hippocratic Oath: "l will use
treatment to help the sick according to my ability and judgment, but I will never
use it to injure or harm them.
 NON-MALEFICENCE
‒ One ought not to inflict evil or harm
 BENEFICENCE
 ‒ One ought to prevent evil or harm
‒ One ought to remove evil or harm
‒ One ought to do or promote good
 Each of these three forms of beneficence requires taking action by preventing
harm, removing harm and promoting good, whereas non-maleficence only
requires intentionally refraining from actions that cause harm.
 Other philosophers and even some bioethicists may have other points by which
they make a distinction between non-maleficence and beneficence. For this
discussion, non-maleficence is explained using the term "harm". Non-
maleficence is not doing harm or inflicting evil on someone, especially physicall
harm. Non-maleficence here is avoiding any intent or cause that will lead to
death.
 Because there are many types of harm, the principle of non-maleficence
supports many specific moral rules. Other principles, such as autonomy and
justice, are also occasionally called upon to help justify these rules. In 1988, Gert,
a bioethicist working in moral-oriented disciplines, gave the following typical
examples of non-maleficence.
1. "Do not kill."
2. "Do not cause pain or suffering to others."
3. "Do not cause offense to others."
4. "Do not incapacitate others."
5. "Do not deprive others of the goods of life."
 Obligations of non-maleficence are obligations of not including harm, and not
imposing risks of harm. A person can harm or place another person at risk
without malicious or harmful intent and the agent of harm may or may not really
be morally or legally responsible.
 To safeguard health care workers, hospitals and medical centers follow a
standard of due care. The standard of due care specifies that with emergency or
urgent cases, attempting to save lives after a major accident justifies the risks
created by such emergency measures. Negligence in caring for someone in
need is considered a departure from the standard of due care. In the Philippines,
hospitals and medical centers, both of the government and private types,
subscribe to this standard of due care.
 When it comes to withholding versus withdrawing treatments, letting go for the
dignity of death versus committing assisted suicide, could very well be an issue.
This often places the health care professionals in a confusing situation. Most of
the time, the health care professional is guided by his or her values, family
practices, philosophies and beliefs. It is in situations like these that guidelines
are very much appreciated. However, not all hospitals and medical centers have
bioethics committees that can issue bioethical guidelines.
 Other Relevant Ethical Principles:
 Principle of Double Effect. The three moral principles of Christian ethics, which
are very relevant in the medical context, are the double effect principle, principle
of totality, and the precept "a good end does not justify an evil means." The
principle of double effect applies to a situation in which a good effect and an evil
effect (which is permitted to occur but not directly intended) will result from a
good cause.
 The performance of such an act (from which a good effect and an evil effect will
follow) is considered morally legitimate provided four conditions are fulfilled:
1. The action directly intended must be good in itself, or at least morally
indifferent;
2. The good effect must follow from the action at least as immediately as the
evil effect;
3. The foreseen effect must not be intended or approved but merely
permitted to occur;
 4. There must be a proportionate and sufficient reason for allowing the evil
effect to occur while performing the action.
 A very good example is the case of a woman who has an ectopic pregnancy.
The life of the mother can be in danger if pregnancy continues. In the present
state of medical science, only the surgical removal of the fetus can save the
mother's life. It would be unreasonable not to remove the fetus and let both
human lives perish. Right reason dictates that it is better to save one life than to
let both human beings die.

PRINCIPLE OF LEGITIMATE COOPERATION

COMMON GOOD
 Vatican II defined the Common Good as “the sum total of social conditions which
allows people, either as groups or as individuals, to reach their fulfilment more
fully and more easily.” It is about the progress of persons.
 A society that wishes and intends to remain at the service of the human being at
every level is a society that has the common good – the good of all people and
of the whole person as its primary goal.
 We must be interested in the good of all, even of people nobody thinks about
because they have no voice and no power. The goods of the earth are there for
everyone. The common good consists not only of the material or external good
of all human beings; it also includes the comprehensive good of the human
being, including even the spiritual good.
 The common good of society is not an end in itself. It is only part of a bigger
picture, the ultimate end of which is God. The common good, as a mere
materialistic socio-economic ideal, would count for little without any
transcendental goal.

THE COMMON GOOD AND POLITICS

 The Catechism of the Catholic Church clearly states that “it is the role of the
state to defend and promote the common good of civil society, its citizens, and
intermediate bodies.”
 The common good, in fact, is the very reason that political authority exists.
 It is the role of political institutions to make available to persons the necessary
material, cultural, moral and spiritual goods required to allow each individual to
achieve their full development. Among the duties of government is the need to
harmonise different sectoral interests with the requirements of justice. It is an
extremely delicate task but one of great importance.

THE UNIVERSAL DESTINATION OF GOODS

 God created the world for all and the goods of the world should in principle, be at
the disposal of all and for the good of all, without preferential treatment. John
Paul II in the encyclical letter Centesimus Annus states: “the earth, by reason of
its fruitfulness and its capacity to satisfy human needs, is God’s first gift for the
sustenance of human life.
 Every person has the right to what is vitally necessary and this must not be
withheld from him. The Church accepts that there is a right to property and that
there will always be differences in how much people own, but if some have more
while others lack the bare necessities there is a need for charity and also for
justice.
 Is private property permissible? It is reasonable for there to be private property;
through work and the acquiring of private property a person shapes the earth
and makes a piece of it his own. Private property encourages freedom and
independence and it also encourages the individual to preserve and care for his
property. The Second Vatican Council, in Gaudium et spes, states that private
 property and other forms of private ownership of goods “assure a person a highly
necessary sphere for the exercise of his personal and family autonomy and
ought to be considered as an extension of human freedom….stimulating
exercise of responsibility, it constitutes one of the conditions for civil liberty.”
 It is, however, important that owners of private property make use of it in a
manner consistent with the common good; that is, the good of all. Property
includes intellectual property, knowledge, and technology. This is particularly
important in the context of wealthy nations and their obligations to poorer nations.

PREFERENTIAL OPTION FOR THE POOR

 The principle of the universal destination of goods requires that the poor and the
marginalised should be the focus of particular concern. We imitate Christ by a
loving preference for the poor, inspiring us to embrace the hungry, the needy,
the homeless, those without healthcare, and those without hope of a better
future.
 The Catechism (103) makes this abundantly clear: “Our Lord warns us that we
shall be separated from him if we fail to meet the serious needs of the poor and
the little ones who are his brethren.” It further states (2248) that the Church,
“since her origin and in spite of the failing of many of her members, has not
ceased to work their [the poor] relief, defiance and liberation through numerous
works of charity which remain indispensable always and everywhere.”
 The Church’s love for the poor is inspired by the Gospel of the Beatitudes, the
poverty of Jesus and his attention to the poor. The Church teaches that one
should assist one’s fellow man in his various needs and fill the human
community with countless works of corporal and spiritual mercy.
 ‘When we attend to the needs of the poor, we give them what is theirs, not ours.
We pay a debt of justice.’ (St Gregory the Great, Regula Pastoralis)

SUBSIDIARITY
 Every task of society should be assigned to the smallest possible group that can
perform it. Only if the smaller group is unable to resolve the problem itself should
a group at a higher level assume responsibility. This idea is summed up in the
principle of subsidiarity.
 For example, if a family is experiencing problems, the state can intervene only if
the family or the parents are overburdened and cannot resolve them. It helps to
avoid too much centralization. Being able to help oneself is an important
component of the dignity of the human person.
 Pope Pius XI’s encyclical letter Quadragesimo Anno, which introduced the
principle, goes as far as to say that ‘it is an injustice and a grave evil and
disturbance of right order to assign to a greater and higher association what
lesser and subordinate organizations can do.’
 It is the same for politics. Only where local government cannot resolve a problem
by itself may the federal/central government claim competence.

2.3 BIOETHICAL PRINCIPLES

PRINCIPLE OF STEWARDSHIP & ROLE OF STEWARDS
 Refers to the expression of one’s responsibility to take care of, nurture and
cultivate what has been entrusted to him.
 Man has to be a steward of the gift of life along with other possessions God has
shared with him.
 The principle requires that the gift of human life & its natural environment be
used with profound respect.
 Man received every gift & grace from God. Must use them in responsible manner
to promote the interest of God.
 As a steward, man does not have absolute ownership of his life.
 In healthcare practice, stewardship refers to:
a. Execution of responsibility of the health care practitioner to look after,
provide necessary health care services, and promote the health & life of
those entrusted in their care.
b. Being just & honest with the exercise of his duties & obligations to uphold
the goodness of human life as God’s creation.
c. Recognize his dependency not so much on his capacity but on God – the
giver of that capacity, to be God’s ambassador of service for the sick, & to
project the very image of God with whom he is to make an ultimate
account of his stewardship.
PRINCIPLE OF TOTALITY & ITS INTEGRITY
 To promote human dignity in community, every person must develop, use, care
for, and preserve all of his or her natural physical and psychic functions in such a
way that:
a. Lower functions are never sacrificed except for the better functioning of the
whole person and even then with an effort to compensate for this sacrifice.
b. The basic capacities that define human personhood are never sacrificed
unless this is necessary to preserve life.
 To be a complete human being is not merely having the higher level of functions
but to have all the basic human functions in harmonious order.
 Human body functions contribute to higher functions not merely by supplying
what is needed for physiological functioning, they also supply part of the human
experience that is essential to human intelligence and freedom.
 The good of the part is essentially subordinate to the good of the whole.
 In case of danger to itself, the whole can dispose of the part for its own benefit.
 In a living physical organism such as the human organism, the parts by their very
nature exist for the sake of the whole.
 Hence, Principle Of Totality, the parts of a physical whole, inasmuch as they are
parts, are ordained or directed towards the good of the whole. It is applied to the
human body, if some part or function becomes an actual threat to the whole
body (e.g. an infected appendix), the suppression of its functions or its removal
is LICIT. This justifies a series of surgical interventions done in daily clinical
practice (kidneys, amputation of diseased leg or extremities, gallbladder).
 CONDITIONS FOR PRINCIPLE OF TOTALITY
a. That the organ by its deterioration in function may cause damage to the whole
organism or at least pose a serious threat to it.
b. That there is no other way than taking the indicated action against it or
obtaining the desired good result.
c. That the damage being avoided to the whole is proportional to that which is
caused by the mutilation or incapacitation of the part.
 Ethical Issues or Special Cases - BODILY INTEGRITY
‒ Biologically speaking, life is the result of the harmonious functioning of a
series of organs.
A. MUTILATION
 The removal or elimination of an organ or suppression of a
function, such as disease or a threat to the entire human body.
This is Licit under the Principle of Totality.
 Is an action by which an organic function/ the use of a member of
the body is intentionally destroyed either partially or wholly.
 Types:
1. DIRECT – Willed in itself, as end or as means, intended and
caused intrinsically wrong. Offends human dignity. Individual
does not have the right to mutilate himself, much less does
society.
 2. INDIRECT (Therapeutic) – Licit is an act of good stewardship
of the body; necessary for the survival of the patient or to free
him of proportional sufferings/ infirmities.
B. STERILIZATION
 Any medical or surgical intervention which is performed on the
patient, to incapacitate her or him (incapable of reproduction),
whether organically (surgical), or functionally (non-surgical),
temporarily or permanent.
 Classification:
a. According to techniques performed:
1. SURGICAL METHODS – suppression of reproductive
organs by operating on their different parts. Female:
oophorectomy (ovaries), salphingectomy (fallopian tubes),
tubal ligation, hysterectomy (uterus). Male: castration
(testicles), vasectomy (vas deferens), emasculation
(suppression of the male genital apparatus, loss of testes
or penis or both).
2. NON-SURGICAL METHOD – involves a blockade of the
maturation process of the ovum using pharmacologic
agents (Anovulatory drugs – inhibits ovulation)
b. According to motives:
1. EUGENIC – performed to avoid the birth of defective or
diseased offspring
2. THERAPEUTIC – remove a pathologic reproductive
organ, which endangers the life of the patient.
3. CONTRACEPTIVE – suppress ovulation.
c. Other types:
1. EUPHORIC – in the interest of conserving the voice.
2. ASCETIC – designed to conquer the sin of lust.
3. PUNITIVE – in order to punish someone for a crime.
4. HEDONISTIC – with intention to evade the complications
and responsibilities of procreation without giving up the
sexual pleasure.
5. DEMOGRAPHIC – to control birthrate by means of
implementing a population policy.
6. PREVENTIVE – to render impossible pregnancies which
might aggravate sickness that already exists without any
causal relation with the sexual function.
 Therapeutic VS Direct Sterilization
1. THERAPEUTIC STERILIZATION
‒ One in which is inevitably required by and for the health or
survival of the person.
‒ Ruled by the Principle of Totality, since the sexual organs
are integral parts which must yield to the good of the
whole.
‒ LICIT in the following conditions:
‒ Sickness must be so grave, properly diagnosed and
definitive that it offsets the evil of sterilization.
‒ Sterilization must be necessary because it is the
most and the only effective remedy.
‒ Purpose be exclusively curative, tolerating
sterilization as the indispensable (needed, essential)
means.
 2. DIRECT STERILIZATION
‒ That which by its very nature & condition has for its only
immediate effect the impossibility of procreation.
‒ Or that which the agent intends as an end or as a means
to make procreation impossible.
C. PLASTIC or AESTHETIC SURGERY
 It is LICIT under the following conditions:
1. Intention is good.
2. The patient is not exposed to grave medical risks.
3. The motives are reasonably proportionate to the extraordinary
means employed – to improve bodily appearance after an
injury cause by accidents, congenital deformities, etc… when
the external features could be psychological, social or
economic handicap with repercussions in the individual’s
adaptation to society (e.g. cleft lip, palate)
D. ORGAN TRANSPLANT AND DONATION
 Transplant – the transfer of an organ or a major or minor portion of
a tissue from one part of the body to another or from an organism
to another. E.g. skin graft, blood transfusion, kidney transplants.
 Types:
1. AUTOTRANSPLANT (autograft or autoplastic grafts) – the
donor & recipient is the same person. E.g. skin graft or bone
graft. Moral Evaluation: Licit (same reason as ordinary surgery)
2. HETEROLOGOUS – the donor & recipient are two different
individuals.
‒ HETEROTRANSPLANT – animal-to-human organ
transplant, considered Licit.
‒ HOMOTRANSPLANT – human-to human transplant,
personal freedom must be respected and organ donation
must not be imposed as an obligation.
 Donor is a LIVING INDIVIDUAL
‒ Justified under the Principle of Finality, a healthy man may
voluntarily donate any part of his body not essential to his
life, without contradicting nature, for the benefit of his sick
neighbor. Done out of generosity, is justified and
meritorious.
 Donor is a CADAVER
‒ Licit as long as performed according to civil laws. If not
law on transplants, donor’s consent must be obtained
prior to death, or if not possible, family must give
authorization. CERTITUDE OF DEATH is important
(where organ concerned is primary to life: heart, lung,
cornea, etc ….)
 RA 7170 - an act authorizing the legacy or donation of all or part
of a human body after death for specified purposes, otherwise
known as “ORGAN DONATION ACT OF 1991”,
 Other Ethical Problems involving Transplants:
1. Determination of the exact moment of death of the donor,
before proceeding to the extraction of organs.
2. Legal nature of the cadaver: who has the authority or power
over it; who can decide its use for therapeutic scientific
purpose, etc…
3. Determination of Death: must not be based on subjective
criteria but rather on strict verifiable standard criteria. Death,
the total & irreversible cessation of functions involving the
 whole organism. Death does not occur instantaneously, it
begins at the cellular level, it initially affects higher centers
incapable of activation when deprived of circulation and
ventilation.
4. Criteria required for Organ Donation & Transplant to be
justified & therefore made LICITLY:
‒ On the part of the donor: The organ is strictly not essential
to life. Donation is voluntary & for honorable purposes.
Donor understands clearly the risks involved.
‒ On the part of the recipient: Transplant is truly necessary
for his health.
‒ On the part of the operation: Has reasonable chance of
success. Benefits to recipient & risks are proportionate.
5. Compensation: “It is meritorious for the donor to refuse any
compensation.”

PRINCIPLE OF ORDINARY & EXTRAORDINARY MEANS

 DETERMINATION OF DEATH
‒ The Uniform Determination of Death Act (UDDA), an act adopted by most
US states and is intended to provide a comprehensive and medically
sound basis for determining death in all situations.
‒ Determination of Death, an individual who has sustained either:
1. Irreversible cessation of circulatory & respiratory functions.
2. Irreversible cessation of all functions of the entire brain, including the
brain stem is dead.
‒ A determination of death must be made in accordance with accepted
medical standards.
‒ Clinical Death
1. Term of cessation of blood circulation & breathing.
2. It occurs when the heart stops beating in a regular rhythm, a condition
called “cardiac arrest”. It is also sometimes used in resuscitation
research.
3. It is a condition that precedes death rather than actually being dead.
4. All tissues & organs in the body steadily accumulate a type of injury
called ischemic injury.
 DISTHANASIA or Employing “Disproportionate” mean of Therapy
‒ Is there limit to the use of therapeutic modalities in a patient? We cannot
permit death to be a mechanical event by the abuse of technology.
 EXTRAORDINARY MEANS VS ORDINARY MEANS – ambiguous terms,
therefore better to use “Disproportionate vs Proportionate” means: When
evaluating the means, one has to take into account the therapeutic modality,
degree of difficulty, the accompanying risks, costs, practicality of application as
against expected results considering the patient’s condition, physical & moral
stamina.
‒ Summary of Approach:
‒ The purpose of medicine (and of the health profession as a whole) is
to protect health, cure disease, alleviate pain, comfort the suffering
always with due respect for the freedom & dignity of the person. In the
absence of alternative therapy, it is LICIT to resort to “new modalities”.
Medicine can be offered with the patient’s consent (generosity for the
benefit of humanity).
‒ But as per agreement between the patient, relatives & competent
physicians, it is licit to interrupt the application of these new modalities
when the results are disappointing (e.g. the expected result is the
artificial delay of death).
 ‒ It is always licit to conform to ordinary / proportionate therapeutic
means. Thus, no one is obliged to utilize risky & expensive therapy –
Disproportionate means.
‒ In the face of imminent death, it is licit to renounce treatment that
would merely obtain a precarious & pitiful extension of existence.
‒ It is never licit to suspend the ordinary means in patients even if
prognosis may be fatal

PRINCIPLE OF PERSONALIZED SEXUALITY

 It is based on the understanding of sexuality as one of the basic traits of the
human person and must be developed in ways consistent with enhancing human
dignity.
 The reason for the emphasis on sexual morality in the teaching of the church is
because this element of human character often leads to a loss of human dignity
and an inability to pursue the truly fulfilling goals of human life.
 Genuine Christian teaching in sexuality is clear enough in the Scriptures & are
as follows:
1. GENESIS 1-3: Teaches that God created persons as male and female and
blessed their sexuality as a great and good gift. Jesus confirmed this
teaching and perfected it by affirming that men must be faithful in marriage
as women. Nevertheless, Jesus also taught that although sexuality is a
great gift, its use in marriage is only a relative value, which can be freely
sacrificed for the sake of higher values “FOR THE KINGDOM OF GOD”.
2. 1 COR 7:25-35: For the Christian, the celibate or single life, with its
freedom from domestic cares to be of service to others, can be a
personally mature and fulfilling as married life.
3. JEWISH-CHRISTIAN TRADITION: Sexuality is always seen in relation to
the family as the basic unit of the community into which we are born and
educated to and on which the community is built.
 The principle of personalized sexuality may be stated as follows: The gift of
human sexuality must be used in marriage in keeping with its intrinsic, indivisible,
specifically human teleology. It should be a loving, bodily, pleasurable
expression of the complimentary, permanent self-giving of a man and a woman
to each other, which is open to fruition in the perpetuation and expansion of this
personal communion through the family they beget and educate.