Bioethics

One weakness of virtue ethical theory is that it

does not take into consideration a person’s
change in moral character.

THEORIES AND PRINCIPLES OF HEALTH CARE

ETHICS ETHICAL PRINCIPLES
Ethics is the moral principles that govern a person’s AUTONOMY
behaviour or the conducting of an activity. NONMALEFICENCE
BENEFICENCE
Morals are concerned with the principles of right and JUSTICE
wrong behaviour and the goodness or badness of human FIDELITY
character. CONFIDENTIALITY
Ethical Issues in Nursing VERACITY
ACCOUNTABILITY
Autonomy
The freedom to make decisions about oneself
The right to self-determination
Healthcare providers need to respect patients’
rights to make choices about healthcare, even if
the healthcare providers do not agree with the
patient’s decision.
INFORMED CONSENT relates to a process by which
patients are informed of the possible outcomes,
althernatives, and risks of treatments, and are required to
give their consent freely.
Theories of Ethics It assures the legal protection of a patient’s right to
Utilitarianism (Consequentalism) personal autonomy in regard to specific treatment and
Act-utilitarianism procedures.
Rule-utilitarianism Patients are given the opportunity to autonomously
Deontlogy choose a course of action in regard to plans of medical
care.
Utilitarianism
NONCOMPLIANCE – unwillingness of the patient to
Right action is that which has greatest utility or
participate in health care activities
usefulness
Nonmaleficence
No action is, in itself, either good or bad
Requires that no harm be caused to an individual,
The only factors that make actions good or bad
either unintentionally or deliberately
are the outcomes
This principle requires nurses to protect
Act-Utilitarianism
individuals who are unable to protect themselves
- A person performs the acts that benefit the most
Beneficence
people, regardless of personal feelings or the
societal constraints such as laws. This principle means “doing good” for others
Rule-Utilitarianism Nurses need to assist clients in meeting all their needs:
Seeks to benefit the most people but through the Biological
fairest and most just means available. It takes into Psychological
account the law and is concerned with fairness. Social
Deontology (Kantianism)
The rightness or wrongness of an act depends 3 major components:
upon the nature of the act, rather than its Do or Promote Good
consequences. Prevent Harm
People should adhere to their obligations and Remove Evil or Harm
duties when engaged in decision making when
Justice
ethics are in play
Every individual must be treated equally
A person who adheres to deontological theory will
This requires nurses to be nonjudgmental
produce very consistent decisions since they will
be based on the individual’s set duties DISTRIBUTIVE JUSTICE – fair and equitable distribution
of goods and services
Virtue Ethics
Fidelity
Judges a person by his/her character rather than
by an action that may deviate from his/her normal Loyalty
behaviour The promise to fulfill all commitments
The basis of accountability

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 Includes the professionals faithfulness or loyalty
to agreements & responsibilities accepted as part
of the practice of the profession
Confidentiality
Anything stated to nurses or health-care providers by
patients must remain confidential The only times
this principle may be violated are:
If patients may indicate harm to themselves or
others
If the patient gives permission for the information
to be shared
Veracity
This principle implies “truthfulness”
Nurses need to be truthful to their clients
Veracity is an important component of building
trusting relationships
Accountability
Individuals need to be responsible for their own
actions
Nurses are accountable to themselves and to
their colleagues
Ethical Dilemmas
Occur when a problem exists between ethical
principles
Deciding in favor of one principle usually violates
another
Both sides have “goodness” and “badness”
associated with them
RELEVANT ETHICAL PRINCIPLES
Principle Of Double Effect
One act can embrace two effects – an intended
good effect and an unintended bad effect •
Morality of the act is governed by the intended
effect
Ethically permissible only if:
Act is morally good or at least morally
neutral
Only good effect is intended
Good results outweighs the bad result
Principle of Double Effect
When can the principle of double effect not be
invoked?
When the act by its nature is evil.
When the good effect directly proceeds from the evil
effect and not from the act itself.
When there is no sufficient reason for the performance of
an act with two effects, one- good, the otherevil.
When the motive of the agent is not honest.
Principle of Cooperation
COOPERATION is working with another in the
performance of an action.
The degrees of cooperation may vary according to the
gravity or essentiality of the shared act in the
performance of an evil action.
FORMAL COOPERATION - consists of an explicit
intention and willingness for the evil act. The one formally
cooperating categorically wills and intends the evil action.
Ex: a medical director who wills and intends the
evil act of contraception by means of
hysterectomy at the request of an interested
party, by arranging with the members of the O.R.
team as to the operation and its schedule.
• MATERIAL COOPERATION - consists of an act other
than the evil act itself but facilitates and contributes to its
achievement. The one materially cooperating may
provide means apart from the evil act itself which is used
to carry out the performance of an evil act.
Principle of Common Good and Subsidiarity
The common good is the "good that comes into
existence in a community of solidarity among active,
equal agents.“
Essential to the common good is participation by all in all
spheres of society.
PRINCIPLE OF SUBSIDIARITY- means that what an
individual, lower or smaller group can achieve within
his/her or its capacity should not be taken away and
transmitted to the custody and performance of a higher
or bigger group.
Ex: in an effort to control the apparent rapid population
growth in the country, the State formulates program on
responsible parenthood which rebounds to the
enactment of a law mandating every family to just limit
the number of its offspring only to one or two under pain
of penalty. And so, the State through the Department of
Health conducts contraceptive programs and distributes
various forms of contraceptive methods to ensure the
State-directed number of children every family ought to
raise.
Principles of Bioethics
Principle Of Stewardship
Human life comes from God and no man is the master of
is own body.
Humans are mere stewards or caretakers, with
responsibility of protecting and cultivating spiritual bodily
functions.
We are obliged to take care of ourselves.
STEWARDSHIP refers to the expression of one’s
responsibility to take care of, nurture and cultivate what
has been entrusted to him.
“No one can in any circumstance, claim for himself the
right to destroy an innocent human being.”
-Donum Vitae
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-Donum Vitae is the "Instruction on Respect for Human It should be a loving, bodily, pleasurable expression of
Life in Its Origin and on the Dignity of Procreation" which the complimentary, permanent self-giving of a man and a
was issued on February 22, 1987, by the Congregation woman to each other, which is open to fruition in the
for the Doctrine of the Faith. perpetuation and expansion of this personal communion
through the family they beget and educate.
Principles of Integrity and Totality FOUNDATIONS OF LAW
These principles dictate that the well-being of the whole Law
person must be taken into account in deciding about any A body of rules of action or conduct prescribed by
therapeutic intervention or use of technology. controlling authority and having binding legal force.
Therapeutic procedures that are likely to cause harm or Minimum standard of expected performance between
undesirable side effects can be justified only by a individuals in a society.
proportionate benefit to the patient.
INTEGRITY refers to each individuals duty to “preserve a Basic Sources for Modern Law
view of the whole human person in which the values of
the intellect, will, and conscience are highly
distinguished”.
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”.
The whole is greater than any of its parts.

Organ Donation Ethical Issues

- Because these donations require a transplant from one
living person to another, a moral dilemma involving the
principle of totality arises. According to this principle, the
parts of the body are ordered to
the good of that specific body. Therefore, the surgical
mutilation of a donor for the good of the recipient must
not seriously impair or destroy bodily functions or beauty
of the donor.
For example, both eyes are necessary for certain visual
functions. A living person would seriously impair his
ability to see if an eye were donated to another.
Such a sacrifice would detract from the wholeness
or full functioning of the donor's body. It would be a
bad means to a good end, and therefore morally
wrong.
Fundamental Principles of Law
Justice and fairness
Plasticity and change
Doctrine of Individual Rights and Responsibilities
Lawsuit
- begins when a plaintiff files a complaint or petition with
the court that addresses the elements of prima facie case
(legally sufficient to establish a case)
Plaintiff a person who brings an action in a court of law
Steps in Lawsuit

Principle of Ordinary and Extraordinary Means

Ordinary means = reasonable hope of
benefit/success; not overly burdensome;
does not present an excessive risk and are
financially manageable
Proportionate to the state of the patient Defendant a person against whom an action is brought
“Ethically indicated” (Strong 1981 p. 84).
Extraordinary means = no reasonable hope of
benefit/success; overly burdensome; excessive
risk and are not financially manageable
No obligation to use it/morally optional
Principle of Personalized Sexuality
Personalized Sexuality is based on an understanding of
sexuality as one of the basic traits of a person and must
be developed in ways consistent with enhancing human
dignity.
The gift of human sexuality must be used in marriage in
keeping with its intrinsic, indivisible, specifically human
teleology.

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Public Law committed by their employees during the course of their
Crimes according to seriousness and level of work
punishment… Intentional Torts
Felony Misdemeanor Assault and Battery
Assault – committed without physical contact, such as
More serious breach of Punishabe by less
someone verbally cursing and threatening
law than a year of
Battery – requires physical contact of some sort
imprisonment in a jail
Defamation of Character
Punishable by death or Theft of small amount Violation of patient’s right to privacy which results to one
improsonment person communicates to a second person about a third
Murder Disorderly conduct in such a manner that the reputation of the person about
whom discussion was held is harmed
Rape
Libel – written communication
Robbery
Slander – spoken defamation
False Imprisonment
Private Law • Illegal confinement of an individual against his or her will
Types of Private Law by another individual in a manner that violates the
Tort Contract Law confined individual’s right to be free from restraint of
movement
A private or civil wrong Breech of contract
Invasion of Privacy
or injury
• Right to live one’s life without having one’s name,
Breach of Contract
picture, or private affairs made public against one’s will.
- Failure, Without legal excuse, to perform
any promise that comprises the whole part of the contract
Basic Objectives of Tort Law
Preservation of peace between individuals MIDTERMS
Determining of fault REPRODUCTIVE ISSUES
Compensation for injury Abortion
Categories of Torts Expulsion of a living fetus from the mother’s womb
Negligent Tort before it is viable.
Intentional Tort Termination of pregnancy, spontaneously or by
induction, prior to viability.
Negligent Torts
14-20 before weeks of viability
Negligence is the unintentional commission or
omission of an act that a reasonably prudent In the Philippines any form of abortion is illegal
person would or would not do under the same or Article II, 1987 constitution: Under the
similar circumstances family code
Harm caused by carelessness of a professional Section 12: Recognizes sanctity of life and shall protect
health provider and strengthen the family. Protect life of mother and
Malpractice is a type of negligence the life of the unborn from conception.
Forms of Negligence
Malfeasance – execution of an unlawful or improper act Criminalized by the Philippine law: Art. 256, 258(highest
prison term on the woman or parents), and 259: RPC
imprisonment for women who undergo abortion, as well
Misfeasance – the improper performance of an act that as those who assist in the procedure.
leads to injury
Misoprostol- drug inserted in the vagina used for
Nonfeasance – failure to perform an act, when there is a abortion
duty to act
RH Bill/Law- prevention of abortion and management of
4 Ds of Negligence post abortion complications.
Duty Intention: Responsible parenthood, family planning
Dereliction of Duty Address cause of abortion, fetal death, and teenage
Direct Cause pregnancy
Damage Ensures that women needing care for post-abortion
Legal doctrines associated with medical complications shall be treated and counseled in humane,
malpractice... non-judgmental and compassionate manner.”
Res Ipsa Loquitor (the thing speaks for itself) – in order but “Abortion remains a crime and is
to prove negligence in a personal injury lawsuit, a plaintiff punishable”
must present evidence to demonstrate that the Types of Abortion
defendant's negligence resulted in the plaintiff's injury Natural abortion(spontaneous/accidental)- unintentional
Respondeat Superior (let the master answer) – allow and involuntary
liability assessment against employers for negligent acts
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Direct or Intentional Abortion- induced expulsion of a All treatments or procedures that include the in vitro
living fetus handling of human oocytes and human sperm or
Therapeutic abortion- induced expulsion of a living embryos for the purpose of establishing pregnancy
fetus in order to save the mother from the danger of death First successful IVF: Louise Brown; 1978
brought on by pregnancy. Issues/Concerns
Eugenic abortion- recommended in cases where certain Rapid development in the field of ART
defects are discovered in the developing fetus. “Moral panic” about the changes that ICF brought
Indirect abortion- removal of the fetus occurs as a about
secondary effect of a legitimate action, which is direct and Continuous ethical dilemmas
primary object of the intention.
Legislation
Moral Issues
Rapid Developments
Euthanasia and impaired infants
Better protocols for ovulation induction
Personhood
Success rates
Sanctity of life
PGD
Quality of life
o Preimplantation genetic diagnosis (PGD) o
Autonomy Screening of embryos for specific genetic traits
Mercy before it is implanted o “Embryo biopsy” o Enables
Two positions couples at risk for certain genetic diseases to determine
Pro-life position- anti-abortion, believes that which of their embryos are affected and which are not
abortion is murder Moral Panic
Pro-choice position- believes that the decision to No society has been neutral about reproduction
abort is one of personal liberty and thus should be Social values
legal Has two sub-components: Morals
Abortion is wrong but it is an individual Fears
autonomy
Separation of sex from reproduction
Abortion is not wrong but depending on
Reproduction with the involvement of a third party
the situation
Gender issue
Principle of Double Effect
Ethical Issue
Distinguish the intended effect of an action from
Ideology or religion o Status of the embryo
the other, the unintended effects
o Sanctity of the family’s genetic lineage
It would be impermissible, to perform an abortion
to save a mother from death if the procedure Utilitarian principles o Best for society
involved the direct killing of the fetus • Best interest of the child
Permissible if the death of the fetus is an indirect
cause of the death ETHICAL CONCERNS
Nursing Ethical Dilemma: Ethical Rights and Autonomy
Responsibilities in Abortion o Patient’s autonomy (respect for autonomy) o
Nurses are agreeable if medically indicated Reproductive freedom o Decision based
Should respect the choices of the mother for as long as on accurate information o Issue of success rates o
the abortion is legal under the state of law Eligibility
Should provide the information of alternative and All infertile couples
respecting the patient’s right to freedom from imposition Only married couples
and the right to receive the utmost care in an environment Single women without partners
that provides privacy, culturally appropriate, and specific Gay couples
nursing expertise. (ANA, 2011)
Lesbian couples
If abortion is against the personal moral, ethical, and
Menopausal women
religious values of the nurse, the nurse has the right to
HIV-positive women or couples
refuse to participate in a voluntary termination of
pregnancy Gamete donor
o Except in emergency situations; patient’s needs should Sperm
not be subjected to coercion, censure, or discipline for Oocyte
reasons of such refusal
Should be aware of abortion laws within the state of Donor anonymity
practice to be more legally binding Right of autonomy of privacy of the parents
Ethical Issues in Assisted Reproductive Right of privacy of the donor
Technologies Right of the child to know his/her origins
Assisted reproductive technologies (ART) Pre-implantation genetic diagnosis (PGD)

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Screening of cells from preimplantation embryos for the
detection of genetic and/or chromosomal disorders
before embryo transfer
Status of the embryo
Discrimination
“Designer” babies
Sex selection
Destruction of unwanted embryos
Ethical Issues/Risk-benefits
Welfare of the child o Medical risks o Family
environment o Social environment
Who is making the decisions for the welfare of the child?
o Parents o Medical personnel o Society
and the law
Is it one’s best interest to be born?
The issues
The outcomes related to their care should be their
own wishes The decision may involve the choice for:
Organ and tissue donations o Advance directives o
Resuscitation
Advanced directives- a general term used to describe the
documents that give instructions about future medical
care and treatments
Living will o Do not resuscitate order
Withholding or withdrawing treatments
Should have proper documentation and consent/waiver
Living will- the lay term used to frequently to describe
any number of documents that give instructions about
future medical care and treatments or the wish to be
allowed to die w/o heroic or extraordinary measures
should the patient be unable to communicate for self
No uniformity in laws on living wills and surrogate
decision makers
In some states, the advanced directives go into effect
only if a patient is terminally ill and death is imminent
Due to inconsistencies and limitation, many authorities
recommend the use of durable power of attorney over a
living will
What to and what not to do
Durable power of attorney
A power of attorney is a legal document that gives
someone you choose the power to act in your place, in
case you become, mentally incapacitated, you’ll need
what are known as “durable” powers of attorney for
medical care and finances
This allows you to name someone as proxy, with the
authority to make medical decisions on your behalf
should you become incompetent and unable to make
decisions for yourself
DNR (Do not resuscitate)
A written physician’s order instructing health care
providers not attempt CPR
Often requested by the family
Must be signed by the physician to be valid must have a
witness
Several types of CPR decisions can be made including:
o Full code o Chemical code o DNR or
“no code”- avoid use of CPR o Slow codes- slows
process
Orders: Code
A call for CPR efforts
Contains all elements of ACLS (advanced cardiac life
support; oxygenation, ventilation, cardiac massage,
electroshock as necessary, emergency drugs)
Orders: No code or Code blue
DNR
Written order placed in medical chart to avoid the use of
CPR efforts
Orders: Slow codes
Health care teams slows the process of emergency
resuscitation so as to appear to be providing the care but
in actual fact is only providing illusion
Intent is more for family comfort than patient benefit
Orders: Chemical code
Provides the drugs needed for resuscitation but does not
provide the other services
Emergency drugs only
DNR Guidelines
Should be documented
Should specify the exact nature of the treatments to be
withheld
Patients, when they are able, should participate in DNR
decisions
Decisions to withhold CPR should be discussed with the
health care team
DNR status should be reviewed on a regular basis
Ethical Issues
- Do DNR patients belong on intensive care units (ICU)?
Withholding or withdrawing treatments
What is to be done and what is not to be done must be
included in clear terms
Honoring the refusal of treatments that a patient does not
desire, are disproportionately burdensome to the patient,
or will not benefit the patient can be ethically and legally
permissible
Organ donations
When it is permissible to remove organs?
Who should receive them?
How is it to be financed?
Ethical issues
Document the gift that an individual executes before
death
Commercialization (exploitation, pay for a service)
The need to obtain family consent in a time of grief and
stress has been a major barrier to organ procurement
Legal and social standing of euthanasia
Euthanasia is currently conceptualized as an action that
aims to end the life of a human being taking into account
humanistic considerations in relation to the person or
society o Quickening of death o Passive euthanasia- the
allowance of deadly process to proceed without
intervention o Active euthanasia- requires action that
speeds the process of dying
o Involuntary euthanasia- ignores the individual’s
autonomous rights and could potentially bring about the
death of an unwilling victim o Voluntary euthanasia- done
upon patient’s request
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Orthotanasia refers to the art of promoting a humane and
correct death o Usual death/normal death
Dysthanasia is the term for futile or useless treatment
treatment, which does not benefit a terminal patient.
It is a process through which one merely extends the
dying process and not life per se
Euthanasia vs. suicide
A person has committed suicide when:
Person brings about his/her own death o Others
do not coerce him/her to do the action
Death is caused by condition arranged by the person for
the purpose of bringing about his/her death
Physician-assisted suicide- allowed in the Netherlands in
2002
Patient must request the assistance freely and frequently
after careful consideration
Physician may act on request only if the patient is
terminally ill, with no hope of improvement and in severe
pain
May be actively-assisted
Physician must consult with another physician and file a
coroner (an official who examines a person’s cause of
death)
Germany
Does not allow active-assisted suicide—where the
physician prescribes and administers the lethal dose
Does not allow direct participation of the physician
Allow assisted suicide, so long as the drug is taken
without any help
Belgium
Legalized physician-assisted suicide
If an inpatient expresses a desire for euthanasia, prior to
becoming comatose, physician may comply with the
request o Include children who with the expressed
permission of their parents may receive lethal injection o
The child must be terminally ill and be conscious of their
decision
USA
Doctors are allowed to prescribe lethal doses of drugs to
terminally ill patients to “aid in dying”
Only 5 states allow physician-assisted suicide
Oregon (1st state to legalize), Washington, Vermont,
Montana, and New Mexico
Active euthanasia is illegal o Oregon act: allows a
terminally ill patient to obtain a physician’s prescription for
a fatal drug
FINALS
CODE OF ETHICS
Systematic guides for developing ethical behavior
Answers normative questions of what beliefs and values
should be morally accepted
Code of Good Governance
▪ Promulgated by the Professional Regulation
Commission on July 23, 2003
▪ States that the hallmark of all professionals is their
willingness to accept a set of professional and ethical
principles which they will follow in the conduct of their
daily lives.
Code of Good Governance
General Principles
Service to Others
Integrity and Objectivity
Professional Competence
Solidarity and Teamwork
Social and Civic Responsibility
Global Competitiveness
Equality of All Professions
Code of Ethics for Filipino Nurses
Provides direction for nurses to act morally
Emphasizes the four-fold responsibility of nurses
To promote health
To prevent illness
To alleviate suffering
To restore health
Emphasizes universality of the nursing practice, scope of
responsibility
Code of Ethics for Filipino Nurses
1982 – PNA (Dean Sotejo) developed a Code of Ethics
for Filipino Nurses, approved but was not implemented
1984 – PRC-BON adopted the Code of Ethics of ICN,
added fifth-fold responsibility “promotion of spiritual
environment”
1989 – Code of Ethics promulgated by PNA was
approved by PRC-BON
ARTICLE I
PREAMBLE
Sec. 1. Health is a fundamental right of every individual.
The Filipino registered nurse believing in the worth and
dignity of each human being, recognizes the primary
responsibility to preserve health at all cost. This
responsibility encompasses promotion of health,
prevention of illness, alleviation of suffering, and
restoration of health. However, when the foregoing are
not possible, assistance towards a peaceful death shall
be his/her obligation.
ARTICLE I
Sec. 2. To assume this responsibility, registered nurses
have to gain knowledge and understanding of a man’s
cultural, social, spiritual, psychological, and ecological
aspects of illness, utilizing the therapeutic process.
Cultural diversity and political and socio-economic status
are inherent factors to effective nursing care.
ARTICLE I
Sec. 3. The desire for the respect and confidence of
clientele, colleagues, co-workers, and the members of
the community provides the incentive to attain and
maintain the highest possible degree of ethical conduct.
ARTICLE II
REGISTERED NURSES AND PEOPLE
Sec. 4. Ethical Principles
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Values, customs, and spiritual beliefs held by individuals
shall be represented.
Individual freedom to make rational and unconstrained
decisions shall be respected.
Personal information acquired in the process of giving
nursing care shall be held in strict confidence.
ARTICLE II
REGISTERED NURSES AND PEOPLE Sec. 5.
Guidelines to be observed
Registered Nurse must:
consider the individuality and totality of patients when
they administer care;
respect the spiritual beliefs and practices of patients
regarding diet and treatment;
uphold the rights of individuals; and
take into consideration the culture and values of patients
in providing nursing care. However, in the conflicts, their
welfare and safety must take precedence.
ARTICLE III
REGISTERED NURSES AND PRACTICE
Sec. 6. Ethical Principles
Registered Nurse must:
Human life is inviolable.
Quality and excellence in the care of patients are the
goals of nursing practice.
Accurate documentation of actions and outcomes of
delivered care is the hallmark of nursing accountability.
ARTICLE III
REGISTERED NURSES AND PRACTICE
Sec. 7. Guidelines to be observed
Registered Nurse must:
Know the definition and scope of nursing practice which
are in the provisions of R.A. No. 9173,known as the
Philippine Nursing Act of 2002 and Board Res. No.
425,Series of 2003, the Rules and Regulations
Implementing the Philippine Nursing Act of 2002, (the
IRR);
Be aware of their duties and responsibilities in the
practice of their profession as defined in the Philippine
Nursing Act of 2002 and the IRR;
Acquire and develop the necessary competence in
knowledge, skills and attitudes to effectively render
appropriate nursing services through varied learning
situations;
If they are administrators, be responsible in providing
favourable environment for the growth and development
of Registered Nurses in their charge;
Be cognizant that professional programs for specialty
certification by the BON are accredited through the
Nursing Specialty Certification Council (NSCC);
See to it that quality nursing care and practice meet the
optimum standard of safe nursing practice;
Ensure that patient’s records shall be available only if
they are to be issued to those who are professionally and
directly involved in their care and when they are required
by law.
Insure that modification of practice shall consider the
principles of safe nursing practice;
If in position of authority in a work environment, be
normally and legally responsible for devising a system of
minimizing occurrences of ineffective and unlawful
nursing practice.
ARTICLE III
REGISTERED NURSES AND PRACTICE
Sec. 8. Ethical Principle
4. Registered Nurses are the advocates of the patients:
they shall take appropriate steps to safeguard their rights
and privileges
ARTICLE III
REGISTERED NURSES AND PRACTICE Sec. 9.
Guidelines to be observed
Registered Nurses must:
Respect the Patient’s Bill of Rights in the delivery of
nursing care;
Provide the patients or their families with all pertinent
information except those may be deemed harmful to their
well-being and
Uphold the patients’ rights when conflict arises regarding
management of their care.
ARTICLE III
REGISTERED NURSES AND PRACTICE
Sec. 10. Ethical Principle
5. Registered Nurses are aware that their actions have
professional, ethical, moral and legal dimensions. They
strive to perform their work in the best interest of all
concerned.
ARTICLE III
REGISTERED NURSES AND PRACTICE Sec. 11.
Guidelines to be observed Registered Nurses must:
perform their professional duties in conformity with
existing laws, rules regulations. measures, and generally
accepted principles of moral conduct and proper
decorum.
not allow themselves to be used in advertisement that
should demean the image of the profession (i.e.
indecent exposure, violation of dress code, seductive
behavior, etc.).
decline any gift, favor or hospitality which might be
interpreted as capitalizing on patients.
ARTICLE III
REGISTERED NURSES AND PRACTICE Sec. 11.
Guidelines to be observed Registered Nurses must:
not demand and receive any commission, fee or
emolument for recommending or referring a patient to a
physician, a co-nurse or another health care worker; not
to pay any commission, fee or other compensations to
the one referring or recommending a patient to them for
nursing care.
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avoid any abuse of the privilege relationship which exists
with patient and of the privilege access allowed to their
property, residence or workplace.
ARTICLE IV
REGISTERED NURSES AND CO-WORKERS
Sec. 12. Ethical Principles
The Registered Nurse is in solidarity with other members
of the healthcare team in working for the patient’s best
interest.
The Registered Nurse maintains collegial and
collaborative working relationship with colleagues and
other health care providers.
maintain their professional role/identity while working with
other members of the health team.
conform with group activities as those of a health team
should be based on acceptable, ethico-legal standards.
contribute to the professional growth and development of
other members of the health team.
actively participate in professional organizations.
not act in any manner prejudicial to other professions.
honor and safeguard the reputation and dignity of the
members of nursing and other professions; refrain from
making unfair and unwarranted comments or criticisms
on their competence, conduct, and procedures; or not do
anything that will bring discredit to a colleague and to any
member of other professions.
respect the rights of their co-workers.
ARTICLE V
REGISTERED NURSES, SOCIETY, AND
ENVIRONMENT
Sec. 14. Ethical Principles
The preservation of life, respect for human rights, and
promotion of healthy environment shall be a commitment
of a Registered Nurse.
The establishment of linkages with the public in
promoting local, national, and international efforts to meet
health and social needs of the people as a contributing
member of society is a noble concern of a Registered
Nurse.
ARTICLE V
REGISTERED NURSES, SOCIETY, AND
ENVIRONMENT Sec. 15. Guidelines to be observed
Registered Nurses must:
be conscious of their obligations as citizens and, as such,
be involved in community concerns.
be equipped with knowledge of health resources within
the community and take active roles in primary health
care.
actively participate in programs, projects, and activities
that respond to the problems of society.
lead their lives in conformity with the principles of right
conduct and proper decorum.
project an image that will uplift the nursing profession at
all times.
ARTICLE VI
REGISTERED NURSES AND THE PROFESSION
Sec. 16. Ethical Principles
Maintainance of loyalty to the nursing profession and
preservation of its integrity are ideal.
Compliance with the by-laws of the accredited
professional organization (PNA), and other professional
organizations of which the Registered Nurse is a member
is a lofty duty.
Commitment to continual learning and active participation
in the development and growth of the profession are
commendable obligations.
Contribution to the improvement of the socio-economic
conditions and general welfare of nurses through
appropriate legislation is a practice and a visionary
mission.
ARTICLE VI
REGISTERED NURSES AND THE PROFESSION Sec.
17. Guidelines to be observed
Registered Nurses must:
be members of the Accredited Professional Organization
(PNA).
strictly adhere to the nursing standards.
participate actively in the growth and development of the
nursing profession.
strive to secure equitable-economic and work conditions
in nursing through appropriate legislation and other
means; and
assert for the implementation of labor and work
standards.
ARTICLE VII
ADMINISTRATIVE PENALTIES, REPEALING CLAUSE
AND EFFECTIVITY
Sec. 18.
The Certificate of Registration of Registered Nurse shall
either be revoked or suspended for violation of any
provisions of this Code pursuant to Sec. 23 (f), Art. IV of
R. A. No. 9173 and Sec. 23 (f), Rule III of Board Res. No.
425, Series of 2003, the IRR.
ARTICLE VII
ADMINISTRATIVE PENALTIES, REPEALING CLAUSE
AND EFFECTIVITY
Sec. 19.
The Amended Code of Ethics promulgated pursuant to R.
A. No. 877 and P.D. No. 223 is accordingly repealed or
superseded by the herein Code.
Sec. 20.
This Code of Ethics for Nurses shall take effect after
fifteen (15) days from its full and complete publication in
the Official Gazette or in any newspapers of general
9|Bioethics
circulation. Done in the City of Manila, this 14th day of
July, 2004.
ETHICS IN GENETICS
Genetics
Branch of biology concerned with the
study of genes, genetic variation, and heredity in
organisms
Three Main Reasons Why Genetics is Ethically
Interesting
Genetic information often identifies risks of medical
conditions that don’t yet affect the patient - The ‘at risk’
patient
Genetic information is about families as well as
individuals
As such, it sometimes doesn’t fit well into our usual
individualistic ways of thinking about consent,
confidentiality, etc.
Genetic research is commercially driven to a very
substantial degree
This raises questions about whether it is legitimate to
allow genes to be ‘owned’ and what people should expect
in return for participating in genetic research
Case Study: Huntington’s Disease
One day a woman’s father comes home and starts
ranting and raving. She has never seen him like this. His
limbs begin moving in strange ways, and he begins to
have seizures. Finally, the doctors have the diagnosis:
Huntington’s disease. Now she founds out that, because
her father’s disease is the result of a dominant gene, she
has a fifty-fifty chance of getting it herself.
Case Study: Huntington’s Disease
A disease which causes deterioration of nerve cells in the
brain
Slowly destroys the affected individual's ability to walk,
think, swallow, talk, ...
Normally begins affecting people when they are between
30 and 50 years old
Death (due to pneumonia, heart failure or other
complications) usually occurs between 10 and 25 years
after symptoms first appear
Genetics for Philosophers
Our chromosomes (which contain our genes) come in
pairs.
We inherit one chromosome from each pair from each of
our parents
The paired chromosomes, while similar, are not identical
About 1 in 10,000 people are thought to carry a mutation
linked to Huntington’s Disease
Inheriting Huntington’s
Huntington’s is an example of a dominant genetic
condition
– i.e., you only need to inherit one copy of a gene for
Huntington’s in order to be almost certain to contract the
condition at some point
If one of your parents carries a mutation linked to
Huntington’s, you have a 50% chance of having inherited
such a gene yourself.
Testing for Huntington’s
Huntington’s is caused by having an enlarged gene on
chromosome 4
Since the early 90’s a very reliable genetic test for such
an enlargement has existed
Even if you presently show no signs of Huntington’s, it
can tell you with great reliability whether you carry a gene
that makes it extraordinarily likely that you will develop
Huntington’s. There is no cure
Assessing Purdy’s Argument
“if it is true that sufferers [from Huntington’s] live
substantially worse lives than do normal persons, those
who might transmit it should not have children.”
Response: this is a pretty big ‘if’
– It seems to require making judgments about what
sort of live is worth living that are deeply troubling
Nonetheless, thinking about this issue should allow you
to appreciate why genetics raises some distinct ethical
questions.
Some Issues Raised by Genetic Testing
Risks of being tested
Problems posed by public conceptions of genetics
Problems with confidentiality & consent
‘Commodifying’ our genes
1. Risks of Being Tested
▪ Psychological
If positive for a ‘bad’ mutation:
Burden of knowing you have the predisposition,
particularly if no treatment is available
Genetic determinism: possible overestimation of
likelihood of actually becoming afflicted – The situation
with Huntington’s is not typical – If negative:
Evidence of ‘survivor guilt’ in some cases
Possible over-confidence
E.g., thinking you won’t get breast cancer because your
test for BRCA1 & 2 came out OK
More Risks of Being Tested
Practical
Employment
Life insurance
Health Insurance (more important in US)
Is it fair for companies to take genetic information into
account when making hiring decisions or decisions about
whether to insure a person?
Do these risks justify being paternalistic regarding who is
given a genetic test, as DeGrazia suggests (pp. 474-
490)?
- ‘Traditionally,’ tests have not been given without genetic
counselling, although this is likely to change. - Recall the
Rule of Justified Paternalism
2. Popular Beliefs about Genetics
Genetic Determinism: The common misconception that
all genes work like the gene for Huntington’s, i.e., the idea
that having a particular gene will guarantee having a
particular trait
- For the most part, having a particular gene
mutation will just increase your chance of developing
some trait, not guarantee it.
– Furthermore, most ‘genetic conditions’ are the
result of a number of different gene mutations (as well as
interactions with the environment)
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We are unlikely to discover ‘the gene makes you good at
math’
3. Confidentiality & Consent
▪ In medical ethics, a great deal of
importance is placed on the idea of individual informed
consent
One aspect of this is that your personal health information
is not supposed to be released without your consent
But the nature of genetic information sometimes gets in
the way of this
Finding out genetic information about you also reveals
genetic information about the people you’re related to
Case: Confidentiality & Huntington’s
Suppose there is a known history of Huntington’s in your
family, but you don’t want to know whether you personally
carry a mutation for Huntington’s.
Your son does, however. He gets tested and discovers
that he has a mutation for Huntington’s. This
almost guarantees that you also carry such a mutation.
We have discovered personal information about you
without your consent – How should we deal with this?
– Should we put restrictions on who your
son can reveal this information to?
Confidentiality & Duty to Warn
Most ethicists agree that, while confidentiality is
important, there are situations in which confidentiality can
be broken
The most common example involves a duty to warn
E.g., a psychiatrist who is told by one of his patients that
the patient plans to kill his wife tomorrow Is there
a genetic duty to warn?
Must we warn family members who are at risk?
Should we warn employers if a person possesses a
genetic mutation that may someday pose a threat?
E.g., the bus driver at high genetic risk of heart failure
Case Study: BRCA 1 & 2
About 5-10% of breast cancer is thought to be hereditary
It has been discovered that those women with particular
mutations in the BRCA 1 or 2 gene are at an elevated risk
of contracting breast cancer
Without these mutations: 2% by age 50, 7% by age 70
With the mutations: 33-50% by age 50, 56- 87% by age
70
Note: information is from Myriad Genetics’ Website
Myriad Genetics & BRCA
Myriad Genetics (Utah, USA) holds patents on BRCA 1
&2
They have recently been insisting that only they (or
companies they have a licensing agreement with) may
perform testing for the BRCA 1& 2 mutations.
The government of Ontario has refused to obey,
preferring to perform its own test, which it claims is both
cheaper and more accurate
4. Commodifying Genes
The Myriad example raises a number of questions
regarding the commercialization of genetic research –
Is gene patenting ethically acceptable?
If our genes are a valuable commercial resource, should
we be paid for them?
Are genes property or person?
Newfoundland & Labrador
Questions about commercial research are particularly
relevant in Newfoundland and Labrador
Most of the present population of the province can trace
their ancestry back to settlers in the 1800s or earlier
Some argue that Newfoundland has a ‘homogeneous’
gene pool that is very valuable for genetic research
We have an elevated rate of some genetically influenced
conditions (e.g., psoriasis)
For these reasons, Newfoundland had been described as
"something of a motherlode to the drug development
industry" (National Post, 2000).
Should You Be Paid for Your DNA?
There has been some local debate about whether
individuals should be paid for providing their DNA to
researchers
One former professor at MUN suggested $50,000 (US)
per donation
A Recent Report
Policy Implications of Commercial Human Genetic
Research in Newfoundland and Labrador – Pullman
& Latus, 2003
Argues that human DNA should be viewed as neither
property nor person, but something in between –
Payments may sometimes be OK, but not
individual ones.
In keeping with our general approach to health care as a
public good, payment should go to improve health care &
research
Gene patenting should be reconsidered
▪ This by no means settles the issue
So what was the point of all this?
Genetics provides a good final example for this course:
New developments in health care almost invariably raises
new ethical problems
New developments often cast old problems in new light –
Health ethics will never run out of problems
But ...
‘All you’ve done is raise questions and problems. What
was the point of that?’ Answer #1: Sometimes
these problems don’t have clear solutions.
Sometimes making people sensitive to problems is the
best solution we can hope for
E.g., while we may not be able to stop a genetic test on
Mary’s son from revealing information about Mary, but by
being aware we can at least try to minimize this problem
Answer #2: Ethics is hard
Progress does occur, but it’s very slow because these are
difficult problems. – The least we can do is subject
these issues to a serious public debate.
RIGHTS AND RESPONSIBILITIES
Patient Reponsibilities
Providing Information
Complying with instructions
Informing the physician of refusal to treatment
Paying hospital charges
Following hospital rules and regulations
Showing respect and consideration
11 | B i o e t h i c s
Nurses’ Bill of Rights
Nurses have the right to practice in a manner that fulfills
their obligations to society and to those who receive
nursing care.
Nurses have the right to practice in environments that
allow them to act in accordance with professional
standards and legally authorized scopes of practice.
Nurses have the right to a work environment that
supports and facilitates ethical practice, in accordance
with the Code of Ethics for Nurses and its interpretive
statements.
Nurses have the right to freely and openly advocate for
themselves and their patients without fear of retribution.
Nurses have the right to fair compensation for their work,
consistent with their knowledge, experience and
professional responsibilities.
Nurses have the right to a work environment that is safe
for themselves and their patients.
Nurses have the right to negotiate the conditions of their
employment, either as individuals or collectively in all
practice settings.
Responsibilities of the Nurse to the Physician
Sec 28 (a) of RA 9173 states that: It shall be the duty of
the nurse to:
A. Provide nursing care through the utilization of the
nursing process. Nursing care includes, but not limited to,
traditional and innovative approaches, therapeutic use of
self, executing health care techniques and procedures,
essential primary health care, comfort measures, health
teachings, and administration of written prescription for
treatment, therapies, oral, topical and parenteral
medications, internal examination during labor in the
absence of antenatal bleeding and delivery. In case of
suturing of perineal laceration, special training shall be
provided according to protocol established;
- Reports results of therapies
▪ If any medical orders were not carried out:
Report to physician
Document
Explore patient’s reason
▪ Familiarize themselves with various routines and
methods of Physicians
Responsibility of the Nurse to their Colleagues
Get along smoothly
Adjust to the organization and know its policies and
procedures
Establish good working relationship
Constructive criticism
Nurses who are cranky, too sensitive, who “backbite”,
who do not see any good in their colleagues, are the type
of nurses who will not be happy in their work
Responisbility of the Nurse to Themselves
Continuous learning
Self respect
To look neat and attractive

12 | B i o e t h i c s