THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
Overview
I. Ethical Theories
○ Deontology
○ Teleology
○ Utilitarianism
II. Virtue Ethics
○ Virtue Ethics in Nursing
○ Core Values of a Professional Nurse
ETHICS AND HEALTHCARE
• From the earliest days of philosophy in ancient
Greece, people have sought to apply reason in
determining the right course of action for a
particular situation and in explaining why it is right
• In the Patient Protection and Affordable Care
Act of 2010 (ACA 2010) era, managers of
healthcare organizations will find the resources to
carry out their charge increasingly constrained by
multiple levels of change, differences in payment
structures, and labor shortages
• With the current emphasis on patient-centered
care, knowledge of ethics can also be valuable
when working with healthcare professionals,
patients and their families, and policymakers
PHILOSOPHY
• Chaos of thoughts, beliefs, assumptions, values
and superstitions
• Philosophy is the intense and critical examination
of beliefs and assumptions. It is both natural and
necessary to humanity
• Gives coherence to the whole realm of thought
and experience
• Offers principles for deciding what actions and
qualities are most worthwhile
• Gives shape to what would otherwise be random
MORALS AND ETHICS
• Moral Philosophy
– is the philosophical discussion of what is
considered good or bad, right or wrong, in
terms of moral issues
• Ethics
– is concerned with the study of social morality
and philosophical reflection on society's norms
and practices
– Offers a formal process of applying moral
philosophy
– Gives us the groundwork for making logical
and consistent decisions
ETHICAL THEORIES
PHILOSOPHICAL BASIS FOR ETHICAL
THEORY
• Most ethics codes specify that members conduct
themselves honestly, fairly, competently and
provide guidance for ethical conduct in morally
ambiguous situations
• Nursing codes of ethics provide guidance to
nurses and their relationships with patients,
colleagues, the profession and society. (i.e.,
American Nurses Association, Canadian Nurses
Association, International Council of Nurses)
• Ethical theories are derived from either of two
basic schools of thought: naturalism and
rationalism
○ Naturalism
– A view of moral judgment that regards
ethics is dependent upon human nature and
psychology
○ Rationalism
– Rationalists believe that there are absolute
truths that are not dependent upon human
nature
– Ethical values have an independent origin
in the nature of the universe and can be
known to humans through the process of
reasoning
DEONTOLOGY
• greek word “deon” – duty
• Deontology is concerned with behaving ethically
by meeting our duties
• The ethics theory of deontology originates from
the german philosopher Kant
• Deontological theories of ethics are based upon
the rationalist view that the rightness or wrongness
of an act depends upon the nature of the act rather
than its consequences
• Occasionally, deontology is called formalism;
some writers refer to this type of ethical theory as
Kantianism.
• Immanuel Kant
– german philosopher
– He contended that ethical rules are universal,
and that humans can derive certain consistent
principles to guide action
– Moral rules apply to all people in all situations
– Categorical Imperative: commands or moral
laws all persons must follow, regardless of their
desires or extenuating circumstances (i.e., not
breaking a promise)
– Categorical refers to moral rules that do not
admit exceptions ; imperative denotes a
command that is derived from principle
– "Act only according to that maxim by which you
can at the same time that it should become a
THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
universal law.”
– Practical Imperative: "Act so that you treat
humanity, whether in your own person or that of
another, always as an end and never as a means
only."
– Categorical Imperative + Practical Imperative =
Politically organized society
TELEOLOGY
• The consequences of the action are what matter,
not their intent.
• Consequentialism is sometimes called
teleology, using the Greek term telos, which refers
to “ends .”
• Greatest good for the greatest number
• Consequentialism has several versions, the best
known of which is utilitarianism.
• Utilitarianism defines morality in terms of the
maximization of the net utility expected for all
parties affected by a decision or action.
• Intention confuses with two issues: (i) will it lead
to good or bad outcomes and (ii) if the doer should
be praised or not
• Utilitarianism
– moral theory that holds that an action is judged
as good or bad in relation to the consequence,
outcome, or end result that is derived from it
– has its basis in naturalism
– The right action is that which has the greatest
utility or usefulness. No action is either good or
bad
• Epicurus (greek philosopher)
– sensation
– good = pleasure : evil = pain
– pleasure can be gained by living a life of
moderation, courage, justice and by cultivating
friendship
– humans control their own destinies
• Jeremy Bentham (Father of Modern
Utilitarianism)
– actions are considered right when they
increase happiness and decrease pain and
misery; actions are wrong when it has the
opposite effect
– proposed that we should measure the product
of an act in terms of the value of a proposed
pleasure
– Six Criteria
> Intensity
> Duration
> Certainty
> Propinquity (nearness in a place or town)
> Fecundity (chance of being followed by
sensations of the same kind)
>.Purity (chance of not being followed by
sensations of the opposite kind)
– justice should have a tendency to augment the
happiness of the community as a whole rather
than diminish it
• John Stuart Mill (A British Philosopher)
– classical utilitarianism
– The basic principle of utilitarianism is that
actions are right to the degree that they tend to
promote the greatest good for the greatest
number .
– He defined “the good” in terms of well - being
and distinguished, both quantitatively and
qualitatively, between various forms of pleasure.
– Mill is closer to the virtue theory idea of
eudaimonia as a goal and that he specified
qualitative distinctions rather than simply adding
of units of happiness or pleasure
– one is duty- bound to perform some acts, even
if they do not maximize utility
– Greatest Happiness Principle meaning
focusing on the happiness of all concerned;
multiplication of happiness
– object of virtue is the multiplication of
happiness
– Happiness - A state of pleasure that is not
restricted to physical pleasure alone
– He described the greatest sources of physical
and mental suffering as “indigence, disease and
the unkindness, worthlessness, or premature
THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
loss of objects of affection”
– he believed utilitarianism to be in the spirit of
the golden rule; the golden rule depicts the ideal
perfection of the utilitarians morality
TYPES OF UTILITARIANISM
• Act - Utilitarianism
– also called as Act Consequentialism
– Each act is considered on the basis of its net
benefit
– this version of utilitarianism has received the
most criticism and does not supported by
modern ethicists
– it suggests that people choose actions that
will, in any given circumstance, Increase the
overall good
– an act is considered morally right if and only if
it produces the best possible results in that
specific situation.
• Rule - Utilitarianism
– The decision maker develops rules that will
have the greatest net benefit. The development
of rules to guide conduct the similar to the
actions of administrator to develop policies
– it suggests that people choose rules that,
when followed consistently, will maximize the
overall good
– an action is right as it conforms to a rule that
leads to the greatest good.
Note: Utilitarianism is widely used in the healthcare
system. It is the basis for many policy level
decisions about the distribution of health care
services and can be integral and medical
emergency triage systems.
: Though utilitarianism is a widely accepted
ethical theory and does not give sufficient thought
to respect of persons. It gives little recognition to
the principle of autonomy, particularly when we
consider utilitarian decision making relative to
distributive justice.
VIRTUE ETHICS
• Virtue ethics is sometimes called character ethics
• it represents the idea that individuals are based
upon a certain degree of innate moral virtues
• Cardinal Virtues:
– wisdom
– courage
– temperance
– justice
– generosity
– faith
– hope
– charity
• Modern and contemporary writers also include
such virtues as honesty, compassion, caring,
responsibility, integrity, discernment,
trustworthiness, and prudence
• Virtue ethics is reemerging as an important
framework for examining moral behavior
• Theories conceived of the demands of morality
similarly; ethics provides guidelines to action which
begins with a question “ what morally ought we to
do”. In contrast, virtue ethics does not ask that
question, instead we could say that virtue is a
character trait that is socially valued
MORAL VIRTUE
• Moral virtue is a character trait that is morally
valued such as truthfulness, kindness, or honesty
• A person with moral virtue has both consistent
moral action and the morally appropriate desire
• the term ethics was derived from aristotle's word
ethika which refers to matters having to do with
character
• ARISTOTLE
– Considered goodness of character to be
produced by the practice of virtuous behavior
rather than virtuous acts being the end result of
a good character
– Virtues are tendencies to act feel and judge
that is developed from a natural capacity by
propertaining and exercise
– Virtue is equal to excellence of character and
depends on motivation, deliberation, clear
judgment, self-control and practice
– Virtue is the fruit of intellectual pursuit
– He considered excellence to be won by
training and habituation and believe that virtuous
character is created by repeated reacting in a
virtuous manner
– Traits of a Virtuous Character:
1. Virtuous acts must be chosen for their own
sake
2. the choice must proceed from a firm and
unchangeable character
3. virtue is a disposition to choose the mean
– Golden mean of virtuous behavior:
practicing moderation
– For him the basic moral question is not “what
should one do” but rather “what should one be”
• PHILIPPA RUTH FOOT
– She proposes that virtue lies not only in
engaging virtuous acts but also in a will
– She defines will as that which is wished for as
well as what is sought
– According to her, a positive or moral will is
sometimes the necessary ingredient in success
– Virtue is not like a skill or an art. It cannot be
practiced but must engage the will. In other
words. An act, though apparently kind or
generous, for example, cannot be considered
virtuous if the intention is not good
• BEAUCHAMP AND CHILDRESS
– The tandem defines character as being made
up of a set of stable traits that affect a person's
judgment and action
– They suggest that although people have
different character traits all have the capacity to
learn or cultivate those that are important to
morality
– Four (4) Focal Virtues
1. Compassion
- The ability to imagine oneself in the
situation of another
- embodies the golden rule
THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
2. Discernment
- Rests on sensitive insight involving
acute judgment and understanding, and
it results in decisive action
3. Trustworthiness
- Trust is a confident belief in the moral
character of another person. It entails
confidence that another will act with the
right motives consistent with moral
norms
4. Integrity
- Is perhaps the cardinal virtue. It means
soundness, reliability, wholeness, and
integration of moral character
VIRTUE ETHICS IN NURSING
• The nightingale pledge implies virtue of character
as nurses promise purity, faith, loyalty, devotion,
trustworthiness, and temperance
• It is reasonable to say that good character is the
cornerstone of good nursing and that the nurse with
virtue will act according to principle
Overview
I. Autonomy
II. Justice
○ Procedural Justice
○ Distributive Justice
III. Non-Maleficence
IV. Beneficence
INTRODUCTION
• In the changing Patient Protection and Affordable
Care Act of 2010 (ACA 2010) era, knowledge of
theories of ethics is especially important for the
appropriate patient and organizational decision-
making.
• Theories form the basis of the principles of ethics
that provide a rationale for action in healthcare
practice.
AUTONOMY
• If a health professional makes a decision for a
patient from the “First do no harm, benefit only”
perspective without involving the patient in the
decision, then the patient’s autonomy has been
violated.
• Leaving the patient out of decisions violates the
patients “self”
• While the motivation may be beneficence, the
patient may not experience this action as one of
kindness or compassion
• Taking appropriate decisions for patients requires
an understanding of the principle of autonomy and
its application in clinical and administrative
decisions
MORAL PARTICULARISM
• utilizes the principles and rules of other moral
theories
• a form of moral theory that embraces the
uniqueness of cases, the culturally significant
ethical features and ethical judgment in each
particular case
• moral particularism enters a situation fully aware
of the ethical principles and maxims of the
profession and apprentices them as illuminators of
moral problems
• Most moral particulars theory such as context,
situations, lacks recognition and sensitivity for
relationships, and individuals.
• Moral particularists claim that this failure
represents a fundamental flaw in these theories.
Even in the face of generally accepted moral
theory, health professionals' moral decisions are
shaped by the practical circumstances of their
work. And this may be especially true for nurses.
AUTONOMY AND THE KANTIAN
DEONTOLOGICAL TRADITION
• Autonomy as a concept means that the person is
self-ruling.
• The term auto is from Greek and means self. The
rest of the term comes from the Greek nomos,
which means rule or law.
• Thus, one can understand autonomy as self-
rule
• Autonomy is the idea that we are to respect other
for who they are
• This view is honored in the medical tradition as far
back as the hippocratic writings. Therefore the duty
of the physician is to treat people's illnesses not to
judge them for why they are ill.
• It might be necessary for the physician to try to
get patients to change what they are doing or who
they are, but that is part of the treatment not a
character judgment
AUTONOMY IN HEALTHCARE
• In the healthcare setting, it is often unclear
whether the patient does or does not possess the
conditions required for autonomy.
THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
• Two important conditions must be met for
autonomy:
1. Are patients competent to make decisions
for themselves?
2. Are patients free of coercion in making
decisions?
*These questions reflect the idea that autonomy
implies the freedom to choose
• Typically people have an understanding of what it
means to be competent and be able to make
choices on their own behalf. However that is not all
there is to competence and autonomy.
• A competent person also needs to be free of
coercion.
• Coercion – he or she is trying to please someone
— parents, children, or care providers — and thus
is hiding his or her real choices
• In healthcare, coercion that might prevent free-
choice occurs in many ways. Providers often
encounter patients whose choices are
compromised or coerced
• Competence can be understood as the ability to
complete a task. This may mean you are able to do
and to understand some things but not others.
Remember: Given the complexity of defining
competence and the need to respect the autonomy
of patients, clinicians must serve as gatekeepers
for decision-making based on their ability to
determine a patient's competence for decision-
making.
JUSTICE
• In general, to know something is unjust is to have
a good reason to think it is morally wrong.
However we must be able to decide whether that
action is truly morally wrong. Therefore, we can ask
questions like "what kinds of facts make an act
unjust rather than simply wrong in general?"
• People use the term injustice to mean that they
are unfairly treated. Injustice in this sense occurs
when patients with similar cases do not receive
similar treatment.
• Following Aristotle, many believe that healthcare
professionals are required, as a formal principle of
justice, to treat similar cases alike except where
there are some relevant or material differences in
the cases.
• Justice usually comes in two major categories:
1. Procedural Justice
- ask "Were fair procedures in place,
and were those procedures
followed?"
2. Distributive Justice
- concerned with the allocation of
resources
• Both of these justice principles start from the idea
that and the distribution of burdens and benefits,
the allocation should be equal unless there is a
material reason to discriminate.
PROCEDURAL JUSTICE
• Procedural justice can be defined as due process.
• For example, in the legal system, we speak of
being equal before the law as part of procedural
justice.
• Procedural justice or due process means that
when you get your turn, you receive the same
treatment as everyone else. One can apply this
concept to healthcare.
• Procedural injustices occur in patient care. But
they are more common when dealing with
healthcare employees.
• Failures of due process or procedural justice can
also occur in the health policy arena, and
policymakers should carefully watch for these
failures.
DISTRIBUTIVE JUSTICE
• The concept of distributive justice relates to
determining what is fair when decision makers are
determining how to divide burdens and benefits.
• To understand distributive justice, you must first
understand that resource allocation issues occur at
all levels.
• For example, a physician has to decide how much
time to spend with each patient. Busy nurses have
to decide how quickly to respond to a call button
relative to the task in which they are currently
engaged. Nurse managers have to effectively
allocate too few nurses to too many patients.
NON MALEFICENCE
• "First do no harm, benefit only"
• The principle of nonmaleficence relates to the first
part of this teaching and means to do no harm.
• In healthcare ethics, there is no debate over
whether we want to avoid doing harm to patients,
professional staff, or the community. However, the
debate occurs when we consider the meaning of
the word harm
• The following ethics theories come into play here:
1. A consequentialist would say that harm is
that which prevents the good or leads to
less good or utility than other choices.
2. A natural law ethicist would say that harm is
that which is opposed to our rational nature,
that which circumscribes or limits our
potential.
3. A deontologist would say that harm is that
which prevents us from carrying out our
duty or that which is opposed to the formal
conditions of the moral law.
THEORIES AND PRINCIPLES OF HEALTH ETHICS
Healthcare Ethics
BSN 2208 | Ma’am Dellyn Ferrera
4. A virtue ethicist, a person of practical
wisdom, would find that harm is that which
is immoderate, that which leads us away
from manifesting our proper ends as
humans.
5. An ethical egoist would define harm as that
which was opposed to his or her self
interest.
WHAT IS HARM IN THE CLINICAL SETTING
• In the clinical setting, harm is that which worsens
the condition of the patient.
• Much of healthcare involves pain, discomfort,
inconvenience, expense, and perhaps even
disfigurement and disability.
• Using the natural law theory of double effect, we
justify harm to patients because there is a greater
good.
• Most healthcare professionals consider harm to
mean physical harm because the long history of
healing was focused primarily on overcoming bodily
disorders. However, harm can occur in other ways.
HARM AS NEGLIGENCE
• Healthcare professionals have developed
numerous protocols to protect patients, families,
organizations, the community, and themselves.
• Failure to engage in these protocols is an act of
omission as opposed to directly during harm, which
is an act of commission. A substantial body of law
and ethical understanding supports the view that
such a failure is negligence (omission).
• Negligence occurs when the person has not
exercised the due diligence expected of someone
and his or her role and level of responsibility.
• Medical professionals are subject to a similar
concept called malpractice. Part of the education of
all healthcare professionals concerns what it takes
to avoid doing harm and avoiding malpractice.
• This shared value of "first do no harm, benefit
only," provides a foundation that is often lacking
and ethical disputes outside of healthcare.
HARM AS A VIOLATION OF AUTONOMY
• If a person elects not to receive treatment
because of a loss of life quality, then many people
believe that imposing the treatment on that person
is wrong. This would violate the principle of
autonomy and evidence paternalism.
• Regardless of circumstances, if one applies the
principle of autonomy, persons own their lives.
• Autonomy is also an issue if the person is
incompetent. In this situation, the ethical approach
is to determine whether one knows the person's
wishes from the time when he or she was
competent and, if so, follows them.
• This practice is termed substituted judgment. If
the person's wishes are unknown, then the
healthcare professional uses an approach called
the best interest or reasonable person decision.
The basis for this approach is the assumption that a
reasonable person would choose what is in his or
her best interest.
BENEFICENCE
• The other part of the hippocratic ethical dictum is
"benefit only"
• The bene is the latin term for well or good
BENEFICENCE AND A HIGHER MORAL
BURDEN
• Beneficence involves more than just avoiding
doing harm. It represents a level of altruism that is
absent from simply refraining from harm.
• We are morally obligated to take positive and
direct steps to help others.
• The underlying principle of consequentialism, the
greatest good for the greatest number, is itself a
statement of beneficence.
• In health care, everyone involved in the provision
of care, including clinicians, administrators, and
support personnel, are expected to act with
beneficence.
• Acting with kindness, compassion, and
understanding, even under extremely stressful
circumstances, is part of the description of
professionalism in healthcare.
• Despite its challenges, beneficence is a part of
the common morality of healthcare.
NON MALEFICENCE AND BENEFICENCE ARE
INSUFFICIENT PRINCIPLES
• In most healthcare situations, the physician was
the person who defined the harm and good.
• Most people were ignorant of what the physician
was doing or talking about or why he or she
prescribed certain treatments.
• Thus, the physician defined the patient's self-
interest and carried it out. When the person who is
receiving a benefit or avoiding harm has little or no
say in the matter, that person receives paternalistic
treatment.
• Paternalistic Treatment
- comes from the latin pater, which means
father
- one treats the patient as one would treat a
child
• Patients increasingly assert their desire to make
decisions for themselves and see themselves as
partners in their own care although paternalism is
still part of healthcare today
• We have to move beyond non-maleficence and
beneficence to include the principle of autonomy.