NCM 119 Module 5M

Ethico-Moral Aspects of Nursing

“It is not enough for today’s nurses to be technically competent, they also have to be morally
and ethically grounded”
- If you want your nurses to be well-rounded in taking care of clients, then they should
not only be technically skilled but they should be morally and ethically upright.

ETHICS
- a branch of philosophy that concerns the distinction between right and wrong based
on a body of knowledge, not just based on opinions.
- Also called Moral Philosophy

Ethics Morals

Study of the principles underlying the Human conduct itself in the light of ethics
desirable types of human conduct
(application of ethics)
(science of ideals)

theoretical practical

NURSING ETHICS
- A system of principle governing the conduct of nurses when they deal with the
clients, the family in the community, their associates or co workers and the society in
general.

REMEMBER:
- Ethics make clear to us why one act is better than another;
- Ethics make way for an orderly social life;
- Moral conduct and ethical systems (past and present must be intelligently appraised
and criticised especially if they are still applicable in the present time
- Ethics seek to point out to men the true values of life.

*If a profession must grow as dignifire and respectable, its members must adopt and put into
practice such principles and rules of conduct that would contribute to the honor and dignity of
their profession.

CODE FOR NURSES

- Adopted from the Council of National Representative of the International Council of
Nurses (ICN) in Mexico City, in May 1973
- Adopted under RA 9173 and promulgated by the BON under Resolution no. 220
series of 2004 last July 14, 2004

While we study the Code for Nurses, we are being reminded that:
- Health is a fundamental right of every individual.
 - Therefore, the nurse’s primary responsibility is to preserve health at all cost
- This responsibility encompasses promotion of health, prevention of illness, alleviation
of suffering and restoration of health.

*Basic to nursing is knowledge and understanding of man

*Inherent in nursing is respect for life, dignity and rights of man

CODE FOR NURSES

1, Nurses and People

- Values, customs and spiritual beliefs held by the individual are to be respected.
- The nurse holds in strict confidence personal information required in the process of
giving care. They use discriminative judgement in sharing this information.

Nurse’s Responsibility to the Patient

1. Carry out the physician’s order
- The patient expects that when the physician prescribes an order, then
the nurse carries it out accurately and conscientiously
2. Plan nursing care with patient and family
- You should involve the significant others in the care of clients so that
when they go home, they know what to do
3. Treat the person, not the symptoms
- We know that physicians treat the symptoms, they could have one
medical diagnosis. But for the person’s responses, which is our
nursing diagnosis, we could have a lot of it and we treat the person
through the responses with medications of these procedures that the
doctor has ordered.
4. Promote learning for the patient
- So no matter how simple these procedures are, if the nurse is inside
the room and tries to teach the patient on the procedures she is doing,
then that is promoting learning for the patient.
- It could be as simple as telling them to look for the signs and
symptoms of an infected IV site, or the bottle must be higher than their
arms.

5. Give facts and information

- The clients deserve what is true and what is needed for them to know.
6. Keep confidential patient’s information
7. Provide safety for the welfare of the patient
- Side rails should be up, mats should be non-slip.

Patient’s Responsibilities
1. Providing information
a. It must be accurate and correct information because it could lead to early
diagnosis and could save lives.
b. For example, if the patient lies if he wasn’t exposed to COVID-infection, then
it could harm the healthcare workers.
2. Complying instructions
 a. Obey instructions, taking medications, and discharge information.
3. Informing the physician of refusal to treatment
a. It is their responsibility to inform.
4. Paying hospital charges
5. Following hospital rules and regulations
6. Showing respect and consideration

Nurses and Practice

- The nurses are accountable for their own nursing practice. They are responsible
for their personal and professional growth and development. When you graduate,
your development doesn’t end there, you have to keep on learning.
- Nurses maintain or modify standards of practice within the reality of any given
situation. Quality care is their goal. So it is not an excuse if you don’t have equipment
or materials. You have to modify it in order to give that care to the client.
- Nurses are the advocates of the patients. They take appropriate steps to
safeguard the patient’s rights and privileges.
- 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.

14:00 - 21:03 PAU

Nurse's Responsibility to the Physician

- To carry out conscientiously and accurately all the legitimate orders of a
physician concerning the treatment of a patient under his medical care.
Are there illegitimate orders? There could be, that’s why you need to look into
the orders if they are legitimate.
- Help plan and implement care. You work with the physician.
- Report patient’s condition including results of therapies. Observe and
report, whether it is a good sign or bad sign.
- Call the attention of a physician of an error before carrying an order. It is
very important to look into an order and try to see if these are the correct
ones. Error: route, if you feel like the route is not right, you contact your
physician or you can channel it through your charge nurse. If you find an
error, you must politely refer it.
- Discontinue treatment, if warranted. For example, if the cause of difficulty
of breathing could be the IVF rate, then you can discontinue the treatment but
once discontinue the treatment, you can inform the physician and you should
have the valid reasons why. Another is discontinuing blood transfusion
because the client is having allergic reactions.
- In emergencies, a nurse may give medical treatment. Oxygen is a medical
treatment. You are not allowed to give oxygen except when there is an
emergency. When you are an ER nurse, you are allowed to give 2-3
liters/minute. Tell the physician that you are giving 2-3 liters/minute because
of emergency purposes and maybe the physician can adjust that if needed.
CPR is another example. These are procedures that could help save the life
of a person.
 - To instill faith & confidence in the patient of the competency of the
physician. Do not try to destroy the character of the physician, instead we
need to instill faith and confidence. We work with the physician
- Some functions do not come under a physician’s order. Vital signs every
4 hours is a protocol of the hospital so it means that the physician does not
order that anymore. The physician may order every hour or every 2 hours.
Another example is monitoring the patient, reporting what is to be reported to
the physician.

Nurses and Society

- Nurses are contributing members of the society. They assume responsibilities
inherent in being members and citizens of the community/society in which they
live/work.
- Nurses recognize the need for change and initiate, participate and support activities
to meet the health and social needs of the people.

Nurses’ Duty to the Public

1. Cooperate with proper authorities in the enforcement of sanitary laws
and regulation. Community nurses for example should be the one that do
health teachings, should inform the community of such laws and regulations
of how to properly follow these regulations.
2. Educate the mass on promotion of individuals & community health. So
health education is a nurses’ duty to the public. Individually, a nurse is able to
promote health and prevent illness. In collaboration, nurses are able to
restore health and maybe alleviate suffering.
3. Must be well informed on health and dietary habits. Keep herself abreast
of new technologists, new medications in order for her to be able to
significantly relay these new information to the public.

Nurses and Co-workers

1. Nurses maintain collaborative working relationships with their co-workers and
other members of the health team. They recognize their capabilities and
limitations in accepting responsibilities and those of their co-workers when
delegating responsibilities to them. So when you delegate responsibilities during
the delegation, you should remember that the responsibility is not taken away from
you. You are still responsible for whatever consequence that is coming from the one
you have delegated to. So when you delegate, make sure that the one you are
delegating to is competent enough to perform such responsibility.

Nurses’ Duty to Colleagues

1. Work together in harmony, work hand in hand, be friendly and cordial
2. Must observe punctuality in reporting to work.
- This is very important. When you are late then you are trying to let the
previous nurse stay longer than her shift because she has to stay
more. You cannot endorse when you are late.
3. Must have caution, tact & prudence in words & in deed.
- What is being said, cannot be taken back
4. Must observe loyalty & discipline in work.
 5. Must refrain from making unfair & unwarranted criticism against another
nurse.
6. Inhibit herself from making inquiries or comments concerning the manner of
care done by another nurse.
7. Should not interfere with the care of another nurse.
- That is why you are given your laid because you concentrate there
unless the nurse asks for help and assistance then you could actually
give your opinion or input but otherwise, stick on your load

NURSES AND THE PROFESSION

- Nurses are expected to be members of the nursing professional organization.

Inherent in this responsibility is to support and uphold its constitution and
bylaws. That is the reason why when you pass the board exam and when you
process your documents, you are asked to join the Philippine Nurses Association
because this is the umbrella association of the professional organization
- Nurses help to determine and implement desirable standards of nursing
practice and nursing education. You need to help yourself so that you are a good
representative of the practice and the nursing education itself.
- Nurses participate actively in the development and growth of the nursing
profession. Keep on learning!
- Nurses strive to secure equitable socio-economic and work conditions in
nursing through appropriate legislation and other means. It is also good to
channel your concerns on the improvement of your craft or the profession itself to the
proper channels and through this you are able to contribute to the socio-economic
and working conditions in nursing.

DUTY TO PROFESSION
1. Should be zealous in her profession by keeping abreast with the latest trend in
Nursing Science, Nursing Art and Nursing Practice; so continue to do research,
continue to read, and attend seminars
2. Must be upright, diligent, sober, modest and well-versed in her profession;
because it is very important that you know better than your clients because it is a
shame if your clients know better than you so you should be well-versed in your
profession.
3. Must not solicit patients by any means; outside of work especially that is a no-no
to your profession
4. Must refrain from performing any act which may be a discredit to herself or the
profession; should be morally and ethically upright.
5. Must bring to the attention of prosper authorities any unprofessional conduct
on the part of any RN; you could channel it to your charge nurse first before going
to the director of nursing service or even going to the president of the hospital.
Channel it properly so that RN’s attention will be called.
6. Must safeguard the profession against the admission of any person who is
unfit or unqualified to become a member of the profession. Be vigilant on those
nurses that come into the profession that they maintain the good name of the
profession
DUTY TO OTHER PROFESSIONALS
1. A nurse should not act in a manner that would amount to an interference in the
legitimate exercise of the other legally established professions; since you are a
nurse; concentrate on nursing. Do not concentrate on medicine because you are not
a physician.
2. Must cooperate in safeguarding the reputation and dignity of other
professions. So cooperation, if you hear something bad, then relay it to the proper
channel. We should respect each other. Respect begets respect; so that they will you
also then you need to be respected as a nurse.

THE NURSE AS AN INDIVIDUAL

- A full-fledged professional who is a product of education and training.
❖ Takes an oath, solemnly declaring before God that she will do well and
faithfully perform her duties and responsibilities towards her profession,
toward the government and toward the public.
❖ And after you take the oath because you already passed the board exam,
then you are ready to be admitted to work in the hospitals as a RN. So
important is taking an oath, you cannot work unless you take an oath.
Remember that

NURSES AND LABOR UNIONS

- Through the instrumentality of labor union, registered Nurses can exercise the right
to collective bargaining with respect to salaries conditions of work and fringe benefits.
❖ Labor union exist in some hospitals, these are organizations within the
hospital that are open to staff nurses who wants to be members so that their
right to collective bargaining, salaries, work conditions, and fringe benefits
could be raised up to management level.
❖ These are staff nurses with the exception of those in the supervisory and
management level
❖ There is nothing wrong to be a member of a labor union when you are a
nurse but you have to bear in mind that if the union says do not work and all
of you do not work what happens to your patients? Remember you took an
oath to take care of your patients so that is just like a point of view to ponder
on once you become nurses and your responsibility later on.

NURSES AND POLITICS

- While it is the civic duty of every nurse to keep herself well posted on the affairs and
activities of the government, not only as to those that affect her profession but also
with respect to those that concern her as a citizen, it does not follow that she should
be in politics.
❖ So once you are a nurse, you cannot be a politician at the same time. So
either become a nurse or become a politician but of course in your work as a
community nurse for example, where you are in the local government unit, a
lot of politics comes in, political power but I hope that you know how to
balance it.
Part 2:
1-7mins (Karina)

Universal Principles of Biomedical Ethics

Professional Ethics
- Are applied ethics to bring about the right conduct of the profession
- In health care delivery, the major purpose might be the pursuit of health, with
prevention of death and the alleviation of suffering as secondary goals
PRIMARY PRINCIPLES
1. Autonomy
- In health care it means are form of personal liberty, where the individual is
free to choose and implement one’s own decisions free from deceit, duress,
constraint, or coercion
- Synonymous with self-determination
Three basic elements in the process of autonomy:
1. Ability to decide
2. The power to act upon one’s decision
3. A respect for the individual autonomy of others
Informed Consent
Elements (to consider when giving informed consent):
➢ Disclosure
➢ Understanding
➢ Competence
➢ Voluntariness
➢ Permission giving
Qualification of a person who can make an informed consent:
1. Competent
- In the right mind
2. Intellectual capacity to make a rational decision
- Can differentiate what is right/ wrong on his own
3. Of legal age
- 18 years old and above
Capacity to Form Consent
Decision-making capacity determined by:
- Appreciation of right to make the choice
- Client must know it is his own personal decision if her proceeds with
procedure or not
- Understanding of risks/benefits of procedure
- Understanding of risks/benefits of opting out of procedure
- Procedure is usually the one that explains
- Ability to communicate decision
- Communication may not always be verbal, can be written or whatever
- Needs to have interpreter
- Use layman terms, normal words
Therapeutic Privilege: is a legal exception of the rule of informed consent which
allows the caregiver to proceed with nursing care.
Situations where therapeutic privilege may be applied:
 ● Emergency situation
- Example: motor vehicular accident; informed consent may be delayed
● Incompetence of patient
- Inability to decide on his/her own; S.O. may be called
● Waiver
- Waiver may say to proceed or not; must be honored
● Implied consent
- When person goes into hospital is really in need of treatment like
pregnant woman about to deliver a baby
Restrictions on autonomy may occur when there is potential harm for others:
1. Communicable diseases
- Client cannot decide on his/her own because it may jeopardize the public
2. Acts of Violence
- If client is able to hurt himself and hurt others
- Confinement may be necessary; hospital or health care workers will not be
liable
● So we cannot allow the client to go home, we have to confine the
client in the hospital. Confinement in the hospital with these two
reasons (Communicable diseases & Acts of Violence) will not hold the
hospital or health care workers liable.

7-14 mins (Ana Marie)

Remember:
● Physician/practitioner obtains consent
● A nurses role is to:
1. Make sure the client understand everything that the physician has explained
- Nurses should not explain on his/her own as it may be different to that
of the physician
2. Sees to it that the person that signs the document is the person who needs to
sign

Autonomy vs. Paternalism

Paternalism - is the intentional limitation of the autonomy of one person by another, where
the person who limits autonomy appeals exclusively to grounds of benefit to the other
person.

Health care professionals have special fiduciary relationship with clients based on:
1. Confidence placed on the practitioners.
2. Inequality of their positions with regard to information.

2. BENEFICENCE
- The duty to do good to others
- Acts of kindness, mercy and charity
- The patient’s bill of rights helps the nurse provide more effective patient care.
- All activities provided to patients must be conducted with deep considerations of their
values and dignity.
 3. NONMALEFICENCE
- The obligation to do or cause no harm to another
- Avoiding deliberate harm or risk of harm that occurs during the
performance of nursing actions.
- Considering the degree of risk permissible.
- Determining whether the use of technological advances provided
benefits that outweigh risks.
- Examples:
- Not harming a person’s reputation by revealing confidential
information
- Not assisting or performing abortion
- Not assisting persons to commit suicide
- Not performing euthanasia or mercy killing
- Not willfully subjecting patients to experimental drugs whose
potential harm is greater than the expected benefit
- Steroids
- Analgesics
- Antibiotics

Nonmaleficence 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

The Principle of Double Effect:

1. The course chosen must be good or at least morally neutral.
2. The good must not follow as a consequence of the secondary harmful effects.
3. The harm must never be intended but merely tolerated as casually connected with
the good intended.
4. The good must outweigh the harm.

With these guidelines from the Principle of Double Effect, you will be able to effectively
implement or apply these bioethical principles of beneficence and nonmaleficence.

4. JUSTICE
- In healthcare, it refers to the right to demand to be treated justly, fairly, and equally.
- The equitable distribution of potential benefits and tasks.
- Determining the order in which clients should be cared for.
- Examples of Justice:
- Essential goods, health and social services shall be available to all people at
affordable cost (DOH)
- Employees from both private and public sector are covered with medicare
privileges (National Health Insurance Act of 1995)
- Honor and justice to the elderly by giving 20% discount under RA 7432
14:12 - 21:44 mins (Yray)
Examples of justice
● Essential goods, health and social services shall be available to all people at
affordable cost (DOH)
● Employees from both private and public sector are covered in Medicare privileges
(National Health Insurance Act of 1995)
● Honor and justice to the elderly by giving 20% discount under RA 7432

Secondary Principles of Ethical Conduct

1. VERACITY - means truthfulness (neither lying or deceiving others)
Deception can take many forms
a. Intentional lying
b. Non-disclosure of information
c. Partial disclosure of information
Withholding an information when such revelation would do more harm to an
emotionally unstable or depressed person (decided upon physician or a group of healthcare
workers) is called benevolent deception
BENEVOLENT DECEPTION: suggest that
➔ The individual is not strong enough to tolerate the truth or more time is
needed to prepare the client for an unpleasant fact

2. FIDELITY - duty of faithfulness and keeping one’s promise

Fidelity is demonstrated when nurses:
Represent the client’s viewpoint to other members of the health care team
Avoid letting their own personal values influence their advocacy for clients
Support the client’s decision, even when it conflicts with their own choices
Nurses should:
➔ Be loyal to their role and responsibilities
➔ Keep promises
➔ Maintain privacy
➔ Meet reasonable expectations of clients

3. CONFIDENTIALITY
- clients have a right to privacy in the healthcare system
- Disclosure of confidential information exposes the nurse to liability for
invasion of client’s privacy
- Confidential information is also termed as privileged communication
because it is given based on trust. Any information gathered by the nurses
during the course of caring for their patient should always be treated
confidentially. This duty extends even after the patient’s death
- Examples of privileged communication
a. Communication between the doctor and the client, a nurse and a
client
b. Priest and the one who confesses
c. Lawyer and the client
d. Husband and wife
- Confidential information may only be revealed when:
 a. Patient themselves permit such revelation
b. The case is medico-legal (rape, gunshot wound, stab wound) which
has to be reported to the local police or NBI
c. The patients are ill of communicable disease and public safety may be
jeopardized
d. Given to members of the healthcare team when if the information is
relevant to his care
e. Upon lawful order of the court or when public safety and order require
otherwise (per article IV, Section 4(I)

21:45 - 28:20 (Anne)

4. MAINTAINING CLIENT CONFIDENTIALITY
● Not discussing client issues with other clients of uninvolved staff in the client’s care
● Not sharing health care information with others without the client’s consent (includes
family members or friends of the client)
● Sharing client information only in private and secluded areas - do not share in
elevators, cafeterias, or any other place where there are a lot people within hearing
distance
● Protecting the medical record from all unauthorized readers - not allowed to read the
patient’s chart unless the patient says okay

END-OF-LIFE ISSUES
1. Euthanasia
- The painless ending of the life of a person suffering from painful or incurable
disease.
- Also called “mercy killing”
TYPES
A. Voluntary - involves two willing parties (doctor or nurse or both and a client)
a. Active
● Client requesting for a lethal dose from physician from which
client will not recover
● Leaving a dying client with a fatal dose of narcotic at bedside
b. Passive
● Withholding antibiotics from a cancer client who is suffering
from pneumonia - If you withhold medication and the client is
terminal and near death then the pneumonia willl aggravate
pneumonia and hasten death
● Not starting cardiac massage to a client who is barely alive
● Turning off a life support equipment to a terminally ill & lifeless
client after discussion with client & family
B. Involuntary - carried without the request or consent of the client
- Usually the family decides if involuntary for the client. Example family
decides to take off life support because its useless plus added inputs
from the doctors then they decide it
2. Do Not Resuscitate (DNR) Order
- A medical order written by a doctor. It instructs health care providers not to do
cardiopulmonary resuscitation (CPR) if breathing stops or if the heart stops
beating.
 - The doctor writes the order only after talking about it with the patient (if
possible), the proxy, or the family
- It is usually renewed more often in the patient’s chart because sometimes
they stop the DNR order. So as a nurse, you must frequently check the DNR
status of the client.
- When you say DNR, this does NOT involve withholding medication or food.
This is just about heart massage when breathing stops or when heart stops
beating
3. Advance Directives
- Legal documents that allow patients to spell out decisions about end-of-life
care ahead of time.
- A patient can make an advance directive even when they are in good health
in case if they get sick in the future.
- This is what we call “living will”
- A living will tells which treatments the patient wants if he/she is dying or
permanently unconscious.
- Patient can accept or refuse medical care.
- Instructions may include:
a. The use of dialysis and breathing machines
b. Resuscitation if breathing or heartbeat stops
c. Tube feeding
d. Organ or tissue donation

TYPES of Advance Directives include the following:

1. Directive to Physician and Family or Surrogate
- Most common. Allows patient to document wishes for treatment or
withdrawal of treatment.
→ While the patient is still healthy he/she documented everything that he/she wants
once he/she is unconscious and that should be followed
2. Medical Power of Attorney
- Allows the patient to designate another person as their decision
maker.
→ The patient will write on a piece of paper that “I will let my wife decide for me.” But
when he writes all the wishes then that falls under Directive to Physician and Family
or Surrogate.

28:20-35:50 (Ubas)

Ethical Dilemma
- Occurs when an individual must choose between two unfavorable alternatives
- The action or situation involves actual or potential harm to someone or something
- The possibility of a violation of what we generally consider right or good

Examples of Ethical Dilemma

 - An elderly client would want without supervision (It is a dilemma for the nurse
because elderly clients need to be supervised because when they walk, they might
fall down. If and when they don’t want supervision , the nurse surely will be on
dilemma)
- Subjecting a newborn child with disability to an unproven procedure which will cause
pain for an only chance of survival
- Prolonging life when the quality of life is poor (you are in dilemma there because the
care that you’ve given , the medication, the space in the hospital could be given to
other person who will have a chance to survive more than this client)

How to Process an Ethical Dilemma

1. Determine whether or not a dilemma
2. Gather all relevant information
3. Reflect on your on your values on the issues
4. Verbalize problem
5. Consider all possible courses of action- including referral to ethics committee
6. Negotiate outcome
7. Evaluate action, not the outcome

Moral Principles

The Golden Rule

- Do unto others what you want others to do unto you (Be kind even if that person is
not kind)

The Two-Fold Effect

- A situation having both good or bad effects, how should you choose which one to
follow?

❖ Guidelines
➢ Action must be morally good
➢ The good effect must be willed, the bad effect merely allowed
➢ The good effect must not come from an evil action
➢ The good effect must be greater than the bad effect

The Principle of Totality

- The whole is greater than any of its parts

The End Doesn't Justify The Means

- We cannot reach goal (“end) by doing evil to get it (the “means” to the goal)

Epikia
- “Exception to the general rule”
- It is a reasonable presumption that the authority making the law will not wish to bind
a person in some particular case, even though the case is covered by the letter of
law
 - An example of these in the ICU, we have rules that there is only visitation on a
certain hours but as a nurse, if you have this moral principle, I think you’ll allow other
members to go in especially when the client is already dying . As a nurses we should
be more compassionate in this case

The greatest good for the greatest number

- “The Utilitarian Principle”
- Although there may be some who may have slight reactions to a vaccine, the greater
majority of the population shall be considered rather than the isolated few.

The end

“Nurses must command respect and ask questions if they feel uncomfortable; they are
intelligent, well educated individuals and deserve a voice at the table, especially as it
pertains to patient care and other related issues.” CHAR SIR