MAJOR BIOETHICAL PRINCIPLES
and increased hatred of each other by
Theories related to Healthcare Ethics
CONSEQUENTIALIST ETHICS: UTILITARIANISM
• Consequentialists stresses that the focus of an
ethical matter and its ethical weight resides on the
person, or agent, by way of that person’s actions or
consequences.
• A broad school of thought is utilitarianism.
Utilitarianism states that morality is about maximizing
the most pleasure and minimizing the most pain as
much as possible.
• Utilitarianism is an ethical theory which states that
the best action is the one that maximizes utility.
• Utility as the sum of all pleasure that results from an
action, minimizes the suffering of anyone involved in
the action. States that the consequences of any action
are the only standard of right and wrong.
• They reject moral codes or systems that consist of
commands or taboos that are based on customs,
traditions, or orders given by leaders or supernatural
beings.
 This is best illustrated by the Sheriff Scenario, by H.
J. McCloskey (1975). An examination of restricted
utilitarianism.
 Suppose that a sheriff were faced with the choice
either of framing a Negro for a rape that had
aroused hostility to the Negroes (a particular
Negro generally being believed to be guilty but
whom the sheriff knows not to be guilty) — and
thus preventing serious anti-Negro riots which
would probably lead to some loss of life
whites and Negroes — or of hunting for
the guilty person and thereby allowing
the anti-Negro riots to occur, while
doing the best he can to combat them.
In such a case the sheriff, if he were an
extreme utilitarian, would appear to be
committed to framing the Negro.
CONSEQUENTIALIST ETHICS: RULE
CONSEQUENTIALISM, (RULE
UTILITARIANISM)
• Rule consequentialism follows all the
same ideas of consequentialism, but with a
backbone or framework of a legal system or
ethical code.
• For example, the right action among
several choices has been laid out within the
ethical system already, and therefore has
been accepted as a moral truth by the
community, because it provides the best
possible outcome.
• This is seen a lot in lawmaking and law
enforcement.
 An example is that a community may
think it is moral to make bank robbers
perform community service work
because it helps the community—that is,
this service work provides a societal
benefit beyond just a jail sentence.
NORMATIVE ETHICS AND DESCRIPTIVE
ETHICS “THINKING RIGHT VERSUS ACTING
RIGHT”
• Any discussion or study of ethics can be
split into two essential but different
questions: “Why?” and “How?”
• Investigations into “why” humans act
cover the guiding, underlying principles of
ethical standards such as virtue, human
behavior, fear of consequence, and desire
for happiness.
• This aspect of ethics is also called normative ethics
and it is concerned with figuring out the meat of
morality. The end goal of normative ethics is to help us
determine the proper course of action for human
behavior, which is to say the most moral, correct, or
just ways of thinking and acting.
• One basic example of normative ethics is Immanuel
Kant’s Categorical Imperative. It states that morality is
an outgrowth of rational thought, and it’s normative
because it seeks to define the best way a person
should act.
• The actions that result (or do not result) from
normative ethics fall under the banner of descriptive
ethics. It’s an examination of behavior itself, as
opposed to the ethics that lead to behavior and
defines good actions as ones that promote happiness
or pleasure.
• Ideals and ideas are normative ethical theories, and
actual actions (and the process that surrounds them)
are descriptive ethics.
• Descriptive ethics are all about action—how those
normative ethics are used where it really counts. It’s
the study of how human beings behave in the ethical
realm, whether they’re actively considering the ethical
ramifications of their actions or not. Descriptive ethics
is what humans do to one another and themselves—
the “applied.
 To illustrate normative ethics versus descriptive
ethics (“Thinking Right Versus Acting Right”)
DEONTOLOGICAL ETHICS
• Deon is the Greek word for duty. From that word
comes the ethical concept of deontology. Deontology
holds that morality is based on duties and
obligations—that we as humans are bound by some
unwritten code or codified system to do and say the
objectively right thing.
• Deontology is a category of normative ethical
theories that encompasses any theory which is
primarily concerned with adherence to certain rules or
duties. Consequences do NOT matter!
• Intention is relevant. “I am acting a certain
way only if I act for the right reason”.
 A child runs away from home because
his parents are abusive, and he seeks
comfort at the home of his uncle, a
deontologist. This deontologist uncle
may believe that abusing one’s child is
inherently wrong, but that same uncle
may also believe that it is morally
correct to reunite the child with his
parents. Knowing full well that the child
will likely be abused again, the uncle
sends the child home, fully confident
that his actions were moral, because the
action in and of itself, without any other
things considered, is the right thing to
do from an extremely objective stance.
VIRTUE ETHICS “ITS GOOD TO BE
GOOD ”
Virtues
• A highly regarded personality trait or
aspect of character (Boone, 2017).
• Excellence of intellect or character.
• Becomes apparent through one’s behavior
and are linked to ethical principles
• Refer to specific character traits
• Examples: compassion, fairness,
integrity, respectfulness, courage
Ethics
• Based on reason
• Studies human act and provides norms for
their goodness and badness
• Deals only with human act
 Deeply held value by a person that
intrinsically leads him or her to behave
in a certain way.
 Virtues influence actions, feelings,
desires, choices, and reactions—all of
which are predictable in a person, if that
value is deeply held.
 And while these values may lead a
person to act out instinctively, they are
 learned behaviors that are well thought out and
deeply felt on the level of a religious belief.
VIRTUE ETHICS
• A virtue ethicist acts because helping another is
charitable, benevolent, or just the “right” thing to do.
It’s a virtue-based, not rule-based ethic.
• Calls attention to the central role which such virtues
as courage, loyalty, integrity, compassion and
benevolence, along with determination and
intelligence, should play in the practices of medical
providers.
• Emphasizes the virtuous character of individuals who
make the choices.
• Focuses on what makes a good person, rather than
what makes a good action.
BIOETHICS
• Etymologically, “bioethics” means ethics of life.
• A discipline that deals with the ethical implications of
biological research.
• It is a branch of ethics that analyzes moral values in
the context of biomedical sciences.
CORE VALUES OF A PROFESSIONAL NURSE
 ALTRUISM
 AUTONOMY
 HUMAN DIGNITY
 INTEGRITY
 HONESTY
ALTRUISM
• The act that promote someone else’s welfare, even
at risk of one’s own.
• A feeling that people should help one another even
without the regard for reward or compensation.
AUTONOMY
• Refers to the freedom and ability to act according to
one's knowledge and judgment, providing nursing care
within the full scope of practice as defined by existing
professional, regulatory, and organizational rules.
• To have the benefit of the autonomous
practice, the nurse must be competent
enough to take charge of the situation they
are responsible in.
HUMAN DIGNITY
• A basic necessity not only for patients, but
also for all human beings.
• Observing human dignity is vital for
establishing an effective nurse-patient
relationship.
INTEGRITY
• Integrity is defined as the quality of being
honest and fair; possessing high moral
principles.
• Applied in healthcare profession, the
healthcare provider practices integrity when
they do their duties and obligation in
accordance to the beliefs, principles and
values they claim and cherish.
HONESTY
• A vital characteristic for a nurse to be able
to build a trusting relationship.
• Honesty sharpens our perception and
allows us to observe everything around us
with clarity.
BIOETHICAL PRINCIPLES
 AUTONOMY
 CONFIDENTIALITY
 VERACITY
 FIDELITY
 JUSTICE
 BENEFICENCE
 NON- MALEFICENCE
ETHICAL PRINCIPLES
CONFIDENTIALITY
• Information related to patients cannot be
obtained and disclosed without their
consent, and digital patient records can only
be used by related people. Information
related to patients cannot be exchanged in
public spheres and in the presence of
unrelated people
VERACITY
• Ethics of telling the truth. Medical personnel are
trust in their community, they are held to high
standards which promote accountability and overall
professionalism.
FIDELITY
• Giving one’s word and keeping the promises made.
Being faithful and true to the promises given and
responsibilities tasked with by providing optimum
standard of care
JUSTICE
• The obligation to be fair to other people. Fair
treatment of individuals to the equitable allocation of
healthcare access and resources.
BENEFICENCE
• To do good and do no harm. Addresses the idea that
a nurse’s actions should promote good. Doing good is
thought of as doing what is best for the welfare of the
patient
NON-MALIFICENCE
• Avoid inflicting harm or evil. Directly tied to the
nurse’s duty to protect the patient’s safety.
APPLICATION OF ETHICAL PRINCIPLES TO
THE CARE OF THE SICK
PART 1
AUTONOMY
 From the Greek word autos meaning
self and the word nomos meaning rule,
governance or law.
 With autonomy, patients have the
choice and freedom to seek other
opinions to validate what the physician
advised them to do.
 Patients have the right to decline or ask
for alternative medical treatment.
MEANING OF PATIENT’S RIGHTS
 Patient’s Rights refers to the moral and
inviolable power vested in him/her as a
person to do, hold, or demand
something s his/her own.
 As the patient enjoys some rights. For
example, the doctor must respect these
rights.
 Duty, therefore, is the correlative of
right.
 Right is something that belongs to a
person by nature.
PATIENT BILL OF RIGHTS
1. Right to Appropriate Medical Care and
Humane Treatment
2. Right to Informed Consent
3. Right to Privacy and Confidentiality
4. Right to Information
5. Right to Choose Health Care Provider and
Facility
6. Right to Self-Determination
7. Right to Religious Belief
8. Right to Medical Records
9. Right to Leave
10. Right to Refuse Participation In Medical
Research
11. Right to Correspondence and to Receive
Visitors
12. Right to Express Grievances
13. Right to be Informed of His Rights and
Obligations as a Patient
1. RIGHT TO APPROPRIATE MEDICAL CARE AND
HUMANE TREATMENT
 Every person has a right to health and medical
care corresponding to his state of health, without
any discrimination and within the limits of the
resources, manpower and competence available
for health and medical care at the relevant time.
 If any person cannot immediately be given
treatment that is medically necessary, he/she shall,
depending on his/her state of health, either be
directed to wait for care, or be referred or sent for
treatment elsewhere, where the appropriate care
can be provided.
2. RIGHT TO INFORMED CONSENT
 The patient has a right to a clear, truthful and
substantial explanation, in a manner and language
understandable to the patient, of all proposed
procedures, whether diagnostic, preventive,
curative, rehabilitative or therapeutic.
 The person who will perform the said procedure
shall provide his name and credentials to the
patient, possibilities of any risk of mortality or
serious side effects, problems related to
recuperation, and probability of success and
reasonable risks involved
 The patient will not be subjected to any procedure
without his written informed consent, except in
the following cases:
a. in emergency cases, when the patient is at
imminent risk of physical injury, decline of
death if treatment is withheld or postponed.
In such cases, the physician can perform any
diagnostic or treatment procedure as good
practice of medicine dictates without such
consent.
b. when the health of the population is
dependent on the adoption of a mass health
program to control epidemic.
c. when the law makes it compulsory for
everyone to submit a procedure
d. When the patient is either a
minor, or legally incompetent, in
which case, a third-party consent Is
required.
e. when disclosure of material
information to patient will
jeopardize the success of treatment,
in which case, third party disclosure
and consent shall be in order.
f. When the patient waives his right
in writing.
 Informed consent shall be obtained
from a patient concerned if he is of legal
age and of sound mind. In case the
patient is incapable of giving consent
and a third-party consent is required.
 The following persons, in the order of
priority stated hereunder, may give
consent:
i. spouse;
ii. son or daughter of legal age;
iii. either parent;
iv. brother or sister of legal age, or
v. Guardian
 If a patient is a minor, consent shall be
obtained from his parents or legal
guardian.
 If next of kin, parents or legal guardians
refuse to give consent to a medical or
surgical procedure necessary to save the
life or limb of a minor or a patient
incapable of giving consent, courts,
upon the petition of the physician or any
person interested in the welfare of the
patient, in a summary proceeding, may
issue an order giving consent.
3. RIGHT TO PRIVACY AND
CONFIDENTIALITY
 The privacy of the patients must be
assured at all stages of his treatment.
 The patient has the right to be free from
unwarranted public exposure, except in the
following cases:
a) when his mental or physical condition is in
controversy and the appropriate court, in its
discretion, order him to submit to a physical or
mental examination by a physician
b) when the public health and safety so demand
c) when the patient waives this right in writing
 The patient has the right to demand that all
information, communication and records
pertaining to his care be treated as confidential.
 Any health care provider or practitioner involved
in the treatment of a patient and all those who
have legitimate access to the patient's record is
not authorized to divulge any information to a
third party who has no concern with the care and
welfare of the patient without his consent,
 Except:
a) when such disclosure will benefit public health
and safety
b) when it is in the interest of justice and upon the
order of a competent court
c) when the patients waives in writing the
confidential nature of such information
d) when it is needed for continued medical
treatment or advancement of medical science
subject to de-identification of patient and shared
medical confidentiality for those who have access
to the information.
4. RIGHT TO INFORMATION
 In the course of his/her treatment and hospital
care, the patient or his/her legal guardian has a
right to be informed of:
 result of the evaluation of the nature and
extent of his/her disease.
 any other additional or further contemplated
medical treatment on surgical procedure
including any other additional medicines to be
administered and their generic counterpart.
 possible complications and other pertinent
facts, statistics or studies regarding his/her
illness.
 any change in the plan of care before the
change is made.
 person's participation in the plan of
care and necessary changes before
its implementation.
 the extent to which payment maybe
expected from Philhealth or any
payor and any charges for which the
patient maybe liable.
 The disciplines of health care
practitioners who will render the care
and the frequency of services that are
proposed to be furnished.
 The patient or his legal guardian has the
right to examine and be given an
itemized bill of the hospital and medical
services rendered in the facility.
 The patient or his/her legal guardian has
the right to be informed by the
physician of his/her continuing health
care requirements following discharge.
5. THE RIGHT TO CHOOSE HEALTH CARE
PROVIDER AND FACILITY
 The patient is free to choose the health
care provider to serve him as well as the
facility except when he is under the care
of a service facility or when public
health and safety so demands or when
the patient expressly waives this right in
writing.
 The patient has the right to seek for a
second opinion and subsequent
opinions, if appropriate, from another
health care provider/practitioner.
6. RIGHT TO SELF-DETERMINATION
 The patient has the right to avail
himself/herself of any recommended
diagnostic and treatment procedures.
Any person of legal age and of sound
mind may make an advance written
directive for physicians to administer
terminal care when he/she suffers from
the terminal phase of a terminal illness,
provided that:
a) Patient is informed of the medical
consequences of his choice.
 b) Patient releases those involved in his care
from any obligation relative to the
consequences of his decision.
c) Patient decision will not prejudice public
health and safety.
7. RIGHT TO RELIGIOUS BELIEF
 The Patient has the right to receive spiritual and
moral comfort, including the help of a priest or
minister of his/her chosen religion.
 He/ she also has the right to refuse medical
treatment or procedures which may be contrary to
his religious beliefs, subject to the limitations:
a) The Patient is of legal age and is mentally
competent;
b) The Patient is informed of the medical
consequences of his/her refusal;
c) The Patient releases those involved in his
care from any obligation relative to the
consequences of his/her decision; and
d) The Patient's refusal will not jeopardize
public health and safety.
8. RIGHT TO MEDICAL RECORDS
 The patient is entitled to a summary of his medical
history and condition.
 He/she has the right to view the contents of
his/her medical records, except psychiatric notes
and other incriminatory information obtained
about third parties, with the attending physician
explaining contents thereof.
 The health care institution shall safeguard the
confidentiality of the medical records and to
likewise ensure the integrity and authenticity of
the medical records.
 The health care institution shall issue a medical
certificate to the patient upon request. Any other
document that the patient may require for
insurance claims shall also be made available to
patient within forty-five (45) days from request.
9. RIGHT TO LEAVE
 The patient has the right to leave hospital or any
other health care institution regardless of his
physical condition, Provided that:
a) he/she is informed of the medical
consequences of his/her decision.
b) Patient releases those involved in
his/her care from any obligation
relative to the consequences of his
decision.
c) His/her decision will not prejudice
public health and safety.
 No patient shall be detained against
his/her will in any health care institution
on the sole basis of his/her failure to
fully settle his/her financial obligations.
 Republic Act (R.A.) 9439, or the Act
Prohibiting the Detention of Patients in
Hospitals and Medical Clinics on
Grounds of Nonpayment of Hospital Bills
or Medical Expenses makes it illegal for
“any hospital or medical clinic, (whether
government or private), to detain or
otherwise cause, directly or indirectly,
the detention of patients who have fully
or partially recovered or have been
adequately attended to or who may
have died, for reasons of nonpayment in
part or in full of hospital bills or medical
expenses.”
 “Detention” occurs when a person is
restrained from leaving the hospital or
medical clinic premises for nonpayment
of hospital bills or medical expenses in
part or in full.
 Under our law, patients are granted the
right to leave the hospital or medical
facility where they are confined should
they signify their desire to leave, subject
to the following conditions: (a) living
patients who desire to leave must have
fully or partially recovered; (b) the
patient is not staying in a private room
(a single occupancy room or ward type
room that may accommodate not more
than four (4) patients); and (c) the
patient executed a promissory note
secured by either a mortgage or by a
guarantee of a co- maker.
10. RIGHT TO REFUSE PARTICIPATION IN MEDICAL
RESEARCH
 The patient has the right to be advised if the
health care provider plans to involve him in
medical research, including but not limited to
human experimentation which may be performed
only with the written informed consent of the
patient: Provided, That,
a) an institutional review board or ethical
review board in accordance with the guidelines
set in the Declaration of Helsinki be established
for research involving human experimentation
b) The Department of Health shall safeguard
the continuing training and education of future
health care provider/practitioner to ensure the
development of the health care delivery in the
country.
c) The patient involved in the human
experimentation shall be made aware of the
provisions of the Declaration of Helsinki and its
respective guidelines.
11. RIGHT TO CORRESPONDENCE AND TO RECEIVE
VISITORS
 The patient has the right to communicate with
relatives and other persons and to receive visitors
subject to reasonable limits prescribed by the rules
and regulations of the health care institution.
12. RIGHT TO EXPRESS GRIEVANCES
 The patient has the right to express complaints
and grievances about the care and services
received without fear of discrimination or reprisal
and to know about the disposition of such
complaints.
13. RIGHT TO BE INFORMED OF HIS RIGHTS AND
OBLIGATIONS AS A PATIENT.
 Every person has the right to be informed of his
rights and obligations as a patient.
 The Department of Health, in coordination with
heath care providers, professional and civic groups,
the media, health insurance corporations, people's
organizations, local government organizations,
shall launch and sustain a nationwide information
and education campaign to make known to people
their rights as patients.
PATIENT’S RESPONSIBILITIES
1. The patient shall ensure that he/she is
fully aware of his/her rights and exercise
those rights reasonably.
2. The patient shall provide accurate and
complete information about all matters
concerning his/her health.
3. The patient shall report or voice out any
changes in his/her health condition to
his/her healthcare provider.
4. The patient shall ensure that he/she
understands the purpose and cost of any
proposed treatment or procedure before
deciding to accept it.
5. The patient shall accept all the
consequences of the patient's own informed
consent.
6. The patient shall ensure that financial
obligations of his/her health care are fulfilled
as promptly as possible, otherwise, he/she
shall make appropriate arrangements to
settle unpaid hospital bills.
7. The patient shall so behave himself or
herself so as not to interfere with the well-
being or rights of other patients or providers
of health care.
8. The patient shall first exhaust the
grievance mechanism provided in this Act
before filing any administrative or legal
action.
APPLICATION OF ETHICAL PRINCIPLES TO THE CARE
OF THE SICK
PART 2
INFORMED CONSENT
 Client’s approval (or that of the client’s legal
representative) to have his or her body touched by
a specific individual.
 The patient's choice to have a treatment or
procedure which is based on their full
understanding of the treatment or procedure, its
benefits, its risks, and any alternatives to the
particular treatment or procedure.
FUNCTIONS OF INFORMED CONSENT
1. Protective
 Protects individual autonomy
 Protects the patient’s status as a human being
 Avoids fraud and duress
2. Participative
 Encourages doctors to carefully consider their
decisions
 Fosters rational decision making by the patient.
 Involves the public generally in medicine.
4 Major Elements of Informed Consent
1. Competence
2. Disclosure
3. Comprehension
4. Voluntariness
COMPETENCE
 Refers to patient’s capacity for decision-making.
 A patient is considered competent when:
(a) One has made a decision.
(b) One has the capacity to justify one’s choice.
Requires deliberation, justification and
articulation of why one made such choice.
(c) One does not only justify one’s choice but
does so in a reasonable manner.
DISCLOSURE
 This refers to the content of what a patient is told
or informed about during the consent negotiation.
If there is a language barrier, an interpreter might
be consulted.
 The patient must be informed and must
understand the information concerning medical
treatment to be undertaken so that the
moral decision can be made.
COMPREHENSION
 This refers to whether the information
given has been understood. The
disclosure of information is not enough.
 If the patient does not understand what
he/she has been told, then information
has not been relayed at all.
 Health care professionals have a
professional language and so they are
expected to translate their jargon so
that it will be intelligible to their
patients.
VOLUNTARINESS
 This means that consent must be
voluntary. The patient must be of
his/her own free will to agree to a
research or undergo a medical
procedure or intervention.
 He/she must make a choice without
being unduly pressured by anyone else.
TYPES OF CONSENT
(a) Implied consent - agreement is given
by cooperating with a healthcare
professional’s instructions for routine
procedures.
 Implied consent is based on asking a
specific question and waiting until
permission (or affirmative consent)
is given or by the observation of a
person's behavior that implies that
they agree to the intervention.
(b) Verbal consent- agreement is given
verbally for a treatment or procedure that
doesn’t carry a significant risk.
 A verbal consent is where a patient
states their consent to a procedure
verbally but does not sign any
written form. This is adequate for
routine treatment such for
diagnostic procedures and
prophylaxis, provided that full
records are documented.
(c) Written consent- agreement is given by signing
a document for a treatment or procedure that is
complex or carries a higher risk.
 Written consent- agreement is given by signing
a document for a treatment or procedure that
is complex or carries a higher risk.
LIMITATIONS OF PATIENT’S RIGHTS
1. Patients’ rights do not include the right to be
allowed to die. Under the concept of personal
paternalism, the physician may make the moral
decision for and on behalf of the patient who can no
longer decide a sin the case of comatose patient.
2. A patient in a moribund condition does not posses
the necessary mental or emotional stability to make
informed choice.
3. Patients’ rights are not absolute
EXCEPTIONS
Who cannot provide consent?
 Minors
 Unconscious or injured patients
 Mentally-ill patients
Several exceptions to the requirement for informed
consent include:
 the patient is incapacitated,
 life-threatening emergencies with inadequate time
to obtain consent, and
 voluntary waived consent.
 In emergency cases, the following types of
patients need not require informed consent:
 Comatose or obtunded patients,
 Blind or illiterate patients
 Underage patients or those unable to understand
the circumstances, and
 Patients limited by language barriers
 Normally, parents, immediate relatives, guardians
or next of kin should be informed, but may not
have time to consult them during emergencies
when time is the essence.
MENTALLY OR EMOTIONALLY INCOMPETENT CLIENTS
 Unconcious
 Under the influence of chemical agents such as
alcohols or drugs
 Chronic dementia or other mental
deficiency that impairs thought
processes and ability to make decisions
IN THE MEDICAL CONTEXT
 In the Philippines, there are two
methods of obtaining informed consent,
first is (a) written consent (i.e., consent
form to be filled out and signed by a
patient as he/she checks in for
admission in a hospital).
 Routine only because the clerk or
admission personnel does not bother to
explain the content and the patient
usually just signs it) however invasive
procedures require an explanation from
the physician before signing.
 The second is a (b) verbal consent.
Whenever the patient verbally signifies
willingness to undergo medical
treatment, informed consent is met.
Usually made after physician briefs the
patient about medical process to be
undertaken.
NURSES’ ROLE ON INFORMED CONSENT
 NOT responsible for explaining the
procedure, but for witnessing the
client’s signature on the form.
 The nurse’s signature confirms three
things:
1. The client gave the consent
voluntarily.
2. The signature is authentic.
3. The client appears competent
to give the consent
 Proxy consent is the process by which
people with the legal right to consent to
medical treatment for themselves or for
a minor. To delegate that right to
another person.
 Three fundamental constraints on this
delegation:
1. The person making the delegation
must have the right to consent.
2. The person must be legally and
medically competent to delegate the
right to consent.
 3. The right to consent must be delegated to a
legally and medically competent adult.
LEGALLY AUTHORIZED REPRESENTATIVE (LAR)
 An individual or judicial body authorized under
applicable law to consent on behalf of another
person.
 The LAR may be a parent, grandparent, caregiver
who has the legal authority to grant consent on
behalf of another who has been invited to
participate in research.
 If the individual has appointed a health care agent
(sometimes referred to as a health care power of
attorney), or if there is a judicially-appointed
guardian, that individual would generally be
considered the legally authorized representative.
ADVANCE DIRECTIVES
 Written instructions that is recognized under state
law and is related to the provision of such care
when the individual is incapacitated.
1. Living Will- a document prepared by a competent
adult that provides direction regarding medical care in
the event the person becomes unable to make the
decisions personally.
2. Durable Power of Attorney (health care proxy) -an
authorization that enables any competent individual to
name someone to exercise decision- making authority,
under specific circumstances, on the individual’s behalf.
3. Advance Care Medical Directive -A document in
which an individual, in consultation with the physician,
relatives or other personal advisers provides precise
instructions for the type of care the client want or does
not want in various clinical scenarios.
APPLICATION OF ETHICAL THEORIES: NATURAL LAW
Natural law ethics – regards the right to informed
consent as morally legitimate. Consent must be given
freely and not by intimidation, deception or coercion.
 Seems to be against the principle of stewardship
and inviolability of life if the latter means act of
commission/omission resulting in self- killing or
euthanasia.
APPLICATION OF ETHICAL THEORIES:
KANTIAN ETHICS
Kant’s ethical principle – one must always
be treated as ends and never only as means.
Patients must not be deceived by physicians
no matter how good the intention.
 Patients have the right to be told what
they are getting into and decide
whether they want to go or not.
 According to Kantian account of
autonomy, informed consent means
obtaining honest permission by avoiding
deception and coercion, without
necessarily promoting personal
deliberation and decision-making.
APPLICATION OF ETHICAL THEORIES:
UTILITARIANISM
Utilitarianism’s principle of utility– requires
healthcare professionals to design medical
treatment in a way that minimize suffering
and harm.
 As far as informed consent is concerned,
utilitarianism does not seem to require
it. If more social good is to be gained my
making patients research subjects
without receiving their consent, then it
is morally legitimate.
APPLICATION OF ETHICAL THEORIES:
RAWLS’ PRINCIPLE
Rawls principle of justice – do not allow
medical treatments or experiments that
violate freedom, which a patient is entitled
to by virtue of being a member of society.
 All experiments and medical treatments
that make use of coercion and
deception are ruled out. Voluntary
informed consent is required of all
subjects of research.
NURSES AND CRIMINAL LIABILITY
Felonies
 Acts or omissions punishable by law.
 Elements:
 Deceit (Dolo)- Committed with intent.
 Fault (Culpa)- Due to imprudence,
negligence or lack of foresight/skill.
STAGES OF FELONIES  Lack of sufficient provocation
1. Consummated
Element: Yes 2. Defense of relative
Result: Yes  Unlawful Aggression
2. Frustrated  Reasonable necessity of the means
Element: Yes employed to prevent or repel it.
Result: No  One making the defense had no part
3. Attempted therein
Element: No
Result: No 3. Defense of stranger
 Unlawful Aggression
DEGREE OF FELONIES  Reasonable necessity of the means
 Grave- Capital punishment, penalty of above 6 employed to prevent or repel it.
years and one day, or fine of more than 6  One making the defense be not induced
thousand pesos. with revenge, resentment or other evil
 Less Grave- Penalty of one month and 1 day- 6yrs, intent.
or fine of not more than 6 thousand pesos.
 Light- Penalty of 1 day to 30 days, or fine of not 4. Fulfillment of Duty or Lawful Exercise
more than 200 pesos. 5. Avoidance of greater evil/ injury
6. Obedience to a lawful order of a superior
CLASSIFICATIONS OF PERSONS WHO ARE CRIMINALLY  Legal lawful order
LIABLE  Lawful means employed
Principal 7. Battered woman syndrome RA 9262
 By direct participation
 By inducement EXEMPTING CIMCUMSTANCES
 By indispensable cooperation 1. Imbecile/ Insane; except during lucid
Accomplice interval
 Accessory before the act 2. Persons under 15 y/o
Accessory Periods of criminal responsibility from RA
 Accessory after the act 9344
 Profiting themselves or assisting others to  15 yrs below- Absolute responsibility
profit  15 yrs 1 day- 18 yrs- Mitigated
 Concealing/ destroying the evidence of the Responsibility
crime  18 yrs- 70 yrs- Full responsibility
 Assisting the escape of the principal 3. Minority (over 15 but below 18)
4. Irresistible Force
CIRCUMSTANCES AFFECTING CRIMINAL LIABILITY 5. Uncontrollable Fear 6. Performance of a
I. Justifying Circumstance lawful act
II. Exempting Circumstance
III. Mitigating Circumstance MITIGATING CIRCUMSTANCES
IV. Aggravating Circumstance 1. Below 18 y/o or over 70 y/o
V. Alternative Circumstance 2. No intention
3. Offender is deaf, dumb, blind or with
JUSTIFYING CIMCUMSTANCE physical defect - Applies if deformity is
1. Lawful Self-defense connected to the crime.
Elements: 4. Voluntary Surrender
 Unlawful Aggression 5. Neurologic Disorder - Illness diminishing
 Reasonable necessity of the means employed to exercise of will power.
prevent or repel it.
AGGRAVATING CIMCUMSTANCES
1. Take advantage of Public position
 Greater perversity of offender springing from his
personal circumstance and the means used in
committing it.
 Elements
2. Committed with abuse of confidence or obvious
3. Occasion of a conflagration, shipwreck, earthquake,
epidemic or other calamity or misfortune.
 The time of the commission of the crime.
4. Consideration of a price, reward, or promise.
5. Fire, poison or explosion
6. Craft, Fraud or Disguise
7. Treachery
 The offender commits any of the crimes against
the person, employing means, methods or forms
in the execution thereof which tend directly and
specially to ensure its execution, without risk to
himself arising from the defense which the
offended part might make.
 The offended party was not given an opportunity
ALTERNATIVE CIRCUMSTANCE
• Either aggravating or mitigating according to the
nature and effects of the crime and other conditions
attending its commission.
a. Relationship
b. Intoxication
c. Degree of instruction/education
CRIMES CONCERNING NURSES
The intentional felonies which nurses could frequently
encounter , but not necessarily commit, in the practice
of their profession are:
1. Parricide
 Deemed the highest form of destruction of human
life.
 Killing of family member.
2. Murder
 A crime committed by a person who kills another,
other than his/her family member, whether
legitimate or illegitimate, which killing is attended
by any aggravating circumstance.
 Reclusion Temporal in its maximum period to
death.
3. Homicide
 Unjustified killing of another human
being which is neither infanticide,
parricide nor murder.
 Reclusion Temporal or a minimum of 12
years and 1 day up to a maximum of 20
years
4. Infanticide
 The killing of any child less than 3 days
or 72 hours.
 Reclusion Perpetua in its maximum
period to death.
5. Simulation of Birth
 The tampering of the civil registry to
make it appear in the record of birth
that a child was born to a person who is
not such child's biological mother,
causing such child to lose his or her true
identity and status.
 PD 651
6. Theft
 Committed by any person who, with
intent to gain but without violence
against or intimidation of persons nor
force upon things, shall take personal
property of another without the latter’s
consent.
7. Robbery
 Any person who, with intent to gain,
shall take any personal property
belonging to another, by means of
violence or intimidation of any person.
8. Assault
 Imminent threat
 Intentional act that puts another
individual in apprehension of immediate
harm.
 The act of causing physical or
psychological harm which causes the
victim to be fearful.
9. Battery
 The intentional act of causing physical
harm to someone.
 Performing any procedure without any form of
consent is battery even if it is done with good
intention.
10. Illegal Detention/ False Imprisonment -
 Deprive another of his freedom of movement or
space.
11. Defamation
 A statement that injures a third party's reputation.
 Character assassination
a. Slander - oral/ spoken statements
b. Libel -Written statements
 5 Key Elements
1) Plaintiff must prove that the information was
published
2) Plaintiff was directly or indirectly identified
3) Remarks were defamatory towards the
plaintiff's reputation
4) Published information is false
5) Defend is at fault
NEGLIGENCE
 Occurs when a healthcare professional fails to take
a reasonable action or intervention to prevent loss
or injury to patient.
3 ESSENTIAL CONDITIONS FOR ACTIONABLE
NEGLIGENCE
1. Existence of a duty on the part of the person
charged to protect the complaining party from the
injury received.
2. Failure to perform that duty.
3. Injury resulting from such failure.
DOCTRINES UNDER NEGLIGENCE:
1. Doctrine of “Res Ipsa Loquitur”
 The thing speaks for itself
 3 Conditions
a) Injury/ accident would not have ordinarily
occurred but for the defendant's negligence.
b) The accident must be caused by an agency or
instrumentality within the exclusive control of
the defendant.
c) Not have been due to any voluntary
action/contribution on the part of the injured
party.
2. Doctrine of “Respondent Superior”
 Let the principal answer for the acts of
his agent
 Embodies the general rule that an
employer is responsible for the
negligent acts or omissions of its
employees within the course of
employment.
 “Captain of the Ship Doctrine” -
Applied inside the OR for head surgeon.
3. Effect of Force Majeure
 Act of God; Irresistible or superior force
 A doctrine that essentially frees both
parties from liability or obligation to
perform when an extraordinary event or
circumstance beyond the control of the
parties occurs.
THE NURSE AND THE DOCTOR’S ORDERS
 It is expected that the nurse exercise
reasonable judgement/sound discretion
in carrying out doctor’s orders.
 If life is endangered due to the
intervention, liable for criminal
negligence or reckless imprudence.
 SOMERA CASE
MALPRACTICE
 Any professional misconduct or any
unreasonable lack of skill or fidelity in
the performance of professional
practice.
 Biggest difference between medical
negligence and malpractice suits is that
a medical malpractice suit aims to prove
that the professional’s actions were
intentionally reckless.
3 MOST COMMON MALPRACTICE FOR
NURSES
1. Giving out prescription
2. Diagnosing
3. No suturing
 Allowed to do episioraphy
 Only with special training
SALIENT POINTS OF RA 9173
 An act providing for a more responsive nursing
profession, repealing for the proposed RA9176.
 “State guarantees the delivery of quality basic
health services through an adequate nursing
personnel system throughout the country.”
 Revised on October 21, 2002
BOARD OF NURSING
a) Composition- a chairperson and six members
b) Appointment:
i. Nominating Body
ii. Recommending Body
iii. Appointing Body
c) Term of Office
- The Chairperson and Members of the Board shall
hold office for a term of three (3) years and until their
successors shall have been appointed.
- may be re-appointed for another term.
- Any vacancy in the Board occurring within the term of
a member shall be filled for the unexpired portion of
the term only.
d) Requirements upon Qualification:
i. Immediately resign from any teaching
position in any institution offering BSN and/ or
review program.
ii. Immediately resign from any government or
private employment.
iii. Not have pecuniary interest in, or
administrative supervision in any institution
offering BSN or review class
e) Qualification:
i. Natural born citizen and resident of the
Philippines
ii. Member of good standing in an accredited
Professional Organization in the Philippines
iii. Be a registered nurse and holder of master’s
degree in nursing, education and allied medical
profession.
iv. Ten years of continuous practice, last 5 years
in the Philippines.
v. No conviction of any offense involving moral
turpitude
f) Powers, functions and Duties
 Regulatory function
1. Conduct licensure exam for nurses
2. Issue, suspend or revoke certificates of
registration in the practice of nursing
3. Monitor and enforce quality
standards of nursing practice
4. Ensure quality nursing education
 Quasi-judicial function
5. Conduct hearings and
investigations to resolve complaints
against nurse practitioners.
 Quasi-legislative function
6. Promulgate a code of ethics
7. Recognize nursing specialty
organizations in coordination with
the accredited professional
organization
8. Prescribe, adopt, issue and
promulgate guidelines, regulations,
measures and decisions as maybe
necessary
g) Grounds for removal or suspension of a
member (3 I’s)
1. Continued neglect of duty or
incompetence
2. Commission or tolerance of irregularities
in the licensure examination
3. Unprofessional immoral and dishonorable
conduct
NURSING PRACTICE
SCOPE OF NURSING PRACTICE (3P, 1C)
1. Performs nursing services to individuals,
families and communities.
2. Provide nursing care from delivery up to
old age.
3. Practitioner, primarily responsible for the
promotion of health and prevention of
illness
4. Collaborates with other members of
health team
DUTIES OF NURSE
D – o utilize nursing process
U – ndertake training and research
T – each, guide, and supervise nursing
student
I – nterlinkages with community resources
and health care team
E – ducate individual, family, and community
S – trict observance of code of ethics
EXAMINATIONS AND REGISTRATION
License – a legal document given by the government
that permits a person to offer to the
public his or her skills and knowledge in a particular
jurisdiction
Registration – recording of names of persons who
have qualified under the law to practice
their respective profession
PURPOSE FOR REGISTRATION/NEED FOR LICENSURE
1. Protect the health of the people by establishing
minimum standards which
qualified practitioners must meet.
2. Discourage certain person who may be tempted to
misrepresent themselves as
nurses.
3. Tool for legal control and enforcement of nursing
practice.
4. Used to gather statistical data about nurses and
nursing in the country.
QUALIFICATION FOR ADMISSION TO THE LICENSURE
EXAM
1. Citizen of the Philippines or by reciprocity
2. Good moral character
3. Holder of a Bachelor's Degree in Nursing from a
college or university that
complies with the standards of nursing education duly
recognized by the
proper government agency.
6. Violation of RA 9173, code of ethics for
nurses (BR 220)
7. Practicing profession during suspension
 Suspension- nurse is not allowed to
practice temporarily until the final
judgment of the case against him or her
is rendered.
 Revocation- the license to practice is
confiscated either temporarily or
permanently
REQUIREMENT FOR RE-ISSUANCE OF
REVOKED CERTIFICATE OR REPLACEMENT
OF LOSS CERTIFICATE
1. Expiration of a maximum of four years
from date of revocation
2. Cause of revocation has disappeared or
has been corrected
3. Request is to replace lost destroyed or
mutilated cert license
4. Proper application
5. Payment of required fees

RATINGS
 General average of at least 75% with a rating of
not below 60% in any subject.
 If above 75% but with a subject below 60% must
repeat that subject with a rating above 75%

Oath taking – priority action of a board passer.

GROUNDS FOR REVOCATION AND

SUSPENSION OF PROFESSIONAL LICENSE:
1. Conviction by final judgement of any criminal
offense involving moral turpitude, immoral or
dishonorable conduct, having unsound mind.
2. Unprofessional or unethical conduct
3. Gross incompetence or serious ignorance
4. Malpractice or negligence
5. Use of fraud deceit or false statement in obtaining a
cert of registration
PRINCIPLES OF ETHICS IN RESEARCH
ELEMENTS OF ETHICAL RESEARCH
1. Protecting human rights.
2. Understanding informed consent.
3. Understanding institutional review of research.
4. Examining the balance of benefits and risk in a study.
HISTORICAL UNETHICAL EXPERIMENTAL PROJECTS
❑ The Nazi Medical Experiments
❑ The Tuskegee Syphilis Study
❑ The Willowbrook Study
❑ The Jewish Chronic Disease
Hospital Study
THE NUREMBERG MEDICAL EXPERIMENTS
During World War II, Nazi physicians performed
horrifying experiments on prisoners of war and
civilians against their will which killed and maimed
many.
❑ Infected with cholera, smallpox, typhus, malaria,
and other diseases.
❑ Given poisons to evaluate the deadly results
❑ Shot to simulate battle wounds
❑ Frozen to death
❑ Starved to death
❑ Sterilized and mutilated
JOSEF MENGELE
“...the infamous Nazi doctor who liked to
study twins...collected children from the
camps, measured their physical features,
performed cross-transfusions,
transplanted genitals, and other organs,
and even created artificial Siamese twins.
He also used his twin collection for
comparative studies, infecting one child
and then killing both for autopsy”.
THE TUSKEGEE SYPHILIS STUDY
In 1932 the U.S. Public Health Service began a 40-
year experiment to study the damaging effects of
untreated syphilis in human beings. The research,
known as the Tuskegee Study, involved around 600
poor black men, about 400 of whom had syphilis
when they entered the experiment. The men were
deceived about the nature of the study, were never
told they had syphilis, and were never
treated for it even when an effective
treatment (penicillin) became readily
available to the researchers. Several of the
men died because of their untreated disease.
THE WILLOWBROOK STUDY
In 1956 researchers began a study of the
natural course of hepatitis in children,
hoping to understand the disease better and
to test a vaccine. Their experimental
subjects were several hundred children
housed at Willowbrook State Hospital in
New York, the state’s largest facility for
retarded persons. The researchers infected
the children with hepatitis when first
admitted and monitored their bodies’
responses. They were condemned for using
children—especially retarded children—in
their study and for the methods they used to
obtain consent from the children’s parents.
THE JEWISH CHRONIC DISEASE HOSPITAL
STUDY
The study involved the injection of foreign,
live cancer cells into 22 senile patients who
were hospitalized with various chronic
debilitating diseases. Patients were not told
that they would receive cancer cells because
the researchers felt it would unnecessarily
frighten them. Researchers defended this
view with the assertion that they had good
cause to predict that the cancer cells were
going to be rejected. The researchers were
found guilty of fraud, deceit, and
unprofessional conduct.
THE NUREMBERG CODE (1947)
Nuremberg Code, a set of minimal ethical
principles meant to govern all scientific
experiments involving humans as a result of
the subsequent Nuremberg trial at the end
of the Second World War. The Nuremberg
Code served as the first set of principles
outlining professional ethics for medical
researchers. The Code is comprised of ten
points including the statement that
"voluntary consent of the human subject is
absolutely essential.
NUREMBERG CODE
❑Aimed to protect human subjects from enduring the
kind of cruelty and exploitation the prisoners endured
at concentration camps after the World War II.
❑A set of ten ethical principles for human
experimentation.
DECLARATION OF HELSINKI
• Set of ethical principles
• Developed by WMA for medical community – human
experimentation
• Followed Nuremberg Code (1947)
• Regarded as cornerstone document of human
research ethics
• Included within clinical trial protocols
BELMONT REPORT
Belmont Report published in 1979 in response to
unethical studies in psychology & medicine. Further
articulated in Common Rule legislation.
Three main principles:
1. Respect for persons: participants know about and
consent to research
2. Beneficence: do no harm; maximize benefits,
minimize risks
3. Justice: fair distribution of costs/benefits to all
potential participants
PROTECTING HUMAN RIGHTS
❑ Claims and demands that have been justified in the
eyes of an individual or by the consensus of a group
of people
❑ Human rights that require protection in research:
1. Right to self-determination
2. Right to privacy
3. Right to anonymity and confidentiality
4. Right to fair treatment
5. Right to protection from discomfort and harm
RIGHTS TO SELF-DETERMINATION
❑ Based on the ethical principle of respect for persons
❑ Indicates that humans are capable of controlling
their own destiny
❑ Humans are “autonomous agents”, having the
freedom to conduct their lives as they choose without
external controls
❑ Researchers should:
1. Inform the participants about the study
2. Allow them to choose whether to participate, and
3. Allow them to withdraw from the study at
any time without penalty
VIOLATION OF THE RIGHT TO SELF-
DETERMINATION
❑ Coercion
Occurs when one person intentionally
presents an overt threat of harm or an
excessive reward to another to obtain
compliance.
❑ Covert data collection
Subjects are unaware that research data are
being collected
❑ Deception
Actual misinforming of subjects for research
purposes
PERSONS WITH DIMINISHED AUTONOMY
Vulnerable and less advantaged because of
legal or mental incompetence, terminal
illness or confinement to an institution
Acceptable if the following are true:
❑The research is therapeutic, that is, the
subjects might benefit from the
experimental process
❑The researcher is willing to use both
vulnerable or non vulnerable people as
subjects
❑The risk is minimized in the study
❑The consent process is strictly
followed to ensure the rights of the
prospective subjects
PATIENT FALLS
✓Do proper nursing assessment
✓Appropriate assistance is given
✓Use protective measures
✓Document all nursing intervention
✓Morse Fall Scale
The Morse Fall Scale (MFS) is a rapid and
simple method of assessing a patient's
likelihood of falling. A large majority of
nurses (82.9%) rate the scale as “quick and
easy to use,” and 54% estimated that it took
less than 3 minutes to rate a patient.
MEDICATION ERROR
• Observe 10 Rights of drug administration
• Check for doctor’s order
• Consult drug handbook/pharmacy
• Not exempted from liability for following doctor’s
order

EQUIPMENT INJURIES
• Refuse to use a devise you don’t know how to
operate.
• Report adverse events to superior.
• Monitor patient regularly.