NCM 108: Health Care Ethics
Lesson 5
SEXUALITY AND HUMAN REPRODUCTION
From an evolutionary viewpoint, sexuality
has been driven by the imperative to reproduce.
During the 20th century, however, reproduction
and sexuality began to move independently, and
today they can be, in many ways, considered
separate, if not independent.
This epochal change has been made
possible by enormous progress in the
understanding of reproductive processes, followed
by a newfound ability to modify them. To
understand the changing relationship between
reproduction and sexuality is imperative to go
beyond biology. Anthropological facts,
philosophical reflections and ethical norms and
religious dictates must also be taken into
consideration. Specifically a review of religious
attitudes toward the new horizons of human
reproduction is fundamental to the understanding
of an evolving human sexuality, because, by and
large, religions continue to oppose change in how
humans view sexuality. All religions have focused
on sexuality and its moral regulation, considering
the sacred origin of life—a gift from God—a
basic concept and a cornerstone of religiosity. By
necessity, the focus here will be limited to the
three major monotheistic religions; for details on
sexuality and religious ethics, the reader is
referred to recently published reviews
(Schenker, 2008; Serour, 2008; Benagiano and
Mori, 2009).
It typically involves sexual intercourse
between a man and a woman.
During sexual intercourse, the interaction between
the male and female reproductive systems results
in fertilization of the woman's ovum by the man's
sperm. These are specialized reproductive cells
called gametes, created in a process called
meiosis.
Sexuality is about your sexual feelings,
thoughts, attractions and behaviours towards other
people. You can find other people physically,
sexually or emotionally attractive, and all those
things are a part of your sexuality. Sexuality is
diverse and personal, and it is an important part of
who you are.
Although sexual activity has, until very
recently, been essential to reproduction, this did
not preclude the non-reproductive importance of
sexual relationships and non-conceptive
copulations. Technological advances, however,
now allow for both sex without reproduction and
reproduction without sex. This review summarizes
social and ethical commentaries on the new
relationship between sex and reproduction.
Your sexuality can play an important role
in your identity and sense of self. Sexuality often
refers to a person's sexual orientation or
preference. Your sexual orientation is
who youare emotionally, mentally,
and physically attracted to. This may be same-sex
(homosexual), male-female (heterosexual) or
bisexual orientation (most genders).
You may consider yourself gay, lesbian, bisexual,
straight, pansexual (attracted to people regardless
of their gender identity), or you may not be
sure of your sexuality.
Sexuality can also refer to a person's capacity for
sexual feelings. More than the need to reproduce,
sexual drive is an important part of human
emotional expression and deep connection with
another. It’s not clear whether our sexuality is a
result of genetic or hormonal factors, our
childhood and parenting, or the society and culture
we grow up in. However, exploring your sexuality
is normal, healthy, and deeply personal.
Human sexuality is the way people
experience and express themselves sexually. This
involves biological, erotic, physical, emotional,
social, or spiritual feelings and behaviors. Because
it is a broad term, which has varied with historical
contexts over time, it lacks a precise definition.
Human reproduction is any form of sex or
reproduction resulting in human fertilization. It
typically involves sexual intercourse between a
man and a woman. During sexual intercourse, the
interaction between the male and female
reproductive systems results in fertilization of the
woman's ovum by the man's sperm. These are
specialized reproductive cells called gametes,
created in a process called meiosis. While normal
cells contains 46 chromosomes, 23 pairs, gamete
cells only contain 23 chromosomes, and it is when
these two cells merge into one zygote cell
that genetic recombination occurs and the new
zygote contains 23 chromosomes from each
parent, giving them 23 pairs. A typical 9-month
gestation period is followed by childbirth. The
fertilization of the ovum may be achieved by
artificial insemination methods, which do not
involve sexual intercourse. Assisted reproductive
technology also exists.
Sex without reproduction
Female accessibility and a concealed fertile period
carried with them a fundamental consequence: the
need to avoid, rather than seek conception during
intercourse.
In this respect humans have tried to practice
contraception ever since they began to leave
written records
Sexuality after menopause
During the second part of the 20th century two
major events substantially modified the population
pyramid of western countries: an extraordinary
increase in life expectancy that—for women—
rose well above 80 years; and a decrease in
fertility often below replacement levels.
This means that at least in western countries, a
large proportion of women may end up spending
more years in post-menopause than in any other
phase of their life; the so-called ‘post-parental
partnership’ is now significantly longer and
becoming more and more important, reaching
about one third of their lives (Hartman et al.,
2004).
This phenomenon has been accompanied by a true
revolution: not too long ago, a post-menopausal
woman was considered an asexual being for
whom sexual desire and sexual activity were no
longer
relevant and appropriate, whereas today virtually
all studies show that the great majority of women
and men can remain sexually interested and active
until the end of life (World Health Organisation,
2004).
For many women sexuality may become critical at
menopausal transition with several factors
contributing to shape future sexuality. These may
be biological, psychological and socio-relational
and they may negatively affect the entire sexual
response cycle, inducing significant changes in
desire, arousal, orgasm and satisfaction (Nappi,
2007).
Sex for pleasure
The practical possibility to separate sex from
reproduction has eased a condition that has always
existed among humans: sex purely for pleasure,
either outside wedlock or adulterous. Traditional
societies, as well as monotheistic religions, have
condemned unequivocally this approach,
considering pre- and extra-marital sex highly
detrimental for societal and marriage stability. At
the other extreme are those who insist that the
meaning of sexuality is pleasure independent of
procreation. No matter what position one takes, it
is probable that modern contraception accelerated
the ‘sex for pleasure’ process.
Reproduction without sex
It is undeniable that in the modern world, sexual
activity will play a decreasing role in
reproduction. A number of technological advances
have made a reality the almost complete
separation of sexuality and reproduction; almost
complete in the sense that masturbation is still the
preferred, but not the exclusive, modality to obtain
male gametes.
Assisted reproduction technology
Pregnancy without copulation, considered science
fiction only half a century ago, became a reality
when Steptoe and Edwards (1978) made possible
the extra-corporeal production of embryos to be
transferred directly to the uterus, thus achieving
pregnancy without coital activity. These
techniques
represent an array of modalities today known as
Assisted Reproduction Technology (ART) and, in
the more complex situations, In Vitro Fertilization
(IVF).
In vitro fertilization
Achieving human fertilization in vitro represented
such a revolutionary social development that, at
least at the beginning, the very idea was rejected
by most, scientists included. On one occasion, a
future Nobel Laureate accused Robert Edwards of
‘condoning murder’, whereas the press
announcing the birth of Louise Brown was full of
allusion to ‘obscene manipulations’ and the
creation of ‘Frankenstein babies’ (Edwards and
Steptoe, 1980). Initially, the Church of England
reacted negatively, although later modified its
position and in 1998 its general synod backed
away from a controversial declaration that IVF
should be restricted to married couples, passing
instead an amendment declaring that marriage was
‘the ideal context for the procreation and rearing
of children’ (Anglican Journal, 1 January 1998).
An interesting early discussion of the ethics of
IVF by a leading Anglican theologian, Dunstan
(1986), was published in the very first issue of
Human Reproduction, in an attempt to create a
dialogue.
Also the Roman Catholic Church reacted in a
strong negative way: an ‘Instruction’ from
the Congregation for the Doctrine of the Faith (the
old ‘Holy Office’) (1987) condemned IVF in all
its many forms, leaving ‘in a suspended state’
only the variant called Gamete Intra-Fallopian
Transfer, a modality all but abandoned today. The
‘Instruction’ used exactly the same argument
already used to ban positive contraception. Pope
Benedict XVI (2008), the author as Joseph
cardinal Ratzinger of the ‘Instruction’, recently
reaffirmed this prohibition: ‘The two fundamental
criteria for moral discernment in this field are: (i)
unconditional respect for the human being as a
person from conception to natural death; (ii)
respect for the originality of the transmission of
life’.
Reproduction after menopause
Thanks to ovum donation, the possibility for a
woman to bear a child (although not biologically
hers) past the natural barrier of menopause has
become a reality. Today, healthy post-menopausal
women can carry out a pregnancy, often without
major problems (Antinori et al., 2003).
This newfound procreative opportunity for women
in their fifties and sixties, has been criticized on
several grounds. First, it has been argued, post-
menopausal mothers may not be able to establish
a correct approach to their
‘children/grandchildren’; also, pregnancy in these
age brackets may represent a major risk for the
future health of prospective mothers; finally,
children may be deprived of their parents earlier
than necessary. In its defence, proponents point
out the major improvement in life expectancy.
This argument has been counteracted with the fact
that, whereas longevity is a new reality, healthy
ageing is still in the making.
Where is sexuality going?
Given the rapid evolution in the meanings of
sexuality and of modalities to achieve
reproduction over the last half-century, it is
difficult to predict the direction in which both will
move.
Some conclusions, however, can still be drawn. A
certain degree of separation between sexuality and
reproduction has always existed among humans.
What was not available until recently was a set of
methods capable of separating these aspects with
high efficacy. The discovery of such methods has
therefore accelerated a trend already present in a
number of cultures (mostly western). Population
explosion forced even pro-natalistic cultures, such
as those of Africa and Asia to rethink their
cultural paradigms and move towards sexuality
without reproduction.
Today, whether this is viewed with great favour or
dismay, sexuality and reproduction are two
separate, although still closely related, human
activities. It seems inevitable that, at least in the
short-term, this hiatus will increase and, with
additional technological advances, reproduction
may become—for some at least—a fact of life
independent from sexuality.
MARRIAGE
Marriage
 a legally and socially sanctioned union,
usually between a man and a woman, that is
regulated by laws, rules, customs, beliefs, and
attitudes that prescribe the rights and duties of
the partners and accords status to their
offspring (if any).
 a formal union and social and legal contract
between two individuals that unites their lives
legally, economically, and emotionally.
Same-sex marriage
 also known as gay marriage - is the marriage
of two people of the same sex or gender,
entered into in a civil or religious ceremony.
 Same-sex marriage has been legalized in
twenty-eight countries, including the United
States, and civil unions are recognized in
many Western democracies. Yet same-sex
marriage remains banned in many countries
 A growing number of countries are legalizing
same-sex marriage amid a steady advance in
rights for LGBTQ+ people, but opposition
remains strong in many countries.
 The most prominent supporters of same-sex
marriage are human rights and civil rights
organizations as well as the medical and
scientific communities, while the most
prominent opponents are religious
fundamentalist groups.
Fundamentals of Marriage:
1. Respect - is defined as a feeling of deep
admiration for someone elicited by their abilities,
qualities, or achievements. Is this how you feel
about your partner? If you cannot honestly answer
in the affirmative, consider if you ever felt this for
your partner. Sometimes, your partner doesn’t
meet your expectations in some way and your
respect for them grows dull. Sometimes, your
partner behaves in a way that reduces our level of
respect for them.
If you are going to improve respect and your
relationship, you will have to get back in touch
with that feeling of respect. Most likely, at some
point, you chose this person as a partner.
Hopefully, you had some positive feelings when
you did this. What were the things that drew you
to your partner? As we grow and change, our
views of respectable qualities may change as well.
Finding respectable qualities in your partner may
present a challenge, but, in truth, everyone has
some respectable qualities. Spend some time
identifying abilities, qualities or achievements that
you respect in your partner.
2. Acceptance - is defined as positive welcome,
favor and endorsement; consent to receive
something offered. Have you been meeting the
definition of acceptance with your partner? Many
times, receiving is conditional rather than having
gratitude for what is offered.
Perhaps here again, your partner has not met your
expectations. Expectations may hinder the spirit of
acceptance. Find one way in which you have not
met your partner with acceptance, but have
insisted your expectations be met.
Can you release this expectation? If not, find one
that you can release.
3. Attributions to positive - this can also be
stated as assuming the positive. Do you attribute
your partner’s positive behavior to their positive
intent? For instance, he helped me because he’s
being nice, NOT he helped me because he wants
something.
Attributing behaviors to negative intent can
poison your relationships, create defensiveness
and undermine efforts by your
partner. The next time you notice yourself doing
this; make a decision to attribute the positive.
4. Positive interactions - When was the last time
you had a positive interaction with your partner?
Good things are built on strong foundations. Each
positive interaction you have is a brick in your
foundation. There is actually a research based
quota for positive vs. negative interactions. Happy
couples have 5 positive interactions for every
negative interaction. Theoretically, you can
change the tide of your relationship by creating 5
positive interactions for every negative
interaction! Isn’t that exciting?
What fun can you have with your partner? Can
you agree to stay away from topics that knowingly
create conflict for
a certain time frame? You can always argue later!
You have to create positive interactions with your
partner.
5. Specific conflict - when you argue, do you
bring in other issues of conflict? Happy couples
tend to focus on the subject at hand rather than
globally criticizing each other. Do you fight
fairly? Do you remain focused on the specific
issue of conflict or do you bring up old and stale
issues from 3 years ago? Do you take the
opportunity of conflict to pick on your partner for
any little thing you can? The next conflict that
arises, practice remaining focused on the specific
issue instead of being diverted to other issues.
6. Rapid repair - Happy couples repair any
ruptures in their relationships quickly. Do you
hold a grudge? Do you go for long periods giving
your partner the silent treatment? The next time a
conflict arises, be the first one to QUICKLY move
to repair. (This can also demonstrate respect and
acceptance).
7. Balance of intimacy and power - Intimacy
and power consists of both emotional and physical
aspects. Everyone has different levels of needs in
regard to intimacy and power. Many times, one
partner wants more emotional or physical
intimacy than their partner is willing to provide.
Sometimes, you may be afraid of being
emotionally open with your partner. Sometimes,
you might want to be more physically connected
with your partner.
In relationships, power is demonstrated in the
ability to negotiate for needs to be met. At times,
sacrifices are made by both partners in healthy
relationships.
Have you created a situation where your partner
feels equal rights to ask for their needs for
intimacy to be met? Is there an imbalance in
power? Does your partner have as much right to
make decisions as you? Does your partner’s
opinion carry as
much import as yours?
ISSUES ON SEX OUTSIDE MARRIAGE
AND HOMOSEXUALITY
Premarital sex is sexual activity which is
practiced by people before they are married.
 incidence of venereal disease
 unwanted pregnancy
Premarital sex threatens to damage a stable
personal relationship in at least three ways:
1. it tends to overemphasize sexual activities
 at the expense of other activities
2. premarital sex tends to overcommit the sexual
partners to each other
 engaging in sexual intercourse usually
intensifies the emotional involvement of
the sex partners and may lead them to
become too deeply committed to their
personal relationship too quickly. .. It
may even cause a mismatched couple to
get married
3. whether casual or stable, destroys one precious
future possibility
 the possibility of sharing in marriage
something unique to that marriage.
 sexual intercourse has been reserved for
marriage gives added significance to marital
sex
Effects of Pre marital sex:
 Unwanted pregnancy
 loss of self-respect
 Teenage pregnancy -
 depression decision—one that helps to ensure responsible
 Abortion parenthood and healthy families.
 loss of family support,
 STIs, HIV/AIDS
 guilt
 regrets
 Substance abuse and even suicidal death
are the health impact of premarital
sexual behaviour among adolescents.

ISSUES ON CONTRACEPTION, ITS

MORALITY, AND ETHICO-
MORAL RESPONSIBILITY OF
NURSES
Contraception also known as birth control, is
designed to prevent pregnancy.
 Voluntary prevention of conception

 Uses artificial means that prevents the

union of sperm and egg

 Synonymous with

 family planning
 planned parenthood
 responsible parenthood
 birth control
Birth control methods may work in a number of
different ways:
1. Preventing sperm from getting to the eggs.
Types include condoms, diaphragms, cervical
caps, and contraceptive sponges.
2. Keeping the woman's ovaries from
releasing eggs that could be fertilized.
Types include birth control pills, patches,
shots, vaginal rings, and emergency
contraceptive pills.
3. IUDs, devices which are implanted into the
uterus. They can be kept in place for
several years.
4. Sterilization, which permanently
prevents a woman from getting pregnant
or
a man from being able to get a woman
pregnant
 Indeed, virtually all major denominations in
America support the morality of
contraception as a personal and family
 The Church teaches option.
that contraception is morally wrong since it
Ethico-Moral Responsibilities of a Nurse:
violates the very purpose and nature of
human sexuality, and this further
undermines the dignity of the human
person. The Church's condemnation of
artificial contraceptives has been
unchallenged for centuries.

Contraception leads to "immoral behaviour"

 Contraception makes it easier for
people to have sex outside marriage
 Contraception leads to widespread
sexual immorality
 Contraception allows people (even
married people) to have sex purely for
enjoyment
Ethico-moral Responsibility of Nurses
 Practice nurses are ideally placed to take
a prominent role in advising clients and
providing them with their chosen
method of contraception.

ISSUES ON ARTIFICIAL
REPRODUCTION, ITS MORALITY AND
ETHICO-MORAL RESPONSIBILITY OF
NURSES

Artificial insemination is a fertility treatment

method used to deliver sperm directly to the
cervix or uterus in the hopes of getting
pregnant. Sometimes, these sperm are washed
or “prepared” to increase the likelihood a
woman will get pregnant.

 unable to conceive within one year of

trying
 prone to irregular periods
 over 35 years of age and trying to
conceive

Is artificial insemination ethical?

The consent of the husband is ethically

appropriate if he is to become the legal father
of the resultant child from artificial
insemination by anonymous donor. ... In the
case of single women or women who are part
of a homosexual couple, it is not unethical to
provide artificial insemination as a reproductive
Individuals have the capacity to think, and based
on these thoughts, make a decision freely whether
or not to seek health care (the freedom to choose).
In vitro fertilization (IVF) is a type of assistive
reproductive technology (ART).
 also called test-tube conception, medical
procedure in which mature egg cells are
removed from a woman, fertilized with
male sperm outside the body, and inserted
into the uterus of the same or another woman
for normal gestation.
Ethical issues
In vitro fertilization has been a source
of moral, ethical, and religious controversy since
its development.
 Major opposition has come from the Roman
Catholic church, which in 1987 issued a
doctrinal statement opposing IVF on three
grounds: the destruction of human embryos
not used for implantation; the possibility of in
vitro fertilization by a donor other than the
husband, thus removing reproduction from
the marital context; and the severing of an
essential connection between the conjugal act
and procreation.
 IVF has also raised a number of unresolved
moral issues concerning the freezing
(cryopreservation) of ovaries, eggs, sperm, or
embryos for future pregnancies.
Is in vitro fertilization morally acceptable?
In vitro fertilization (IVF)
is morally objectionable for a number of reasons:
 the destruction of human embryos,
 the danger to women and newborn infants,
 the replacement of the marital act in pro-
creation.
Surrogate motherhood, practice in which a
woman (the surrogate mother) bears a child for a
couple unable to produce children in the usual
way,
usually because the wife is infertile or otherwise
unable to undergo pregnancy.
Surrogacy refers to a contract in which a
woman carries a pregnancy “for” another couple.
Number of infertile couples from all over the
World approach India where commercial
surrogacy is legal.
Surrogacy is often referred to as “womb
renting” wherein a bodily service is provided for a
fee.
Ethics of Surrogacy
Surrogacy is often thought to be a ‘treatment’
option for the infertile or an alternative to
adoption, and so to be celebrated in fulfilling
people’s desires to be parents. However,
surrogacy also brings a wealth of more complex
ethical issues around gender, labour, payment,
exploitation and inequality.
Ethical issues with surrogacy
the rights of the children produced; the ethical and
practical ramifications of the further
commodification of women’s bodies; the
exploitation of poor and low income women
desperate for money; the moral and ethical
consequences of transforming a normal biological
function of a woman’s body into a commercial
transaction.
Is surrogate motherhood moral?
Surrogacy is a very controversial issue. There are
plenty of ethical concerns to be addressed about it.
... Yet surrogate motherhood is
fundamentally moral in the sense that it helps
infertile women to have a family. It is the right of
every couple to have their own child.
MORALITY OF ABORTION, RAPE AND
OTHER PROBLEMS RELATED TO
DESTRUCTION OF LIFE
Abortion the expulsion of a fetus from
the uterus before it has reached the stage of
viability (in human beings, usually about the 20th
week of gestation). An abortion may occur
spontaneously, in which case it is also called
a miscarriage, or it may be brought on
purposefully, in which case it is often called an
induced abortion.
There are 2 main types of abortion:
1. medical abortion ("abortion pill") – taking
medicine to end the pregnancy
 involves taking 2 different medicines to
end the pregnancy.
 The pregnancy is passed (comes out)
through the vagina.
 It does not need surgery or an anaesthetic.
2. surgical abortion – a procedure to remove
the pregnancy
 involves an operation to remove the
pregnancy from the womb.
Types of Abortion:
1. Natural abortion/ Spontaneous
accidental abortion
 The expulsion of fetus through natural or
accidental causes
2. Direct or intentional abortion
 Deliberately induced expulsion of a living
fetus before it has become viable
3. Therapeutic abortion
 Deliberately induced expulsion of a living
fetus in order to save the mother from tha
danger of death brought on by pregnancy.
4. Eugenic abortion/Selective abortion or
Abortion on fetal indications
 This is recommended in cases where certain
defets are discovered in the developing fetus
5. Indirect abortion
 It declares the abortion is never
permissible if and only it is required
to save the pregnant woman’s life, as
in the case of the removal of a
cancerous uterus, or the removal of
the fallopian tube, or a part of it,
because of ectopic pregnancy.
2. The Liberal
 States that abortion is always
permissible, whatever the state of
fetal development maybe, they must
ultimately have full freedom to
control their own reproductive
capacities
 “The fetus has no ontological status;
it is neither an individual, human, nor
a person, but only a tissue in a
woman’s uterus; therefore, it
or
possesses on rights and no moral
status.”
3. The Moderate or Intermediate
 It holds that abortion is morally
permissible up to certain stage of
fetal development, or for some
limited set of reasons sufficient to
justify the taking of life in this or
that special circumstances. As far
as the moderated are concerned,
the fetus attains ontological status
at quickening or viability.
“If you prick us do we not bleed, if you tickle us
do we not laugh, if you poison us do we not
die…” - Shakespeare the Merchant of Venice
Methods of Abortion
1. PLANTS AND PLANT PREPARATIONS

 The removal of the fetus occurs as a  E.g.,Makabuhay, Essencia maravilosa.

secondary effect of a legitimate or elicit 2. PHYSICAL METHODS
action, which is direct and primary object of
the intention.  Massage and abdominal pressure are
applied by the hilot, or sometimes by
 Viewpoints on Abortion: the pregnant woman herself.
1. The Conservative
3. INSERTION OF CATHETERS
 Women have been known to insert
hangers, brooms, walis tingting.
4. DILATION AND CURETTAGE
 Usually, this is done with women who
had already began the abortion, in
which case it is called completion
curettage.
5. MENSTRUAL REGULATION (MR)
 This involves the use of suction or
vacuum aspiration to terminate a very
early pregnancy.
6. DRUG
 These include medicines such as
quinine, an anti-malarial;
methylergometrin, a uterine stimulant
and methotrexate, an anti-cancer drug.
 Bricanyl (terbutaline) is perceived as
an abortifacient in large doses.
 Misoprostol (cytotec) is actually a drug
used to prevent ulcers but has abortion
as a side effect. Another drug called
RU486 (Mifepristone) is now legal in
China and a few European countries.
7. SALT POISONING
and philosophically; that abortion is a way for an
individual woman to correct a mistake that she
and her partner have made and avoid
Rape is a type of sexual assault usually
involving sexual intercourse or other forms of
sexual penetration carried out against a person
without that person's consent. The act may be
carried out by physical force, coercion, abuse of
authority, or against a person who is incapable of
giving valid consent, such as one who is
unconscious, incapacitated, has an intellectual
disability, or is below the legal age of consent
 unlawful sexual activity, most often involving
sexual intercourse, against the will of the
victim through force or the threat of force or
with an individual who is incapable of giving
legal consent because of minor status, mental
illness, mental deficiency, intoxication,
unconsciousness, or deception.
Morality of Rape
rape is wrong because of the serious harm
it causes its victims. At times it is physical harm,
but more often, it is severe psychological harm. In
almost all cases, rape brings about a decline in the
victim's prospects; it initiates a change for the
worse in her life.

 A needle is inserted through the

mother’s abdomen and 50-250 ml of
amniotic fluid is withdrawn and
replaced it with a solution of
concentrated salt.

8. HYSTEROTOMY

 Incisions are made in the abdomen and

uterus. The baby, placenta and
amniotic sac are removed.

Morality of Abortion

As politicians and lobbying groups of

varying backgrounds seek to restrain the rights of
women in terms of access to abortion it must be
remembered that: abortion is justifiable morally
 Lesson 6
DIGNITY IN DEATH AND DYING

 ‘What is dignity’? The word dignity originates

in conflict with the goals and values of the
from two Latin words, dignitus (merit) and
patient or family.
dignus (worth).
 This was evident in the recent national news
 The International Council for Nurses Code of
story about 13-year old Jahi McMath (Fox
Ethics 2012 instructs that the observance of
News, 2013). In this case, the family wanted
dignity should not be limited by the
to continue to keep their young daughter on
individual's age, colour, creed, culture, gender,
life support which conflicted with what the
sex, nationality, race, social status, or health
health care facility wanted. After several
status. However, while dignity is accepted as a
evaluations, the child was determined to be
universal need which is fundamental to the
medically brain dead, and therefore
well-being of every individual in all societies,
continuation of medical treatments was
the actual ‘practical’ meaning of dignity
considered to be futile.
remains complex and unclear because it is a
 Caring for patients who are nearing or at the
multidimensional concept.
end of life often enables nurses to bear witness
 ‘How can dignity be promoted?’ Dignity can
to the complicated and difficult decisions that
be upheld by measures such as symptom
patients and families must make surrounding
control; promoting independence, privacy,
many sensitive issues. Although nurses have
social support and a positive tone of care;
their own morals, values, and beliefs, they
listening, giving appropriate information,
sometimes do not correspond with the
having a caring bedside manner; and showing
patients’ values, beliefs, or wishes, and an
respect, empathy and companionship. Spiritual
internal conflict for the nurse can ensue.
care has been shown to be facilitated by
Regardless of the intervention or treatment,
having sufficient time, employing effective
the nurse should focus on helping the patient
communication, and reflecting on one's
weigh the benefits and burdens of the
personal experiences.
intervention, rather than focus on the
 There are often ethical issues that can arise in
intervention itself.
the context of end-oflife care, particularly
when patients and families make Biological vs. Biographical Life
decisions regarding the care they will accept
What is life anyway? What do you mean "life"?
or not accept. As nurses, sometimes our
morals and values are in conflict with those 1. One clear answer is that "life" is biological
that our patients have, and this can cause some life. So to be alive is to be biologically
distress for the nurse. By having an alive or engaging in the processes of living
understanding about some of the issues that things: taking things in, putting stuff out,
can arise during end of life decisions, the growing, and repairing, and so on.
nursing student or novice nurse can be better 2. There's another legitimate meaning of
prepared for what to expect and how best to "life" though. To see this meaning,
handle ethical issues. In the clinical setting, it consider this example:
is not uncommon to witness conflicts between
Suppose a 20-something was in a car crash
the patient’s wishes and those of their family.
20 years ago. She had been in a deep coma
Sometimes, there can be conflicts between
ever since, because her brain was
what the clinicians believe to be best for the
extremely damaged, but her body - which
patient and what the patient and family want
breathed on its own - finally died
to have done. Other times, the insurance or
yesterday.
health care system has specific criteria that
may come When did her life end? When did she cease
to be alive?
 We might want to say that her biological
life ended yesterday, but that her what we
could all her biographical life end 20 years
ago: the "story" of her life ended at the car
crash: the person she was ended then.
Brain Death
• In the practice of critical care, ‘the care of a
severely brain injured patient’ is one of the
toughest challenges for a critical care
physician. Initial therapy provided for patients
with severe brain injury or insult, is directed
towards preservation and restoration of
neuronal function. When this primary
treatment is unsuccessful and the patient's
condition evolves to brain death, the critical
care physician has the responsibility to
diagnose brain death with certainty and to
offer the patient's family the opportunity to
donate organs and / or tissues.
• There is a clear difference between severe
brain damage and brain death. The physician
must understand this difference, as brain death
means that life support is futile, and brain
death is the principal prerequisite for the
donation of organs for transplantation.
• Brain death is defined as the irreversible loss
of all functions of the brain, including the
brainstem. The three essential findings in
brain death are coma, absence of brainstem
reflexes, and apnoea. An evaluation for brain
death should be considered in patients who
have suffered a massive, irreversible brain
injury of identifiable cause. A patient
determined to be brain dead is legally and
clinically dead.
• The diagnosis of brain death is primarily
clinical. No other tests are required if the full
clinical examination, including each of two
assessments of brain stem reflexes and a single
apnoea test, are conclusively performed.
Persistent Vegetative State
• The vegetative state is a clinical condition of
complete unawareness of the self and the
environment, accompanied by sleep-wake
cycles, with either complete or partial
preservation of hypothalamic and brain-stem
autonomic functions. In addition, patients in a
vegetative state show no evidence of
sustained, reproducible, purposeful, or
voluntary behavioral responses to visual,
auditory, tactile, or noxious stimuli; show no
evidence of language comprehension or
expression; have bowel and bladder
incontinence; and have variably preserved
cranial-nerve and spinal reflexes. We define
persistent vegetative state as a vegetative state
present one month after acute traumatic or
nontraumatic brain injury or lasting for at least
one month in patients with degenerative or
metabolic disorders or developmental
malformations.
• The clinical course and outcome of a
persistent vegetative state depend on its cause.
Three categories of disorder can cause such a
state: acute traumatic and nontraumatic brain
injuries, degenerative and metabolic brain
disorders, and severe congenital
malformations of the nervous system.
• Recovery of consciousness from a
posttraumatic persistent vegetative state is
unlikely after 12 months in adults and
children. Recovery from a nontraumatic
persistent vegetative state after three months is
exceedingly rare in both adults and children.
 Patients with degenerative or metabolic
disorders or congenital malformations who
remain in a persistent vegetative state for
several months are unlikely to recover
consciousness. The life span of adults and
children in such a state is substantially
reduced. For most such patients, life
expectancy ranges from 2 to 5 years; survival
beyond 10 years is unusual.
 In Christianity, the phrase sanctity of life
 In Western thought, sanctity of life is
 To expand into other areas of philosophy,
Difficult Decisions in End-of-life care
2. Euthanasia and Prolongation of Life
1. Inviolability of Human Life
 Among the most poignant of the questions
 In religion and ethics, the inviolability of
life, or sanctity of life, is a principle of
implied protection regarding aspects of
sentient life that are said to be holy, sacred,
or otherwise of such value that they are not
to be violated. This can be applied to both
animals and humans or micro-organisms;
for instance, in religions that practice
Ahimsa, both are seen as holy and worthy
of life. The value is inherent: Life is
created in the womb (or artificial
environment to mimic womb). Man does
not have ability to create life; thus, man
does not have authority to destroy life. It is
the only way for humankind to exist.
refers to the idea that human life is sacred,
holy, and precious. The sanctity of life is
inherent as man cannot create life.
Therefore, man has no authority to destroy
life. It is the only way for humankind to
exist. The sanctity of life principle, which
is often contrasted with the "quality of
life" to some extent, is the basis of all
Catholic teaching about the sixth
commandment in the Ten Commandments.
usually applied solely to the human
species (anthropocentrism, sometimes
called dominionism), in marked contrast to
many schools of Eastern philosophy,
which often hold that all animal life is
sacred―in some cases to such a degree
that, for example, practitioners of Jainism
carry brushes with which to sweep insects
from their path, lest they inadvertently
tread upon them.
ask the following question: "Would you
kill Hitler in 1939?” Both possible answers
(yes/no) can be seen as contrary to sanctity
of life. Answering this question is a clear
way to distinguish individuals with a
consequentialist or deontological personal
sense of morality.
that often have to be answered is whether a
patient on the brink of death should be
allowed to die then and there, or whether
measures should be taken to keep him
alive a little longer even when there is no
hope of recovery. Ultimately, society itself
may be forced to make equally difficult
decisions
 regarding prolongation of life in general,
and for periods that may be counted in
years rather than merely days or hours.
 The ability of modern medicine to prolong
life has raised a variety of difficult legal,
ethical, and social issues on which
reasonable minds can differ. Among these
is the morality of euthanasia in cases of
deep coma or irreversible injury, as well as
the Dead Donor Rule with respect to organ
harvesting and transplants. As science
continues to refine and develop lifesaving
technologies, questions remain as to how
much medical effort and financial
resources should be expended to prolong
the lives of patients suspended between
life and death. At what point should death
be considered irreversible? What criteria
should be used to determine when to
withhold or withdraw life-prolonging
treatments in cases of severe brain damage
and terminal illness?
 The concept of Euthanasia has been a
controversial topic since its inception. The
word ‘Euthanasia’ is derived from Greek,
‘Eu’ meaning ‘good’ and ‘thanatos’
meaning ‘death’, put together it means
‘good death’.
 Euthanasia is defined as the hastening of
death of a patient to prevent further
sufferings.
 Active euthanasia refers to the physician
deliberate act, usually the administration
of lethal drugs, to end an incurably or
terminally ill patient’s life.
 Passive euthanasia refers to withholding
or withdrawing treatment which is
necessary for maintaining life.
 There are three types of active euthanasia,
in relation to giving consent for
euthanasia:
a) Voluntary: When euthanasia is
conducted with consent. Voluntary
euthanasia is currently legal in
Belgium, Luxembourg, The
Netherlands, Switzerland, and the
states of Oregon and Washington
in the U.S.
b) Non-voluntary: When euthanasia is
conducted on a person who is
unable to consent due to their
current health condition. In this
scenario the decision is made by
another appropriate person, on
behalf of the patient, based on their
quality of life and suffering.
c) Involuntary: When euthanasia is
performed on a person who would
be able to provide informed
consent, but does not, either
because they do not want to die, or
because they were not asked. This
is called murder, as it’s often
against the patients will.
 Factors which are responsible for decision
making are classified into physical and
psychological factors. Physical conditions
that affect the quality of life in these
patients are unbearable pain, nausea and
vomiting, difficulty in swallowing,
paralysis, incontinence, and
breathlessness. Psychological factors
include depression, feeling a burden,
fearing loss of control or dignity, or dislike
of being dependent. But some argues that
suicidal ideation and inadequate palliative
care might also be the underlying reasons
for seeking euthanasia.
 Passive euthanasia is generally accepted
worldwide. Active involuntary euthanasia
is illegal in almost all countries. Practicing
active voluntary euthanasia is illegal and
considered as criminal homicide in most of
the countries and will faces punishment up
to imprisonment for 14 years. While active
involuntary euthanasia is legal in countries
such as Netherland, Belgium, and
Luxembourg, assisted suicide is legal in
Switzerland and the United States of
Oregon, Washington, and Montana.
 Euthanasia is illegal in the Philippines. In
1997, the Philippine Senate considered
passing a bill legalizing passive
euthanasia. The bill met strong opposition
from the country's Catholic Church.
3. Euthanasia and Suicide
 Assisted suicide, also known as assisted
dying or medical aid in dying, is suicide
 undertaken with the aid of another person.
The term usually refers to physician-
assisted suicide (PAS), which is suicide
that is assisted by a physician or other
healthcare provider.
 Once it is determined that the person's
situation qualifies under the physician-
assisted suicide laws for that place, the
physician's assistance is usually limited to
writing a prescription for a lethal dose of
drugs.
 In many jurisdictions, helping a person die
by suicide is a crime. People who support
legalizing physician-assisted suicide want
the people who assist in a voluntary death
to be exempt from criminal prosecution for
manslaughter or similar crimes.
 Physician-assisted suicide is legal in some
countries, under certain circumstances,
including Canada, Belgium, the
Netherlands, Luxembourg, Spain,
Switzerland, Germany, parts of the United
States (California, Colorado,
 Hawaii, Maine, Montana, New Jersey,
Oregon, Vermont, Washington and
Washington, D.C.) and Australia
(Tasmania, Victoria and Western
Australia). The Constitutional Court of
Austria and Colombia legalized assisted
suicide, but their governments have not
legislated or regulated the practice yet.
New Zealand legalized assisted suicide in
a referendum in 2020, but it will come into
force on 6 November 2021. The
parliament of Portugal passed the
legalization of assisted suicide, but is now
under consideration of the Constitutional
Court.
 In most of those states or countries, to
qualify for legal assistance, individuals
who seek a physician-assisted suicide must
meet certain criteria, including: having a
terminal illness, proving they are of sound
mind, voluntarily and repeatedly
expressing their wish to die, and taking the
specified, lethal dose by their own hand.
Opposition:
 Code of Ethics - The most current version
of the American Medical Association's
Code of Ethics states that physician-
assisted suicide is prohibited. It prohibits
physician-assisted suicide because it is
"fundamentally incompatible with the
physician’s role as healer" and because it
would be "difficult or impossible to
control, and would pose serious societal
risks".
 Hippocratic Oath - Some doctors remind
that physician-assisted suicide is contrary
to the Hippocratic Oath, which is the oath
historically taken by physicians. It states "I
will not give a lethal drug to anyone if I
am asked, nor will I advise such a plan."
The original oath however has been
modified many times and, contrary to
popular belief, is not required by most
modern medical schools, nor confers any
legal obligations on individuals who
choose to take it. There are also
procedures forbidden by the Hippocratic
Oath which are in common practice today,
such as abortion.
I swear by Apollo Physician and Asclepius
and Hygieia and Panaceia and all the gods and
goddesses, making them my witnesses, that I will
fulfil according to my ability and judgment this
oath and this covenant:
To hold him who has taught me this art as
equal to my parents and to live my life in
partnership with him, and if he is in need of
money to give him a share of mine, and to regard
his offspring as equal to my brothers in male
lineage and to teach them this art - if they desire
to learn it - without fee and covenant; to give a
share of precepts and oral instruction and all the
other learning to my sons and to the sons of him
who has instructed me and to pupils who have
signed the covenant and have taken an oath
according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the
sick according to my ability and judgment; I will
keep them from harm and injustice. I will neither
give a deadly drug to anybody who asked for it,
nor will I make a suggestion to this effect.
Similarly I
will not give to a woman an abortive remedy. In
purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers
from stone, but will withdraw in favor of such men
as are engaged in this work. Whatever houses I
may visit, I will come for the benefit of the sick,
remaining free of all intentional injustice, of all
mischief and in particular of sexual relations with
both female and male persons, be they free or
slaves.
What I may see or hear in the course of the
treatment or even outside of the treatment in
regard to the life of men, which on no account one
must spread abroad, I will keep to myself, holding
such things shameful to be spoken about.
If I fulfil this oath and do not violate it, may it
be granted to me to enjoy life and art, being
honored with fame among all men for all time to
come; if I transgress it and swear falsely, may the
opposite of all this be my lot.
 Declaration of Geneva - The Declaration
of Geneva is a revision of the Hippocratic
Oath, first drafted in 1948 by the World
Medical Association in response to forced
(involuntary) euthanasia, eugenics and
other medical crimes performed in Nazi
Germany. It contains, "I will maintain the
utmost respect for human life."
 International Code of Medical Ethics -
The International Code of Medical Ethics,
last revised in 2006, includes "A
physician shall always bear in mind the
obligation to respect human life" in the
section "Duties of physicians to patients".
 Statement of Marbella - The Statement
of Marbella was adopted by the 44th
World Medical Assembly in Marbella,
Spain, in 1992. It provides that
"physician- assisted suicide, like
voluntary euthanasia, is unethical and
must be condemned by the medical
profession."
4. Dysthanasia
 The etymology of the term is from the
Greek language: δυσ, dus; "bad, difficult"
+ θάνατος, thanatos; "death"
 Dysthanasia is the term for futile or
useless treatment, which does not benefit
a terminal patient. It is a process through
which one merely extends the dying
process and not life per se. Consequently,
patients have a prolonged and slow death,
frequently accompanied by suffering,
pain and anguish. When one invests in
healing a patient who has no chance of
cure, s/he is actually undermining the
person's dignity. Advanced measures and
their limits should be assessed to benefit
the patient and not to hold science as an
end in itself
 In medicine, dysthanasia means "bad
death" and is considered a common fault
of modern medicine.
 Dysthanasia is a term generally used
when a person is seen to be kept alive
artificially in a condition where,
otherwise, they cannot survive;
sometimes for some sort of ulterior
motive.
 Dysthanasia occurs when a person who is
dying has their biological life extended
through technological means without
regard to the person's quality of life.
 Technologies such as an implantable
cardioverter defibrillator, artificial
ventilation, ventricular assist devices, and
extracorporeal membrane oxygenation
can extend the dying process.
 As a result of these difficulties in
accepting the limitation of curative
efforts, dysthanasia is practiced.
Considered therapeutic obstination or
therapeutic futility, it is a controversial
subject in the field of bioethics, being
described in the dictionary of bioethics as
a difficult or distressing death, as its
practice prolongs the suffering of the
terminal patient without entailing any
therapeutic benefit. Such conduct harms
human rights, leads to degrading and
disrespectful treatment, negatively
impacts biological life, and impairs
quality in life and dying. Faced with the
impossibility of recovery, the persistent
adoption of life-prolonging invasive
treatments results from the denial
 of mortality, which disregards the fact
that death is part of life and that treatment
must always be dignified and humane
5. Orthothanasia
 By its etymological meaning,
orthothanasia derives from the Greek
orthos, which means “correct,” and
thanatos, meaning “death.” In other words,
death at the appropriate time with due
respect to the limits of life. Orthothanasia
can also be considered a natural death,
favoring the acceptance of the human
circumstance when faced with death,
without abbreviating or prolonging
suffering, but only providing, as far as
possible, quality of life and relief of
suffering in general.
 This conduct allows the patient to
understand human finitude and to die in
peace, as it guarantees dignity in the
process of death. It also helps all those
involved in this process – patient, team,
family, and friends – to accept death more
calmly. This is because, from this
perspective, death does not present disease
as something to be healed, but the end of
the cycle of life. From this point of view, it
is emphasized that when caring for an
individual in an irreversible or terminal
clinical condition, the medical team should
avoid unnecessary procedures and futile
therapeutic measures.
 Orthothanasia refers to the art of
promoting a humane and correct death, not
subjecting patients to misthanasia or
dysthanasia and not abbreviating death
either, that is, subjecting them to
euthanasia. Its great challenge is to enable
terminal patients to keep their dignity,
where there is a commitment to the well-
being of patients in the final phase of a
disease.
6. Administration of Drugs to the
Dying/Palliative Sedation
 Palliative sedation (PS) is the use of
medications to induce decreased or absent
awareness in order to relieve otherwise
intractable suffering at the end of life.
Although uncommon, some patients
undergoing aggressive symptom control
measures still have severe suffering from
underlying disease or therapy-related
adverse effects. In these circumstances,
use of PS is considered. Although the goal
is to provide relief in an ethically
acceptable way to the patient, family, and
health care team, health care professionals
often voice concerns whether such
treatment is necessary or whether such
treatment equates to physician-assisted
suicide or euthanasia.
 Palliative sedation is used at the end of life
to relieve an unacceptable degree of
suffering that is refractory to other
therapies or when other therapies are
estimated to be unhelpful in the given time
frame. Palliative sedation is used when
traditional opioid-based therapies are
either inadequate to control suffering or
cause unacceptable adverse effects. Often,
PS is used to treat delirium, pain, dyspnea,
nausea, or other physical symptoms.6
Palliative sedation may be considered
when patients or surrogate decision makers
have given informed consent and generally
when consensus exists among patients,
families, and staff about the
appropriateness of the therapy.
7. Advance Directives
 An advance directive is a document by
which a person makes provision for health
care decisions in the event that, in the
future, he/she becomes unable to make
those decisions.
 There are two main types of advance
directive — the “Living Will” and the
“Durable Power of Attorney for Health
Care.”
a. Living Will is the oldest type of health care
advance directive.
• It is a signed, witnessed (or notarized)
document called a “declaration” or
“directive.” Most declarations instruct an
attending physician to withhold or withdraw
 medical interventions from its signer if he/she
is in a terminal condition and is unable to
make decisions about medical treatment.
• Since an attending physician who may be
unfamiliar with the signer’s wishes and
values has the power and authority to carry
out the signer’s directive, certain terms
contained in the document may be interpreted
by the physician in a manner that was not
intended by the signer.
• Family members and others who are familiar
with the signer’s values and wishes have no
legal standing to interpret the meaning of the
directive.
b. Durable Power of Attorney for Health Care
is a signed, witnessed (or notarized) document in
which the signer designates an agent to make
health care decisions if the signer is temporarily or
permanently unable to make such decisions.
• Unlike most Living Wills, the Durable Power
of Attorney for Health Care does not require
that the signer have a terminal condition. o An
agent must be chosen with great care since the
agent will have great power and authority to
make decisions about whether health care will
be provided, withheld or withdrawn from the
signer.
• It is extremely important that the signer
carefully discuss his/her values, wishes and
instructions with the agent before and at the
time the document is signed. Such discussions
may also continue after the document is
signed.
• It is also important that the agent be willing to
exercise his/her power and authority to make
certain that the signer’s values, wishes and
instructions are respected.
c. Physician Orders for Life-Sustaining
Treatment (POLST) is a recently developed
program that is designed to improve the quality of
care people receive at the end of life. Although it
can be used by anyone, it is best suited for people
who have chronic, serious or advanced illness, are
frail, or are of advanced age.
• The POLST effectively communicates certain
medical orders based on your advance care
planning wishes using a brightly colored form.
It can be transferred from one care setting to
another, and healthcare providers have
promised to honor it. For example, when your
POLST form is shown, your advance care
plans will be honored by the Emergency
Medical Service team (ambulance or fire
personnel), staff in the emergency room, the
hospital team, and nursing home staff.
• Since the POLST contains a set of valid legal
orders, it requires a discussion with your
physician and their signature to be fully
activated. When you complete the POLST, it
is best to keep it at home in a visible spot, like
your refrigerator, so it can be easily found by
an emergency responder.
• Limitations: o Advance directives have
limitations. For example, an older adult may
not fully understand treatment options or
recognize the consequences of certain choices
in the future. Sometimes, people change their
minds after expressing advance directives and
forget to inform others. Many times, advance
directives are too vague to guide clinical
decisions. For example, general statements
rejecting "heroic treatments" are vague and do
not indicate whether you want a particular
treatment for a specific situation (such as
antibiotics for pneumonia after a severe
stroke). In this situation, a surrogate who
understands your preferences can help make
the best decision for you.
• On the other hand, very specific directives for
future care may not be useful when situations
change in unexpected ways. New medical
therapies may also have become available
since an advance directive was written. You,
your surrogate, your family, and your
healthcare provider can do a great deal to
avoid these problems by discussing advance
directives with each other.
8. DNR
 Since its introduction in the 1960s,
cardiopulmonary resuscitation (CPR) has
been universally available to all hospital
patients unless the consultant in charge has
specified a 'do not resuscitate' (DNR)
order. The public perception of CPR has
tended to
 be one of overoptimism, but this is not with minimal pain, discomfort, and
matched by the low survival to discharge restriction. It also emphasizes a
ratio of approximately 1:10. In addition, coordinated team effort to help the patient
there is the risk of prolonging suffering, and family members overcome the severe
compared with the quick and relatively anxiety, fear, and depression that occur
pain free alternative offered by cardiac with a terminal illness. To that end,
arrest. Decisions about resuscitation pose hospice staffs encourage family members
many ethical dilemmas for those involved to help and participate in patient care,
and should take into consideration the thereby providing the patient with warmth
patient's wishes, prognosis and quality of and security and helping the family
life. caregivers begin the grieving process even
 DNRs are Do Not Resuscitate orders. A before the patient dies.
DNR order on a patient's file means that a
doctor is not required to resuscitate a
patient if their heart stops and is designed
to prevent unnecessary suffering.
 The usual circumstances in which it is
appropriate not to resuscitate are:
o when it will not restart the heart or
breathing
o when there is no benefit to the
patient
o when the benefits are outweighed
 Everyone involved in this method of care
by the burdens
must be committed to high-quality patient
 Although DNRs can be regarded as a form
care, unafraid of emotional involvement,
of passive euthanasia, they are not
and comfortable with personal feelings
controversial unless they are abused, since
about death and dying. Good hospice care
they are intended to prevent patients
also requires open communication among
suffering pointlessly from the bad effects
team members, not just for evaluating
that resuscitation can cause: broken ribs,
patient care but also for helping the staff
other fractures, ruptured spleen, brain
cope with their own feelings.
damage.
Nursing Responsibilities Based from Ethical
9. End-of-life Care Plan
Principles
 End-of-life nursing encompasses many
Autonomy, beneficence, nonmaleficence, and
aspects of care: pain and symptom
justice are four of the basic ethical principles used
management, culturally sensitive practices,
to guide nurses and clinicians in the care and
assisting patients and their families
decision making of patients. Many of these same
through the death and dying process, and
standards apply for nurses who are involved in
ethical decision making.
clinical research as they are a way to ensure that
 Hospice care provides comprehensive
people’s rights are protected as guided by specific
physical, psychological, social, and
moral principles.
spiritual care for terminally ill patients.
Most hospice programs serve terminally ill Respect for Autonomy
patients from the comforts and relaxed
This principle is described as an agreement to
surroundings of their own home, although
respect another’s right to self-determine a course
there are some located in inpatient settings.
of action and to support another’s independent
The goal of the hospice care team is to
decision making (ANA, 2015).
help the patient achieve a full life as
possible,
Sometimes it can be difficult to see a patient make
a decision about their health that the nurse does
not personally agree with or that the nurse does
not feel is the best decision for that patient’s
individual circumstances. As nurses, we must
support and advocate for our patients’ rights,
including their right to make decisions. While a
nurse might not agree with a patient’s decision,
they must support it. For example, a nurse has
been caring for an elderly gentleman for several
months as he has been receiving treatment for
cancer. This patient has decided to stop his cancer
treatments and focus on spending time enjoying
his family for the time he has left. While the nurse
has grown fond of this patient and would not want
him to die, they must respect the patient’s wishes
and choices for his own medical care.
Beneficence
Beneficence is the principle of “doing good”
and has been suggested as having four distinct
parts. These include:
• Not to inflict evil or harm.
• To prevent evil or harm.
• To remove evil or harm.
• To do good or promote good.
Sometimes it might be difficult to differentiate
between doing good and doing no harm, which is
nonmaleficence, because it is often easier to
determine what is clearly bad or harmful more
than what might be good or a benefit. Kennedy
Swartz recommended that there is a greater
obligation to not cause harm than there is to do
something that might benefit the patient. Nurses
should keep that in mind when assisting patients
with difficult decisions.
Nonmaleficence
Nonmaleficence is the principle of refraining
from causing unnecessary harm. Although some
of the interventions that patients receive might
cause pain or some harm, nonmaleficence refers to
the moral justification behind why the harm is
caused. Sometimes harm may be caused to a
patient in order to prevent them from further
harm. If the act is for a greater good for the patient
and is not meant to deliberately harm them, it is
justifiable. An example of this is the all too
common clinical situation that occurs in end-of-
life care. A patient whose death is imminent is in
pain and requires pain medication to maintain
comfort. The patient is very close to death with
irregular respirations around 8 breaths per minute.
The nurse needs to administer the pain medication
but fears that giving it may hasten (or accelerate)
death. According the Code of Ethics for Nurses
(ANA, 2015), the nurse may “not act deliberately
to terminate life”; however, the nurse has a
moral obligation to provide interventions “to
relieve symptoms in dying patients even if the
intervention might hasten death.”
Justice
Justice is the principle that governs social
fairness. It involves determining whether
someone should receive or is entitled to receive a
resource. The Code of Ethics for Nurses (ANA,
2015) states that nurses’ commitment is to patients
regardless of their “social or economic status.” In
healthcare, sometimes the benefits must be
balanced with the burdens to determine who is
eligible to receive some type of care. As
mentioned in the beginning of this chapter,
medical futility is continuing to provide a medical
intervention or treatment that would not provide a
cure or benefit to the patient. As with the young
Jahi McMath, who was determined to have brain
death, continuing to keep her alive on life support
would be futile, as
there is little or no hope for recovery. So this
decision was considered just, as discontinuation of
life support was not based on her age, ethnicity or
socio-economic status. It was based on her
medical diagnosis.
The American Nurses Association recommends
that:
 Nurses act to respect
human dignity supporting the patient’s right
to accept, refuse, or terminate treatment
and be given necessary support throughout the
decision-making and treatment process,
including resuscitation decisions.
 Nurses actively participate in ensuring the
responsible and appropriate use of
interventions regarding do-not-resuscitate
orders through active involvement in
evaluation, revision, and implementation of
established institutional policies.
 Nurses care for patients with do-not-
resuscitate orders as they would care for any
other patient, including respect and advocacy
for the patients’ preferences and values,
promotion of well- being, and alleviation of
suffering.
 Nurses support the patient’s wishes in
reviewing and revising advance directive
decisions and comply with the patient’s
wishes. Further, they promote advance care
planning conversations and are knowledgeable
about the benefits and limitations of various
advance directive documents.
 Nurses provide accurate, complete, and
understandable information in a manner that
facilitates an informed decision and are
available to assist with weighing the benefits,
burdens, and risks of available options in
treatment, including the choice of no
treatment.
 Nurses advocate for using an interdisciplinary,
collaborative approach when making
decisions about resuscitation. Nurses foster
discussions with the health care team, patient,
and family (or designated
surrogate), and ensure that the patient’s wishes
are respected.
 Nurses recognize that moral distress may be
associated with do-not-resuscitate decision-
making and should seek support as
needed for themselves, health team
members, patients, and families.
 Nurses seek opportunities to learn more about
the evidence associated with do-not-
resuscitate orders, as well as best practices for
approaching patients and families when do-
not-resuscitate orders may be part of the plan
of care.
 Remain objective when discussing end-of-life
options with patients who are exploring
medical aid in dying.
 Have an ethical duty to be knowledgeable
about this evolving issue.
 Be aware of their personal values regarding
medical aid in dying and how these values
might affect the patient-nurse relationship.
 Have the right to conscientiously object to
being involved in the aid in dying process.
 Never “abandon or refuse to provide comfort
and safety measures to the patient” who has
chosen medical aid in dying. Nurses who work
in jurisdictions where medical aid in dying is
legal have an obligation to inform their
employers that they would predictively
exercise a conscience-based objection so that
appropriate assignments could be made.
 Protect the confidentiality of the patient who
chooses medical aid in dying.
 Remain objective and protect the
confidentiality of health care professionals
who are present during the aid in dying
process, as well as the confidentiality of those
who choose not to be present.
 Be involved in end-of-life policy discussions
and development on local, state, and national
levels, including advocating for palliative and
hospice care services.
 Furthermore, research is needed to better
understand the phenomenon.
 Lesson 7
BIOETHICS AND RESEARCH
A. PRINCIPLES OF ETHICS IN RESEARCH National Commission for the Protection of Human
Subjects of Biomedical and Behavioral Research.
Principles of beneficence, respect for human
dignity and justice underlie the ethical conduct of
research. The principle of beneficence implies the
right to protection from harm and discomfort,
including a balance between the benefits and risks
of a study. The principle of respect for human
dignity implies the rights to full disclosure and
self- determination or autonomy. The principle of
justice implies the rights of fair treatment and
privacy including anonymity and confidentiality.
Recognition of the need to regulate research
on human beings can be traced back to reactions
against the abuses associated with German and
Japanese research during World War II. However,
as the twentieth century rolled out it was Some Important Considerations
increasingly recognized that a number of abuses,
in terms of research on human subjects, continued Human beings are deserving of respect and
protection as inalienable rights. This is equally the
into the post-war period in both democratic and case during research activities as it is in any other
communist countries. The most cited violations of circumstances. Based on the work of the
human rights in research are those that were philosopher Immanuel Kant1 such values are
perpetuated by the Nazis during the World War II expressed in the principle of respect for persons,
sometimes translated as respect for autonomy.
and that came to public awareness during the Such expressions of course raise questions of the
Nuremberg trials. definition of person and autonomy and when and
in what set of circumstances such concepts are
The first internationally accepted set of ethical and are not applicable.
guidelines with regard to these issues was the However, for the purposes of this chapter we
Nuremburg Code published in 1947. The World will take it that respect is applicable to all
Medical Association (WMA) publicly endorsed the human participants in nursing and health care
principles expressed in the Nuremburg Code by research. The question then arises regarding what
drawing up the Declaration of Helsinki in 1964 (WMA this actually means in the case of individual
1964). This Declaration has been revised a number of participants in a particular research project. At a
minimum, the considerations explored below are
times since its first publication.
relevant.
International efforts to provide guidelines for
B. ETHICAL ISSUES IN EVIDENCES BASED
protection of human rights have been documented
PRACTICE
in the NUREMBERG CODE, which was Ethical issues permeate the entire
developed as a set of principles for the ethical research process from the identification of the
conduct of research against which the experiments research question and selection of research
in the concentration caps could be judged, and the participants, to dissemination of findings. Many
DECLARATION OF HELSINSKI, issued by the texts focus their discussions of ethical issues in
World Medical Assembly in 1964 and revised in research primarily on protection of human rights.
1975 and in 2001 to guide clinical research.
Included in the BELMONT REPORT, the Respect for the Human Person - Dignity
Within the context of research activity, the
principles set forth in these codes serve as the
principle of respect for persons is frequently
basis for policies developed by the United States
articulated in terms of rights – both rights to must specify
autonomous participation and welfare rights
(welfare rights refer to the right to have one’s
support and protection needs respected).
Some such rights are the following:
• The right not to be injured or mistreated.
• The right to give informed, un-coerced
consent to participate in the particular piece
of research.
• The right to privacy, confidentiality and/or
anonymity.
In terms of protecting the participant’s right
not to be injured or mistreated, it is normally the
duty of the research team not to expose the
research participant to significantly burdensome,
unreasonable, known or predictable risk. On
occasion however, when significant burden or
predictable material risk is unavoidable, it is the
duty of the research team to provide appropriate
information on the likely burden and /or risk
involved, so that the participant can determine if
they fully understand and accept such burden or
risk. Thus, for example, in drug trials and trials
involving medical devices, the trials are phased
and normally commence with non-human
(laboratory and animal) trials. Such measures help
to provide insight into likely effects of the
particular drug or device – at least on non-human
subjects. Thus, by the time clinical trials (trials
using human participants) commence, previous
phases give insight into the actions of the agent
(drug or device for example). This provides a
certain level of confidence that the agent will
either not cause significant physical risk to the
trial participants or that any such risks, which will
be explained to the participant prior to
participation, can and will be managed and /or
mitigated by the research team. Where discomfort,
burden and/or risk cannot be avoided such
discomfort, burden and/or risk must be
proportionate to the anticipated gain, either
directly to the individual participant and/or to
humanity or society.

A Summary of the ANA Guidelines for the

Protection of Human Rights
Right to Freedom from Intrinsic Risk of Injury
• When an individual participating in research is
exposed to increased risk for social,
emotional, or physical injury, the investigator
 the degree of risk and estimate how the risk consent must be obtained.
to the individual compares to the benefit to
humanity through knowledge gained.
• All relevant information concerning
activities that go beyond established and
accepted procedures for meeting personal
needs must be given to a prospective
participant prior to that person's
participation in the study. • Nurses must be
vigilant in their concern for persons who are
unable to effectively protect themselves
from harm or injury due to illness or other
condition and be aware of potentials for
exploiting captive populations, such as
persons in institutions, students, or
prisoners.

Right to Privacy
• Since an investigator cannot decide for
another what is considered an invasion of
privacy for that person, all proposals,
protocols, investigative instruments, and
procedures to be used in research activities
must be specified and discussed with the
prospective participant.
• . The above must be discussed as well with
any workers who are expected to take part
in the research as data gatherers or research
participants.

Right to Anonymity
• There must be safeguards against
unanticipated physical, psychological, or
social disadvantages occurring to
participants because of their role in the
research, either during the study or from
dissemination of findings.
• Assurance that a participant's anonymity
will be protected must be provided when the
participant agrees to share personal
information that might not be divulged to
others in another context.
• When collected data is not to remain under
the control of the investigator, mechanisms
for protecting the identity of the participant
and safeguarding confidentiality must be
established.
• . When the plan of the study or the report of
the findings will sacrifice the participant's
anonymity or confidentiality-specific prior
• Potential violations of human dignity from
demeaning or dehumanizing situations in the
research protocol require special
consideration, recognizing that such violations
can have long- range repercussions when
significant values of the individual are
involved.
Informed Consent
Respect for the individual’s right to make
decisions about themselves and their life (respect
for autonomy) requires that research participants
are adequately and properly informed regarding
the nature of the research project.
For example, potential participants must be
informed with regards to what will be required of
the individual participant, including the
approximate time requirement, any procedures
that will be performed on him/her, any known or
predictable risks or side effects, the nature of the
trial (where a clinical trial is part of the research
design), whether a placebo is being used, whether
the trial is blinded and so forth. Such information
enables the potential research participant to give
informed consent to participate in the particular
research activity or project.
There are two other crucial elements that must
be in play in order to ensure that consent is not
only informed but also voluntary—and thus
autonomously exercised.
These elements are:
1. The participant must have the capacity to
both understand the information being
provided regarding the particular piece of
research, including the implications of
participation for the individual, and the
(cognitive) ability to exercise consent.
2. The participant must be free from coercion.
Thus, the participant must be assured and
accept, for example, that refusal to consent
will not affect her/his current care and
treatment if the individual is being cared for
by any member of a health care team; either in
hospital or in the community. The individual
should also be free from any other form of
duress related to the research in question –
from the research or
health care team or from relatives or
significant others.
Nurses who are assisting with
research or who work on units where research
is being conducted must be familiar with the
elements of an informed consent. If the
elements of the consent are incomplete, nurse
should bring this to the attention of the
investigators or the institution ethics
committee.
Research participants, in order to be properly
protected from unwarranted risk of such personal
information becoming available in public and thus
potentially being used to the detriment of the
research participant, (and to enable the participant
to feel safe to participate in the particular study)
should be assured that such personal information
will be kept private and confidential. Where strict
confidentiality cannot be assured appropriate
mechanisms should be designed into the study to
protect participants. Participants can thus be
assured that their identity will not be divulged –
i.e. the data collection, handling and storage
processes protects anonymity. In this latter case,
for example, participants are normally not asked
to divulge their names on self-completed
questionnaires– such as when completing patient
satisfaction questionnaires or when a staff member
completes a staff survey
Beneficence and Non-Maleficence
Two of the internationally accepted,
fundamental core principles underpinning both
nursing practice and research are the principle of
beneficence (do good) and the mirror principle of
non-maleficence (do not harm). Thus, one should
do good to and should not harm one’s patients,
clients or research participants. Clearly some
interventions (for diagnostic, therapeutic and/or
research purposes) may be uncomfortable,
burdensome or painful. Some may cause a degree
of harm - for example surgical intervention,
dressing of wounds and burns and so forth.
However, the basic stance is that the core function
of the health care professional is to work for the
benefit of the patient or client from a health
perspective. Thus, the practitioner or the
researcher
must not cause unnecessary or avoidable harm or
distress to one’s patients, clients or research
participants. Article 6 of the Declaration of
Helsinki states that this position with particular
clarity:
“In medical research involving human subjects,
the well-being of the individual research
subject must take precedence over all other
interests.”
In order to continue to develop the evidence
base for health care and nursing practice, relevant,
well-designed research is both important and
essential. Conversely, the results of poorly
designed research may, at worst, seriously harm
participants or, at best, waste their time, while at
the same time make misleading or detrimental
contributions to the evidence base. This means
that significant time and effort should be invested
into research training and research oversight and
governance.
A corollary of the principles of beneficence
and non-maleficence, in terms of clinical trials, is
that a study must be stopped immediately, when
the risks are found to outweigh the potential
benefits. A similar imperative exists when there is
conclusive evidence of positive and beneficial
results from one of the agents under investigation.
Justice
The principle of justice includes the rights to
privacy and to fair treatment. The nature of
research is to gather information about what is
being studied. When persons are the focus of a
study, the right to privacy is a critical issue.
Attentiveness to privacy means the participant
determines when, where and what kind of
information is shared, with an assurance that
information, attitudes, behaviors, records,
opinions and the like that are observed and
collected will be treated with respect, kept secure
and kept in strict confidence. Privacy is
maintained through anonymity, confidentiality
and informed consent.
Because the concept of privacy may vary in
different cultures, the kind of information
participants feels confutable allowing to be shared
may also vary. If even the researcher can’t link the
information with a particular participant, then
anonymity exists. Confidentiality refers to the
researcher’s assurance to participants that
information provided will not be made public or
available to anyone other than those involved in
the research process without the participant’s
consent. Confidentiality is maintained by using
codes rather than personal identification on data
collection forms and restricting access to raw data
to those on the research team who need the use of
data.
The right to fair treatment is related to the
right to self-determination. Equitable treatment of
participants in the selection process, during the
study, and after the completion of the study is at
the basis of this right. Factors to consider in the
selection of fair treatment includes the following:
• Selecting participants based on the research
needs, not on the convenience or compromised
position of a group of people
• Equitably distributing the risks and benefits of
the research among participants regardless of
age, gender, socioeconomic status, race or
ethnic background
• Honoring any agreements made or benefits
promised
• Treating participants with respect, providing
access to research personnel or other
professionals as needed
• Treating persons who decline to participate or
withdraw from the study without prejudice
• Debriefing as needed to clarify issues or when
information had been withheld prior to the
study
C. ETHICO-MORAL OBLIGATIONS OF
THE NURSE IN EVIDENCE BASED
PRACTICE
Nurses must be accountable for the quality of
care they deliver and research is one way of
documenting the efficacy of nursing practice.
Both the art and science of nursing are expanded
through research.
Research is necessary for the ongoing
development of the unique body of knowledge
that undergirds the discipline of nursing and
provides an organizing framework for nursing
practice.
 Participating in research can be exciting and
encourage professional growth. It can also present
some dilemmas for the nurse and nurse researcher
in the academic and clinical realms. Seeking new
knowledge and understanding is the expected
motivation for conducting research. However,
personal or institutional gains related to rewards
like grant funds, prestige, the need to succeed or
promoting a product can be other motivating
factors that may challenge principled behavior in
regard to research.
A nurse who works in clinical areas where
research is being conducted must be aware of
principles for the conduct of research, regardless
of whether the nurse has an active role with the
research project. In this regard, guidelines from
the American Nurses Association state:
“A relationship of trust between nurse and patient has
always been an essential element of the professional
code of ethics. In research, a relationship of trust
between the subject and investigator requires that the
investigator assume special obligation to safeguard
the subject...
The individual has the right to self-determination
concerning what will be done to his person. Each
practitioner of nursing has an obligation to endorse
and support self-determination as a moral and legal
right of the individual. The responsibilities of
safeguarding the rights of others must be fully
accepted by nurses whether their roles are as
practitioners, educators or researchers.”
GUIDELINES AND PROTOCOLS IN
DOCUMENTATION AND HEALTH
CARE RECORDS
Purpose of Guidelines
These guidelines support employers, policy
makers, managers and clinical staff in
documentation practices and policies that
demonstrate the professional obligation,
accountability and legal requirements to
communicate patient health information and
clinical interventions in the public interest. It
should be assumed that any and all clinical
documentation will be scrutinized at some point.
Maintaining Quality Documentation Practice
As partners in efforts to achieve a quality
practice setting clinical staff, medical record staff
and hospital managers have a shared responsibility
and legal accountability to create and maintain
environments that support competent clinicians in
providing quality, evidence-based outcomes for
patients. In ensuring quality documentation
practice, these documentation guidelines
encourage employers, medical record and clinical
staff to incorporate strategies, policies and
procedures that strengthen effective
documentation practices within the work setting.
Documentation Policy
Medical Record Officers should ensure they
have documented policy, procedure and quality
assurance mechanisms in place which clarify:
• the legislative requirements for documentation
• the minimum requirements for documentation
• format and type of documentation (including
acceptable documentation tools and forms)
• the roles and responsibilities of the clinical
staff in relation to documentation
• accepted abbreviations in the organization
(including their agreed meaning)
• any requirements for witnessing or counter
signing documentation (and the meaning and
responsibility assigned to these practices)
• requirements for access, storing, archiving and
retaining documentation
• requirements for documentation of verbal
orders and provision of telephone
advice/information
• requirements for confidentiality and privacy.
CLINICAL COMPETENCE IN RELATION
TO DOCUMENTATION
Appropriate documentation promotes;
• a high standard of clinical care
• continuity of care
• improved communication and dissemination
of information between and across service
providers
• an accurate account of treatment, intervention
and care planning
• improved goal setting and evaluation of care GUIDELES FOR MEDICAL RECORD AND
outcomes CLINICAL DOCUMENTATION
• improved early detection of problems and
changes in health status Medical Record and Clinical Documentation
• evidence of patient care. 1. Clear
A clinician’s documentation should be able to 2. Concise
demonstrate; 3. Complete
4. Contemporary
• a full account of the clinician’s assessment of 5. Confidential
the patient and the care planned and provided 6. Patient Centered
• relevant information in relation to the patient’s 7. Collaborative
condition at any given time and the 8. Comprehensive
interventions 9. Correct
• and actions taken to achieve identified health 10. Consecutive
outcomes and/or respond to actual or potential
adverse events Key Point Summary
• evidence that the clinician met their duty of • Documentation includes all forms of
care and taken all reasonable decisions and documentation by a doctor, nurse or allied
actions to provide the highest standard of care health professional (physiotherapist,
• evidence that the clinician met their duty of occupational therapist, dietician etc) recorded
care and that any actions or omissions did not in a professional capacity in relation to the
compromise the patients’ safety or identified provision of patient care.
health outcomes • Documentation and record keeping is a
• a record of all communications with other fundamental part of clinical practice. It
relevant others in relation to the patient demonstrates the clinician’s accountability and
GUIDING PRINCIPLES FOR records their professional practice.
DOCUMENTATION • Documentation is the basis for communication
between health professionals that informs of
Guiding Principle 1: Comprehensive and the care provided, the treatment and care
complete record planned and the outcome of that care as a
Clinical staff have a professional obligation to continuous and
maintain documentation that is clear, concise and • contemporaneous record.
comprehensive, as an accurate and true record of • Documentation is a record of the care and the
care. clinical assessment, professional judgement
and critical thinking used by a health
Guiding Principle 2: Patient centered and professional in the provision of that care
Collaborative • Documentation should be clear, concise,
Documentation is patient centered, patient consecutive, correct, contemporaneous,
focused, collaborative and appropriate to the complete, comprehensive, collaborative,
setting in which the care is provided and the patient-centered and confidential.
purpose for which the information recorded. • Documentation must be patient focused and
based on professional observation and
Guiding Principle 3: Ensure and maintain assessment that does not have any basis in
confidentiality unfounded conclusions or personal
Documentation systems (including electronic judgements.
systems) will ensure and maintain patient • Clinical staff must able to competently
confidentiality, in all care settings. communicate effectively with individuals and
groups using formal and informal channels of
 communication and ensuring documentation is
accurate and maintains confidentiality.
• Clinical staff are required to make and keep
records of their professional practice in
accordance with standards of practice of their
profession and organizational policy and
procedure.
• Documentation is often used to evaluate
professional practice as a part of quality
assurance mechanisms such as performance
reviews, audits and accreditation processes,
legislated inspections and critical incident
reviews.
• Documentation systems should promote
appropriate sharing of information amongst
the multidisciplinary and teams.
• Accurate and comprehensive documentation is
a valuable source of data for data coding,
health research and a valuable source of
evidence and rationale for funding and
resource management.
• Documentation should record both the actions
taken by clinical staff and the patient’s needs
and/or their response to illness and the care
they receive.
• Clinical staff have legislative, professional and
ethical obligations to protect patient
confidentiality. This includes maintaining
confidential documentation and patient
records.
• Precautions must be taken to ensure that
clinicians are fully informed of appropriate,
safe and secure use of electronic information
systems and the potential risks involved in
using such systems in ensuring and maintain
confidentiality.
• It should be assumed that any and all
clinical documentation will be scrutinized at
some point.
ETHICAL TREATMENT OF DATA
Scholarship issues regarding data include how
the data is handled during the collection and
analysis process and how the data is reported.
Ethical treatment of data implies integrity of
research protocols and honesty in reporting
findings. The honesty and integrity of the
researcher are of utmost importance in the ethical
treatment of data. Taking care to ensure that only
those who are involved in the research process
have access to the data and to maintain
confidentiality were mentioned previously. A
critical ethical obligation of qualitative nursing
researchers is to present and describe the
experiences of others as authentically and
faithfully as possible, even when it is contrary to
our own aims. The imperative to report the
findings as accurately as possible is an ethical
obligation in quantitative studies as well.
Nurses involved in research are accountable to
professional standards for reporting findings.
Principles that guide academic honesty apply as
well to nurse researchers in reporting outcomes of
studies. It is dishonest to exaggerate results,
withhold negative findings, or adjust facts of a
study in order to maximize or minimize particular
outcomes or hypotheses. When information from
someone else is included in a report without
appropriate referencing, this is plagiarism. In
recent years, scientific misconduct has become a
concern within the scientific community. Articles
have been published in professional journals
reporting studies that were never conducted,
findings that were fabricated or findings that were
intentionally distorted by researchers. Although
these reports have related more to biomedical
studies than to nursing research, such reports
present problems to disciplines whose clinical
practice may be changed based on research
findings. They also serve as reminders to nurses to
be vigilant regarding ethical reporting of research
findings.
 Lesson 8
ETHICAL CONSIDERATIONS IN LEADERSHIP AND MANAGEMENT
Leadership is an important issue related to
how nurses integrate the various elements of
nursing practice, how to ensure highest quality
care for clients. Nurses are leaders in their roles as
health care providers and advocates.
LEADERSHIP IN NURSING
Leadership
 the process through which an individual
attempts to intentionally influence another
individual or a group in order to
accomplish a goal (Pointer, 2006, p. 125).
 a qualitative statement of personal or
individual ability.
 a set of knowledge, skills, and attitudes
that can be used by all nurses.
MANAGEMENT - tasks, leadership is about
perception, judgment, and philosophy.
The American Association of Colleges of
Nursing (AACN) documents on baccalaureate
(2008) and master’s essentials (2011) support the
development of leadership competencies in all
nurses. Scott and Miles (2013) state that “if nurses
are to make an impact on the advancement of
patient care and the promotion of patient safety,
then leadership must be considered an integral
dimension of nursing education across the
continuum” (p. 78).
In the baccalaureate document, essential II
states that “knowledge and skills in leadership,
quality improvement, and patient safety are
necessary for the provision of high-quality health
care” (p. 3). In addition, “The baccalaureate
program prepares the graduate to engage in ethical
reasoning and actions to provide leadership in
prompting advocacy, collaboration, and social
justice as a socially responsible citizen”
ETHICAL LEADERSHIP
 the study of ethical issues related to leadership
and the ethics of leadership. It consists of
what is right, wrong, good, evil, virtue, duty,
rights, obligations, justice, fairness in human
relationships with each other and other living
things. It always directs people and
communities toward the common good, i.e.,
towards justice.
Ethical leadership really has two elements.
First, ethical leaders must act and make decisions
ethically, as must ethical people in general.
Secondly, ethical leaders must also lead ethically
– in the ways they treat people in everyday
interaction, in their attitudes, in the ways they
encourage, and in the directions in which they
guide their organizations or institutions or
initiatives.
Ethical leadership is both visible and invisible.
The visible part is in the way the leader works
with and treats others, in his behavior in public, in
his statements and his actions. The invisible
aspects of ethical leadership lie in the leader’s
character, in his decision-making process, in his
mindset, in the set of values and principles on
which he draws, and in his courage to make
ethical decisions in tough situations.
The two top leadership qualities are Integrity
(Being strongly committed to doing what he/she
knows right) and Trustworthiness (worthy of
being trusted; honest, reliable and dependable).
Ethical leaders are ethical all the time, not just
when someone’s looking; and they’re ethical over
time, proving again and again that ethics are an
integral part of the intellectual and philosophical
framework they use to understand and relate to the
world.
Before nurse leaders can adapt and implement
ethical standards, they must understand the
components of ethical decision-making as they
apply to the field. The American Nurses
Association (ANA) and other nursing leadership
organizations outline these basic principles as a
baseline for ethical nursing practice:
 1. Benevolence
Nurses must be committed to helping patients and
seeking out the best possible healthcare outcomes
for them.
2. ▪Nonmaleficence
Nurses must make sure they are not purposely
harming patients in their care. While treatment or
procedure can have negative impacts on patients,
nurses should not cause intentional harm.
3. Fidelity
Nurses should be faithful to their promises and
responsibility to provide high quality and safe
care.
4. Accountability
Nurses must accept personal and professional
consequences for their actions.
5. Veracity
Truthfulness is a cornerstone in nursing and
something patients depend on.
Patients should be able to depend on nurses for the
truth even if the information is distressing.
6. Patient autonomy
Patients are entitled to know about all of their
treatment options and have the right to make
decisions about their healthcare based on their
personal beliefs. Patients have the right to refuse
treatment or medication. If a patient does not have
the capacity to understand the information, the
patient’s healthcare power of attorney should be
consulted.
In addition to understanding components of
ethical decision-making, nurse leaders must be
able to help staff nurses handle the implications
that arise from poor ethical choices. Failure to
address moral distress that results from poor
ethical decision-making can wreak havoc on a
nursing unit, the nursing workflow production
platform Lippincott Solutions said.
“As moral distress on a unit increases, so too does
staff turnover and a loss of job satisfaction,” the
organization said.
A. MORAL DECISION-MAKING
A moral decision is a decision made in a way
so that action or inaction conforms to one’s
morals/ typically, we refer to a moral decision
when the choice made is not the choice that would
be valid per some rationale such as greater
comfort, financial reward or lower sost or
elimination of some problem.
Morals are acquired (learned or self-
developed) rules of behavior categorized into right
or wrong, where the rules typically omit context
and nuance.
1. PRINCIPLE OF MORAL DISCERNMENT
Principle of Discernment is rooted in the
understanding that God is ever at work in one’s
life, “inviting, directing, guiding and drawing one
into the fullness of life”. It presupposes an ability
to reflect on the ordinary events of one’s life, a
habit of personal prayer, self-knowledge,
knowledge of one’s deepest desires and openness
to God’s direction and guidance. It is a prayerful
‘pondering or mulling over’ the choices a person
wishes to consider. It is a process that should
move inexorably toward a decision. It is both to
understand and to decide.
Discernment refer to the ability to discern the
moral good, discern a moral right from wrong,
and must have the standard with measure or
compare the good thing and bad thing. Moral
discernment defines the moral convictions that
determine one’s behavior and ultimately one’s
life. The person with moral integrity can lives
with consistent of convictions or believes of
themselves. Carter (1996) defined the people that
have moral integrity that consistent to hold the
moral principle, conviction. Olson (2002) defined
moral discernment refer to the ability to discern
what is morally right from morally wrong that
requires moral reflectiveness on the meaning of
good and bad. It refers to ability to draw
conclusions from the discernment to develop
convictions. Livesey (2012) defined discernment
that including both rule knowledge and reasoning.
Discernment is the ability to obtain sharp
perceptions or to judge well (or the activity of so
doing). In the case of judgment, discernment can
be
psychological or moral in nature. Within As judgement of intellect, it makes declaration of
judgment, discernment involves going past the
mere perception of something and making
nuanced judgments about its properties or
qualities. Considered as a virtue, a discerning
individual is considered to possess wisdom, and
be of good judgement; especially so with regard to
subject matter often overlooked by others. In
Christianity, the word may have several meanings.
It can be used to describe the process of
determining God's desire in a situation or for one's
life or identifying the true nature of a thing, such
as discerning whether a thing is good or evil. In
large part, it describes the interior search for an
answer to the question of one's vocation, namely,
determining whether or not God is calling one to
the married life, single life, consecrated life,
ordained ministry or any other calling.
Discernment of Spirits is a term used in both
Roman Catholic and Charismatic (Evangelist)
Christian theology to indicate judging various
spiritual agents for their moral influence.

2. PRINCIPLE OF WELL-FORMED
CONSCIENCE

 states that to have a good judgement of

conscience, one is obliged to form it diligently
accordance with some reasonable processes so
that one arrives at a right moral decision. -
indicates that people are obligated to inform
themselves about ethical norms, incorporate
that knowledge into their daily lives, act
according to that knowledge, and take
responsibility for those actions.
 the moral precepts as objective norms of
morality can be compared to signposts and
markers on the road which indicate the
direction the traveler must take in order to
reach his goal.
 Conscience are guides on our
journey in our lives.
 Directs us to the right path to our
goals.
CONSCIENCE

 subjective norm of morality

 maybe erratic and prone to miscalculations
 based on human intellect which is imperfect,
therefore prone to errors.
 truth and untruth
 goodness and badness
 actions he wants to pursue
 Thoughts he wants to
believe. May be affected by:
 family
 environment
 School,
 church
 individual’s own biases
 narrowness of experience or outlook
 moral obligations

3. STRATEGIES OF MORAL DECISION-

MAKING PROCESS
a. Recognizing Personal Circumstances -
Thinking about origins of problem, individuals
involved, and relevant principles, goals &
values; considering one’s own role in causing
and/or resoling the problem.

b. Anticipating Consequences of Actions -

Thinking about many possible outcomes such as
consequences for others, short & long term
outcomes based upon possible decision
alternatives.
c. Considering the Effects of Actions on Others
- Being mindful of others’ perceptions, concerns,
and the impact of your actions on others, socially
and professionally.
d. Seeking outside Help - Talking with a
supervisor, peer, or institutional resource, or
learning from others’ behaviors in similar
situations

e. Questioning your own and Others’ Judgment

- Considering problems that people often have
with making ethical decisions, remembering that
decisions are seldom perfect.
f. Dealing with E motions - Assessing and
regulating emotional reactions to the situation.
g. Analyzing Personal Motivations -
Considering one’s own biases, effects of one’s
values and goals, how to explain/justify one’s
actions to others, & questioning ability to make
ethical decisions.
B. MEANING AND SERVICE VALUE OF
MEDICAL CARE
VALUE-BASED HEALTH CARE - also known
as VALUE-BASED CARE - a payment model
that rewards healthcare providers for providing
quality care to patients. Under this approach,
providers seek to achieve the triple aim of
providing better care for patients and better health
for populations at a lower cost.
Focuses on care coordination that ensures
patients are given the right care by the right
provider at the right time. Thus, in a value-based
healthcare model, physicians may collaborate with
each other on a patient's care, rather than making
decisions separately that can lead to gaps or
overlaps in care.
Examples of value-based healthcare models
 Hospital Value-Based Purchasing
Program, which rewards acute care
hospitals with incentive payments
for the quality of care they provide
to Medicare patients. This program
is designed to improve the patient
experience during hospital stays.
 Hospital Readmission Reduction
Program, which lowers payments
to Inpatient Prospective Payment
System hospitals that have too
many readmissions. This program
incentivizes hospitals to improve
their communication, care
coordination and how they work
with patients and caregivers on
post-discharge planning.
 Value Modifier Program or
Physician Value-Based Modifier,
which measures the quality and
cost of care for Medicare patients.
This program determines the
amount of Medicare payments
physicians will receive based on
their performance on certain cost
and quality measures.
 Hospital Acquired Conditions
Program, which encourages
hospitals to reduce the number of
infections or illnesses that patients
receive while admitted. This
program reduces payments for
hospitals that rank the worst for
how often patients get hospital
acquired conditions.
Benefits of Value-Based Healthcare Delivery
1. Patients spend less money to achieve better
health
Managing a chronic disease or condition like
cancer, diabetes, high blood pressure, COPD, or
obesity can be costly and time-consuming for
patients. Value-based care models focus on
helping patients recover from illnesses and
injuries more quickly and avoid chronic disease in
the first place. As a result, patients face fewer
doctor’s visits, medical tests, and procedures, and
they spend less money on prescription medication
as both near- term and long-term health improve.
2. Providers achieve efficiencies and greater
patient satisfaction
While providers may need to spend more time on
new, prevention-based patient services, they will
spend less time on chronic disease management.
Quality and patient engagement measures increase
when the focus is on value instead of volume. In
addition, providers are not placed at the financial
risk that comes with capitated payment systems.
Even for-profit providers, who can generate
higher value per episode of care, stand to be
rewarded under a value-based care model.
3. Payers control costs and reduce risk
Risk is reduced by spreading it across a larger
patient population. A healthier population with
fewer claims translates into less drain on payers’
premium pools and investments. Value-based
payment also allows payers to increase efficiency
by bundling payments that cover the patient’s full
care cycle, or for chronic conditions, covering
periods of a year or more.
4. Suppliers align prices with patient outcomes
Suppliers benefit from being able to align their
products and services with positive patient
outcomes and reduced cost, an important selling
proposition as national health expenditures on
prescription drugs continue to rise. Many
healthcare industry stakeholders are calling for
manufacturers to tie the prices of drugs to their
actual value to patients, a process that is likely to
become easier with the growth of individualized
therapies.
5. Society becomes healthier while reducing
overall healthcare spending
Less money is spent helping people manage
chronic diseases and costly hospitalizations and
medical emergencies. In a country where
healthcare expenditures account for nearly 18% of
Gross Domestic Product (GDP), value-based care
has the promise to significantly reduce overall
costs spent on healthcare.
ALLOCATION OF HEALTH RESOURCES
Health Care Resources
 defined as all materials, personnel,
facilities, funds, and anything else
that can be used for providing
health care services.
Health care resources have never been
unlimited in any society, regardless of the type of
health care system that was employed. At least for
the foreseeable future, this fact is unlikely to
change, but it is this fact that necessitates some
form of what is normally referred to as the
rationing of health care resources. Health care
resources include not only the availability of in-
patient hospital (and other medical facility) beds,
emergency room beds, surgical units, specialized
surgical units, specialized treatment centers,
diagnostic technology, and more, but also
personnel resources, that is, health care
professionals of every description.
Whenever the availability of health care
resources is exceeded by the demand for health
care resources, the financial costs of such
resources will rise; to the extent that, historically,
there has been a consistent progression of the
demand for such resources exceeding their
availability, the financial costs of health care have
also, consistently, risen.
Because there are many other causal factors
for this financial phenomenon, the rise in the
financial costs of health care has been consistently
exponential, in many countries, since the latter
part of the 20th century. By the nature of the case,
this occurs to a greater extent, and at a more rapid
pace, in any country the politicians and public
policy makers for which decide to employ a health
care system that does not provide universal
coverage.
Within contexts of diverse values, beliefs, and
interests, pediatricians are faced with a variety of
ethical decisions in daily practice. From how to
offer parental advice when beliefs differ (eg, in
vaccine refusal) to who is best equipped to make
decisions for a child, his or her family, and society
(eg, in chronic fatal disease), pediatricians must
use ethical principles to consider the views and
values of all involved parties.
Resolving ethical dilemmas involves
comprehensive reflection and use of the bioethical
principles of autonomy, beneficence,
nonmaleficence, and justice. These commonly
accepted 4 principles provide guidance for
assessing and balancing potential harms and
benefits within medical care.
1. The first principle is that the allocation of
health care resources should improve people’s
health.
2. The second principle is that patients and
members or prospective members of health
care organizations should be informed about
how health care resources are allocated and
the rationale for the allocation
3. The third principle carries the second a step
further; once provided with information,
patients, members, and prospective members
of a health care organization should have the
opportunity to consent to or deny that
organization’s allocation of health care
resources.
4. The fourth principle states that conflicts of
interest should be minimized by individuals
making decisions regarding the allocation of
health care resources.
 ISSUES INVOLVING ACCESS TO CARE
a. Costs and transparency - Implementing
strategies and tactics to address growth of
medical and pharmaceutical costs and impacts
to access and quality of care.
b. Consumer experience - Understanding,
addressing, and assuring that all consumer
interactions and outcomes are easy,
convenient, timely, streamlined, and cohesive
so that health fits naturally into the “life flow”
of every individual’s, family’s and
community’s daily activities.
c. Delivery system transformation
Operationalizing and scaling coordination and
delivery system transformation of medical and
non-medical services via partnerships and
collaborations between healthcare and
community-based organizations to overcome
barriers including social determinants of
health to effect better outcomes.
d. Data and analytics - Leveraging advanced
analytics and new sources of disparate,
nonstandard, unstructured, highly variable
data (history, labs, Rx, sensors, mHealth, IoT,
Socioeconomic, geographic, genomic,
demographic, lifestyle behaviors) to improve
health outcomes, reduce administrative
burdens, and support transition from volume
to value and facilitate individual or provider or
payer effectiveness.
e. Interoperability/consumer data access -
Integrating and improving the exchange of
member, payer, patient, provider data, and
workflows to bring value of aggregated data
and systems (EHR’s, HIE’s, financial, admin,
and clinical data, etc.) on a near real-time and
cost-effective basis to all stakeholders
equitably.
f. Holistic individual health - Identifying,
addressing, and improving the
member/patient’s overall medical,
lifestyle/behavioral, socioeconomic, cultural,
financial, educational, geographic, and
environmental well-being for a frictionless and
connected healthcare experience.
g. Next-generation payment models -
Developing and integrating technical and
operational infrastructure and programs for a
more collaborative and equitable approach to
manage costs, sharing risk and enhanced
quality outcomes in the transition from
volume to value (bundled payment, episodes
of care, shared savings, risk-sharing, etc.).
h. Accessible points of care - Telehealth,
mHealth, wearables, digital devices, retail
clinics, home-based care, micro-hospitals; and
acceptance of these and other initiatives
- moving care closer to home and office.
i. Healthcare policy - Dealing with
repeal/replace/modification of current
healthcare policy, regulations, political
uncertainty/antagonism and lack of a
disciplined regulatory process. Medicare-for-
All, single payer, Medicare/Medicaid buy-in,
block grants, surprise billing, provider
directories, association health plans, and short-
term policies, FHIR standards, and other
mandates.
j. Privacy/security - Staying ahead of
cybersecurity threats on the privacy of
consumer and other healthcare information to
enhance consumer trust in sharing data.
Staying current with changing landscape of
federal and state privacy laws.
 Lesson 9
ETHICAL ISSUES RELATED TO TECHNOLOGY IN THE DELIVERY OF HEALTH CARE
TELEMEDICINE
 the use of medical information and
technology to advance clinical care at a
distance has the potential to transform
patient-centered care. New technology
platforms allow us to communicate with
patients through a variety of means,
including text, e-mail, and mobile-device
applications.
 can integrate remote monitoring and
sensing mechanisms with automated
interactions and reminders to better
engage patients when they are not in a
doctor’s office. The technology can also
facilitate communications between
members of the care team, improving
coordination of care.
TELEHEALTH
 a general term that describes the use of
telecommunication technologies in
support of clinical health care, education,
and public health.
 services include not only traditional video
conferencing but also e-mail, remote
patient monitoring devices, and even
facsimile.
 Telehealth technology allows physicians
and other providers to consult and assist
with data interpretation and patient care
regardless of geographic separation. For
example, a specialty radiologist may read
advanced imaging for a primary care
physician in a remote area.
 pushes the boundaries of informed
consent, justice, and provider
competencies, as well as a number of
professional regulatory domains. To
begin with, telehealth users may have
variable levels of experience and
technical savviness. Therefore, risks
associated with telehealth (e.g.,
miscommunication or incomplete
examination of a patient) may not be
recognized completely by the
novice patient or proxy. As a result,
telehealth challenges “what ‘informed’
[consent] means when new technologies
require education about benefits and
burdens associated with their use”. This is
especially true when users, either provider
or patient, have limited understanding of
the technology itself. Informing patients
and ensuring their understanding about
the scope of telehealth is critical. It is
essential for individuals to understand
both the strengths and limitations of this
technology.
EHEALTH
 refers to the use of information and
communication technologies (ICTs) in
healthcare.
 combine intelligent health record aggregation
and clinical referral coordination.
 provide potential support for disease self-
management, but the value of current
applications is unclear to patients with
multiple chronic conditions (MCCs).
 Key benefits of eHealth technologies may
include:
 save a lot of time,
 give people more information
about their health.
 doctors can safely and easily share
information with colleagues.
 E-health services and concept can be applied
and utilized in the following areas:
 Medical and healthcare
management
 Health education
 Strategic health planning
 Medical education and training
 Patient care and support
 Preventive health services
 Provision of health services
 Knowledge-based services
 Electronic medical record
 Telemedicine communication
  Evidence-based medicine (EBM)
 Epidemiological surveillance
 Geographic information systems
There are many direct or indirect potential
benefits of implementing the concept and services
of e-health. Three possible benefits can be
identified for the application of e-health services:
1. Quantitative benefits
 the perceived and calculated benefits
of the application of e-health such as
financial economic benefits.
2. Qualitative and non-direct benefits
 improving the efficiency and quality of
health services, reducing medical
errors, increasing the speed of
response, speed of access to
information, sharing of access and use
of information.
3. Strategic benefits
 includes data collection and utilization
in research and strategic planning
processes and identification of long-
term needs.
Common types of technology in healthcare
include:
1. common desktop applications, such as:
 email
 word processors
 spreadsheets and
 Internet-based programs
2. medical devices and equipment, such as:
 imaging technologies such as
 Positron Emission Tomography (PET),
 Computerized Tomography (CT),
 digital radiology and
 remote cameras
3. advanced surgical applications such as
 robotic surgery
 monitoring devices such as
 blood sugar and falls monitors
4. automated devices such as
1. bed lifts and sterilization equipment
2. implants, such as
 pacemakers and prosthetic
joints
5. medical system software applications, such as
 Electronic health records
 event notification systems
 practice management software
 digital image repositories and distribution
software and
6. information technology (IT), such as
 electronic reminders
 electronic clinical decision support aids and
 electronic medication ordering systems.
Advantages of Medical Technology
1. Communication Systems in Healthcare
Hospitals
2. Technology Improving Healthcare in Hospitals
3. Electronic Health Records of Patients in
Hospitals
Disadvantages of Medical Technology
1. Increased Cost of the Treatment for the Patients
2. Show the Wrong Result of the Patients
Condition
3. Lack of Information of the Patients
4. Time-Consuming in Recovery
5. Damaging Cells and Organs of the Body of
the Patients
6. Patients Online Treatment Through
Technology
7. Automatic Machine Treatment
DATA PROTECTION AND SECURITY
Security is an issue that we have been familiar
with for years but there are new issues to be dealt
with as a result of developments in technology and
developments in the practice of health care.
1. DATA PRIVACY ACT OF 2012 (RA 10173
SERIES OF 2012)
 a comprehensive and strict privacy legislation
“to protect the fundamental human right of
privacy, of communication while ensuring
free flow of information to promote
innovation and growth”. It protects and
maintains the right of customers to
confidentiality by setting a legal list of rules
for companies to regulate the collection,
handling, and disposal of all personal
information.
 This Act applies to the processing of all types
personal information and to any natural and
juridical person involved in personal
information processing including those
personal information controllers and
processors who, although not found or
established in the Philippines, use equipment
that are located in the Philippines, or those
who maintain an office, branch or agency in
the Philippines.
 The processing of the personal information
shall be allowed, subject to compliance with
the requirements of this Act and other laws
allowing disclosure of information to the
public and adherence to the principles of
transparency, legitimate purpose and
proportionality.
 Personal information refers to any
information whether recorded in a material
form or not, from which the identity of an
individual
 Privileged information refers to any and
all forms of data which under the Rules of
Court and other pertinent laws constitute
privileged communication.
 The processing of sensitive personal
information and privileged information
shall be prohibited unless consent was
given.
 About an individual’s race, ethnic origin,
marital status, age, color, and religious,
philosophical or political affiliations;
 About an individual’s health, education,
genetic or sexual life of a person, or to any
proceeding for any offense committed or
alleged to have been committed by such
person, the disposal of such proceedings,
or the sentence of any court in such
proceedings;
 Issued by government agencies peculiar to
an individual which includes, but not
limited to, social security numbers,
previous or current health records, licenses
or its denials, suspension or revocation,
and tax returns;
 Specifically established by an executive
order or an act of Congress to be kept
classified.
 These personal information must be
safeguarded and protected against any
accidental or unlawful destruction,
alteration, disclosure and other unlawful
processing.
What is Consent?
Consent of the data subject refers to any freely
given, specific, informed indication of will,
whereby the data subject agrees to the collection
and processing of personal information about
and/or relating to him or her.
Consent shall be evidenced by written,
electronic or recorded means. It may also be given
on behalf of the data subject by an agent
specifically authorized by the data subject to do so
(Republic Act. No. 10173, Ch. 1, Sec. 1).
What are the rights of the data subject?
The data subject or the individual sharing
his/her personal information has right to be fully
informed of several factors of the data collecting
process. This list includes, but isn’t limited to:
1. the purpose for use
2. scope and methods for access
3. the recipients or classes of recipients to whom
they are or may be disclosed;
4. the identity and contact details of the personal
information controller
5. the period for which the information will be
stored for
6. access to their rights
What is the penalty?
Violations include improper/unauthorized
processing, handling or disposal of personal
information.
Violators can be penalized by imprisonment
up to six years and a fine of not less than Five
hundred thousand pesos (PHP 500,000) but not
more than Five million pesos (Php5,000,000.00).
What should the management and health care
professionals need to take in compliance with
the Act?
Companies and healthcare professional must
ensure that the methods of their data collection
and
processing regarding health information are
properly handled with confidentiality and the data
subjects must be well-aware of the process,
including a breach of security, should there be
any.
A Data Protection Officer must be appointed
to create privacy knowledge programs and privacy
and data policies to regulate the handling of all
types of information and to regularly review the
quality of data protection.
So what does this mean for Occupational
Safety and Health (OSH) professionals?
 OSH professionals have the right to access
their contracts or working agreement and
know the scope of their work in
occupational health and safety.
 They must understand their confidentiality
and non-disclosure agreement to the
company that they are working.
 All gadgets used in data collection and
processing must be taken care of including
laptops, mobile phones, tablets and
desktop computers. These gadgets should
be password protected and encrypted.
 Ensure that all the health records and
reports are confidential.
 Be careful with paper medical records and
reports. These records must be properly
stored and must be accessed by authorized
staff only.
 Ensure that your clinic computer or
laptops are locked when leaving the clinic
so that trackers and reports would not be
exposed.
 Avoid posting patients or any activities
inside your clinics or treatment rooms to
any form of social media.
 Don’t use your own home laptops for any
personal/sensitive data.
 Only record relevant information in your
health trackers and medical records. Data
held must not be excessive.
 Only use personal data for the purpose for
which it was obtained.
 Limit the recipients and information of
your health reports
 Only access what you need to do your job.
 If in doubt ask for advice (if you can, use a
data protection officer or a lawyer).
B. BENEFITS OF TECHNOLOGY IN
HEALTHCARE
 Reducing healthcare costs
 Predicting epidemics
 Avoiding preventable deaths
 Improving quality of life
 Reducing healthcare waste
 Improving efficiency and quality of care
 Developing new drugs and treatments
CHALLENGES OF TECHNOLOGY IN
HEALTHCARE
While the arguments for introducing new
technologies to improve patient safety are
becoming increasingly compelling, there are a
number of obstacles and challenges to introducing
new technologies, particularly in the case of new
IT applications and systems.
1. Access to budget and capital resources to
introduce major initiatives.
2. Resistance from clinical staff to new
technologies.
3. Lack of fit with workflow.
4. Lack of safety evidence.
5. Lack of IT staff resources.
6. High turnover rate.
7. Resistance from facility’s executive and
organizational leadership.
Key Challenges for eHealth
1. Lack of adequate awareness of the value of
medical informatics and e-health in the
development of health services.
2. The absence of a clear vision among the health
institutions designated to provide health care
services.
3. Lack of interest in developing the basic
strategic plans appropriate to the situation of
the medical institution. Some strategic plans
are not applicable because they are not
appropriate and do not take into account the
needs and qualifications of available
resources.
4. Inability to bear the costs of developing the future will never be a
infrastructure and the application of e-health
services.
5. Lack of experience and lack of good and
qualified human capabilities in the field of
medical information.
6. Weak infrastructure, including the
rehabilitation of human cadres medical and
non-medical to deal with the concept of e-
health and the provision of services.
7. Absence or weakness of laws and legislations,
regarding the provision of e-health services.
8. Marginalizing the role of the private sector
and private medical institutions.
9. Poor level of cooperation and linkage between
different health sectors.
To overcome e-health challenges, apply the
following tips and techniques:

 Develop a clear vision for the Ministry

through a strategic plan based on data and
inclusive of all current and future needs and
take into account all local conditions and
factors.
 Focus on building qualified cadres and
rehabilitation of existing cadres to deal with
the concept of e-health and the provision of
services.
 Emphasis on the concept of electronic health
file.
 Provide full cooperation between all health
sectors and health care providers.
 Set up the standards, laws, and legislation
related to e-health and ethics of the profession
with emphasis on confidentiality and
preservation of patient information.
 Spread information awareness among all
sections of society, especially with regard to
medical informatics.
CURRENT TECHNOLOGY: ISSUES AND
DILEMMA
More and more the tendency is towards the
use of mechanical aids to diagnosis; nevertheless,
the five senses of the doctor do still, and must
always, play the preponderating part in the
examination of the sick patient. Careful
observation can never be replaced by the tests of
the laboratory. The good physician now or in the
diagnostic robot. (The surgeon Sir William ethical criteria, has emerged to orient
Arbuthnot Lane writing in the November 1936
issue of New Health) Human values should
govern research and practice in the health
professions. Health care informatics, like other
health professions, encompasses issues of
appropriate and inappropriate behavior, of
honorable and disreputable actions, and of right
and wrong. Students and practitioners of the
health sciences, including informatics, share an
important obligation to explore the moral
underpinnings and ethical challenges related to
their research and practice. Although ethical
questions in medicine, nursing, human subjects
research, psychology, social work, and affiliated
fields continue to evolve, the key issues are
generally well 379 380
K. W. Goodman and R. A. Miller known. Major
questions in bioethics have been addressed in
numerous professional, scholarly, and
educational contexts. Ethical matters in health
informatics are, in general, less familiar, even
though certain of them have received attention
for decades. Indeed, informatics now constitutes
a source of some of the most important and
interesting ethical debates in all the health
professions. People often assume that the
confidentiality of electronically stored patient
information is the primary source of ethical
attention in informatics. Although
confidentiality and privacy are indeed of vital
importance and significant concern, the field is
rich with other ethical issues, including the
appropriate selection and use of informatics
tools in clinical settings; the determination of
who should use such tools; the role of system
evaluation; the obligations of system
developers, maintainers, and vendors; and the
use of computers to track clinical outcomes to
guide future practice. In addition, informatics
engenders many important legal and regulatory
questions. To consider ethical issues in health
care informatics is to explore a significant
intersection among several professions—health
care delivery and administration, applied
computing, and ethics— each of which is a vast
field of inquiry. Fortunately, growing interest in
bioethics and computer-related ethics has
produced a starting point for such exploration.
An initial ensemble of guiding principles, or
decision making in health care informatics. These and assuring accurate information is in the medical
criteria are of practical utility to health informatics.
Insufficient clinical information transfer to the
opposite side, broken communication between
doctor and patient, inaccurate and unclear
reporting, security of personal health information
maintained in electronic form, the reliability and
risk of housing, How much the responsibility of
the physician during the consultation with the
patient will be, What will happen in the event of
consultant physician disagree with the patient's
physician, How to be and how to inform the
patient informed consent (Gülhan, Y., 2006,
p.138), the decrease in the control might be
caused a defect in informing patients, using
growing technology plays difficulties in
autonomy, in own specific cases these
technological developments might reasoning
errors, decreases the concept of trust between
doctor and patient (Do an, H., 2006, p.103),
During surgery applications who belong to the
legal responsibility (Gülhan, Y., 2006, p.138).
The unique relationship between doctors and
patients requires trust built by the ethical care of
patients and family. Technology in health care can
continue to move fast and break things, including
breaking the trust between patients, family, and
staff. A moral and ethical issue because it not only
affects quality of care, but it may even impact
patient safety. One of the tools for protecting the
doctor-patient relationship and the reputation of
the health care industry is the hospital clinical
ethics committee. Ethics committee members
work with patients, families, and hospital staff to
find ethical solutions to complex medical cases.
Most ethics cases deal with clinical questions but
don’t address largescale concerns about the effects
of technology on medical care and the hospital
culture.

There are a variety of ethical and legal issues

that arise with the growing use of health
information technology in clinical settings. While
privacy and confidentiality of information is an
important consideration in any electronic system,
some of the issues related to using these systems
to improve patient safety include changes to the
standard of care in regard to using electronic
rather than paper medical records, user training,
record and provided to users. There are other
unique issues involved with the use of clinical
decision support tools, exchange of health
information across institutions, and the
incorporation of genomic information into the
clinical record. Informed consent for exchange
of information as well as for the use of
specialized tools will also be important to
address. Health care information technology is
rapidly improving and momentum is building
for its expanded implementation. Strategies
need to be developed to maximize the benefits
of health information technology while
minimizing the risks of harm associated with its
implementation. The ethical issues raised in this
article need to be addressed if the enormous
potential of these systems to improve patient
safety and quality of care is to be realized.

Ethical issues are important to health

informatics. An initial ensemble of guiding
principles, or ethical criteria, has emerged to
orient decision making:

1. Specially trained humans remain, so far,

best able to provide health care for other
humans. Hence, computer software should
not be allowed to overrule a human
decision.
2. Practitioners who use informatics tools
should be clinically qualified and
adequately trained in using the software
products.
3. The tools themselves should be carefully
evaluated and validated.
4. Health informatics tools and applications
should be evaluated not only in terms of
performance, including efficacy, but also in
terms of their influences on institutions,
institutional cultures, and workplace social
forces.
5. Ethical obligations should extend to system
developers, maintainers, and supervisors as
well as to clinician users.
6. Education programs and security measures
should be considered essential for protecting
confidentiality and privacy while improving
appropriate access to personal patient
information.
 Lesson 10
CONTINUING EDUCATION PROGRAMS ON ETHICO-MORAL PRACTICE IN NURSING
A. Lobbying / Advocating for Ethical Issues
related to Health Care
Advocating for the health, safety and rights of
patients at the bedside is discussed in Provision 3
of the Code of Ethics. Provisions 9.3 and 9.4
address advocacy outside work in terms of social
justice in nursing and health policy. Those
policies indicate that nurses have a duty to
promote open and honest communication that
advances the agenda for health.
Provision 9.4 reads, in part, “Nurses must
promote open and honest communication that
enables nurses to work in concert, share in
scholarship, and advance a nursing agenda for
health. Global health, as well as the common
good, are ideals that can be realized when all
nurses unite their efforts and energies”. Those
issues can include topics such as climate change,
pesticides in food, decreasing harmful emissions,
preventing violence and building community
immunity through wider coverage of vaccinations.
Advocacy can start small. The ANA encourages
nurses to start within their local communities.
Advocacy means a coordinated combination of
problem identification, solution creation, strategy
development and actions taken to make
positive change.
 the act or process of supporting a cause or
proposal.
 ex. To advocate is to bring up and publicize an
issue within a community, like making health
care a part of the national discussion and a
focus in the media.
Nurses advocate for their patients,
coworkers, employees and themselves. It’s
common to encounter nurse advocacy throughout
the workplace, like appealing for improvements
that increase the quality of care or advocating for
the adoption of technology to better serve patients.
Nurse leaders and nurse executives have an
essential duty to advocate for their nurses and
patients, conveying concerns or communicating
staffing needs. Nurses may also champion causes,
like awareness campaigns for diseases or health
issues relevant to their specialty. Advocacy can
also occur outside the organization, like speaking
on behalf of patients’ rights as consumers in light
of overall industry trends. Nurse advocates
have many platforms from which to speak. Not
only can they advocate to decision-makers in
their organizations; they can also utilize forums
like social media or professional conferences to
publicize issues and gain support.
Lobbying is defined as “to promote
(something, such as a project) or secure the
passage of (legislation) by influencing
public officials.
 To lobby is to direct that effort at those in
positions of power, namely public officials,
politicians, governmental bodies and
regulatory agencies. For example, when the
Affordable Care Act was being crafted, nurses
and professional associations were key voices
in ensuring nurses had input on provisions and
were involved in the process of creating the
final legislation.
 The means to the end of effecting that desired
change.
Nurse lobbyists can be differentiated
through their express intent to drive those
conversations toward a clear objective:
influencing public policy or the creation of
legislation. Nurse lobbyists are active across local,
state and federal levels, and may work for all
kinds of organizations in health care, or interested
in it. For instance, nurse lobbyists may be
employed by:
• Health care organizations, including hospital
systems and independent practices
• Pharmaceutical companies and insurance
groups
• Professional associations like the American
Nurses Association or the American
College of Nurse-Midwives
• Groups that focus on advancing public health
or patient rights
• Health care technology firms developing
telehealth solutions or implantable devices
• Governmental bodies like the Department of
Veterans Affairs or nurse unions
 professional behavior.

Professional nurse lobbyists are the

conduit for advocacy campaigns to reach those in
positions of power. The nurse lobbyist is the
person who can directly lay out concerns or
opportunities and work with the politician’s office
to ensure those sentiments are addressed in
legislation. Interprofessional communication is
key, such as that between nurse lobbyists and
politicians, or between nurse leaders and other
patient-safety stakeholders.
Advocates and lobbyists must collaborate
and work on shared missions.
B. Code of Ethics for Nurses
History of ANA (AMERICAN NURSES
ASSOCIATION)’s Code of Ethics
The need for ethical guidance for
healthcare providers was one factor that led to
ANA being created in the late 1880s. The first
version of the code was adopted in 1950, and the
most recent update was published in 2015. The
code is continually updated to address
changes in
the art, science, and practice of nursing and as
awareness grows of the link between global
health and social, political, and cultural equality.
Definition
- a formal statement of group’s ideals and
values.
- a set of ethical principles that reflects the
group’s moral judgements over time and
serves as a standard for their professional
actions.
- - serves as a guide for nurses to practice with
competence and integrity. People’s own set of
ethics and morals influence their actions and
decision-making, as well as how they perceive
the consequences of those actions. In
healthcare, ethics allow nurses and other
professionals to identify moral dilemmas and
apply good judgment to their decisions.
Functions
• To inform the public about the minimum
standards of the profession and to help them
understand professional nursing conduct.
• To provide a sign of the profession’s
commitment to the public it serves.
• To provide general guidelines for the
• To remind nurses of the special
responsibility they assume when caring for
the sick.
The code’s NINE PROVISIONS guide
nurses to act ethically in their daily duties and
responsibilities. The provisions are based on the
four main principles of nursing ethics—
nonmaleficence, beneficence, autonomy, and
justice.
The Principles of the Code
The nine provisions of the American
Nurses Association’s Code of Ethics can guide
nurses to deliver care in a manner by integrity
and moral principles. These provisions are
commonly divided into three distinct parts:

Overview of the ANA Code of Ethics

ANA describes the nursing code of ethics
as “non-negotiable in any setting.” The code
serves as the foundation for “nursing theory,
practice, and
praxis” in expressing the “values, virtues, and
obligations that shape, guide, and inform nursing
as a profession.”
1. Compassion
Nurses recognize the dignity, worth, and
uniqueness of all people. They understand that
the right to healthcare applies to everyone, and
they respect at all times their patients, co-
workers, and everyone else they interact with.
2. Commitment
Nurses’ primary commitment is to their
patients. They have a duty to recognize and
address potential conflicts of interest that may
jeopardize their commitment to their patients. This
commitment extends to individuals, families,
groups, and communities.
3. Advocacy
Nurses promote and protect patients’ rights,
health, and safety by understanding privacy
guidelines, consent, and the need for full
disclosure and honesty when dealing with
patients.
Misconduct or other threats to patients’ well-being
must be reported in a timely manner.
4. Responsibility
Nurses are accountable for the care they
provide their patients. They must ensure that their
care aligns with professional guidelines, ethical
concerns, and patients’ rights.
5. Self-Regard
Nurses must apply the same care standards
their patients receive to self-care. Their
responsibility to promote health and safety
extends beyond the workplace to their homes and
other settings. They have a duty to
improve and adapt to maintain competence and
grow in their profession.
6. Safety
Nurses have a duty to maintain a safe work
environment that promotes quality care to all
patients. Institutions are responsible for outlining
safety standards and enforcing ethical obligations
of care to ensure optimal patient outcomes.
7. Healthcare Advancement
In all the roles they play, nurses are charged
with advancing the profession through research,
development of professional standards, and
creation of nursing and health policy. They must
ensure that professional practice standards evolve
as new healthcare approaches are developed.
8. Human Rights
In collaboration with other healthcare
professionals, nurses protect human rights, foster
health diplomacy, and address healthcare
inequities. As part of this process, nurses are
obliged to commit to constant learning and
preparation to respond appropriately to novel and
unusual situations.
9. Social Justice
Social justice principles must be integrated
into a nurse’s practice and advocacy for equitable
healthcare policies. By taking part in
organizations and committees that acknowledge
and address ethics issues, nurses strengthen their
voices in calling for social justice.
A Nurse’s Core Values and Commitments
ANA describes the nursing code of ethics as
“self-reflective, enduring, and distinctive.”
• It restates the nursing profession’s
fundamental values and commitments.
• It identifies the boundaries of duties and
loyalty.
• It explains how nurses’ roles extend beyond
individual patient interactions.
 It addresses the many relationships nurses
have with other healthcare professionals,
patients’ families, and the public.
 It makes nurses more aware of the
sociopolitical, economic, and environmental
context of their profession.
INTERNATIONAL CODE OF ETHICS
 first adopted by the International Council of
Nurses (ICN) in 1953. It has been revised and
reaffirmed at various times since, most
recently with this review and revision
completed in 2012.
 a guide for action based on social values and
needs. It will have meaning only as a living
document if applied to the realities of nursing
and health care in a changing society.
PREAMBLE
1. Nurses have four fundamental responsibilities:
to promote health, to prevent illness, to
restore health and to alleviate suffering. The
need for nursing is universal.
2. Inherent in nursing is a respect for human
rights, including cultural rights, the right to
life and choice, to dignity and to be treated
with respect. Nursing care is respectful of
and unrestricted by considerations of age,
color, creed, culture, disability or illness,
gender, sexual orientation, nationality,
politics, race or social status.
3. Nurses render health services to the individual,
the family and the community and coordinate
their services with those of related groups.
Four Basic Ethical Principles:
1. Fundamental responsibility of the nurse is four
fold.
2. Nurse renders service regardless of race,
creed, nationality or political belief.
3. Nurse protects life and respects the dignity of
man.
4. Nurse works in collaboration with members of
the health team.
ELEMENTS OF THE CODE
1. Registered Nurses and People
• The nurse’s primary professional
responsibility is to people requiring nursing
care.
• In providing care, the nurse promotes an
environment in which the human rights,
values, customs and spiritual beliefs of the
individual, family and community are
respected.
• The nurse ensures that the individual receives
accurate, sufficient and timely information in
a culturally appropriate manner on which to
base consent for care and related treatment.
• The nurse holds in confidence personal
information and uses judgement in sharing this
information.
• The nurse shares with society the
responsibility for initiating and supporting
action to meet the health and social needs of
the public, in particular those of vulnerable
populations.
• The nurse advocates for equity and social
justice in resource allocation, access to health
care and other social and economic services.
• The nurse demonstrates professional values
such as respectfulness, responsiveness,
compassion, trustworthiness and integrity.
2. Registered Nurses and Practice
• The nurse carries personal responsibility and
accountability for nursing practice, and for
maintaining competence by continual learning.
• The nurse maintains a standard of personal
health such that the ability to provide care is
not compromised.
• The nurse uses judgement regarding
individual competence when accepting and
delegating responsibility.
• The nurse at all times maintains standards of
personal conduct which reflect well on the
profession and enhance its image and public
confidence.
• The nurse, in providing care, ensures that use
of technology and scientific advances are
compatible with the safety, dignity and rights
of people. The nurse strives to foster and
maintain a practice culture promoting ethical
behavior and open dialogue.
3. Registered Nurses and Co-workers
• The nurse sustains a collaborative and
respectful relationship with co-workers in
nursing and other fields.
• The nurse takes appropriate action to
safeguard individuals, families and
communities when their health is endangered
by a co-worker or any other person.
• The nurse takes appropriate action to support
and guide co-workers to advance ethical
conduct.
4. Registered Nurses, Society, and
Environment
• The preservation of life, respect for human
rights, and promotion of healthy environment
shall be a commitment of a RN.
• The establishment of linkages with the public
in promoting local, national, and international
 efforts to meet health and social needs of the
people as a contributing member of society is
a noble concern of a RN
5. Registered Nurses and the Profession
• The nurse assumes the major role in
determining and implementing acceptable
standards of clinical nursing practice,
management, research and education.
• The nurse is active in developing a core of
research-based professional knowledge that
supports evidence-based practice.
• The nurse is active in developing and
sustaining a core of professional values.
• The nurse, acting through the professional
organization, participates in creating a positive
practice environment and maintaining safe,
equitable social and economic working
conditions in nursing.
• The nurse practices to sustain and protect the
natural environment and is aware of its
consequences on health.
• The nurse contributes to an ethical
organizational environment and challenges
unethical practices and settings.
CODE OF ETHICS FOR FILIPINO NURSES
 used by Filipino nurses prior to 1984, was
the code promulgated by the International
Council for Nurses. In 1982, the PNA
Special Committee developed a Code of
Ethics for Filipino Nurses, but was not
implemented. It was approved in 1989, by
the Professional Regulation Commission
and was recommended for use. This was
approved In October 25, 1990 by the
general assembly of the PNA .
 strongly emphasizes the fourfold
responsibility of the nurse, the universality
of nursing practice, the scope of their
responsibilities to the people they serve, to
their co-workers, to society and
environment, and to their profession.
CODE OF GOOD GOVERNANCE
 sets out the principles and key elements of
good governance for the boards of
voluntary and community organizations.
 adopted by the Professional Regulation
Commission on July 23, 2003 and the 42
Professional Regulatory Boards to cover
an environment of good governance in
which all Filipino professionals shall
perform their duties.
 After consultation on October 23, 2003 at
Iloilo City with the accredited professional
organization of registered nurses, the code
was adopted under the Republic Act 9173
and promulgated by the Board of Nursing
under Resolution No. 220 Series of 2004
last July 14, 2004.
States that:
 The hallmark of all professionals is their
willingness to accept a set of professional
and ethical principles which they follow in
the conduct of their daily lives.
 The acceptance of these principles requires
the maintenance of a standard of conduct
higher than what is required by law.
General Principles of Good Governance:
1. Service to others
o implies commitment to a life of
sacrifice and genuine selflessness.
2. Integrity and Objectivity
o refraining from engaging in any
activities that would prejudice their
abilities to ethically carry out their
duties nor make any representations
that would likely cause a reasonable
person to misunderstand and be
deceived.
3. Professional Competence
o keeping up with new knowledge and
techniques in their field and upgrade
their level of competence, taking part
in a lifelong continuing education
program.
4. Solidarity and Teamwork
o each professional shall maintain and
support one professional organization.
5. Social and Civic Responsibility
o carrying out one’s professional duties
with due consideration of the broader
interest of the public and serve them
with professional concern.
6. Global Competitiveness
o shall remain open to the challenges of
a more dynamic and interconnected
world, rise up to global standards and
maintain professional practices fully
assigned with global best practices.
7. Equality of all professions
o treating colleagues with respect and
striving to be fair in dealings with one
another.
Preamble
1. Health is a fundamental right. The Filipino
RN, believing in the worth and dignity of
each human being, recognizes
the primary responsibility to preserve
health at all cost. This responsibility
encompasses promotion of health,
prevention of illness, alleviation of suffering,
and restoration of health. However, when the
foregoing are not possible, assistance towards
a peaceful death shall be his/her obligation.
2. To assume this responsibility, RNs have to
gain knowledge and understanding of man’s
cultural, social, spiritual, psychological, and
ecological aspects of illness, utilizing the
therapeutic process. Cultural diversity and
political and socio-economic status are
inherent factors to effective nursing care.
3. The desire for the respect and confidence of
clientele, colleagues, coworkers, and the
members of the community provides the
incentive to attain and maintain the highest
possible degree of ethical conduct.
The Code of Ethics for Filipino Nurses
embodies ethical principles and guidelines to
be observed.
The ethical principles are stated below.
1. Responsibilities of Nurses to their Clients
 Primary responsibility: give the client
the kind of care his/her condition needs
regardless of his/her race, creed, color,
nationality or status.
 Ethical Principles:
▪ Values, customs and spiritual
beliefs shall be respected.
▪ Individual freedom to make
decisions.
▪ Personal information acquired must
be held in confidence.
 Guidelines to be Observed:
▪ Individuality and totality of patients
▪ Respect
▪ Uphold the rights of the individuals
▪ Take into consideration culture and
values in the event of conflict,
welfare and safety take precedence.
 Nurses should not accept tips or expensive
gifts that may induce them to give more
care to favored clients and neglect those
who cannot give.
 The nurse can plan with the client and
family a specific nursing care of the client
according to his needs or the needs of his
family.
 A nurse is expected to be more
compassionate to the client than the
doctor.
 Responsible to give facts or information to
the client and his family which they are
entitled to know.
 Should guard as a sacred trust, any
confidential or private information about
the client. The privacy of communication
and correspondence shall be inviolable
except upon lawful order of the court or
when the public safety and order require
otherwise.
▪ TARASOFF CASE: Prosinjit
Podder, an Indian graduate student
studying at Berkeley, begins to date
Tatiana Tarasoff. They kiss. He
feels that she is his. He gets upset
when she expresses interest in
other men. He goes to counseling at
the University Health Service. He
tells the psychologist Dr. Moore,
that he wants to get a gun and shoot
Tarasoff. Dr. Moore sends letter to
campus police, they investigate
Podder, they think he is not a
danger, tell him to avoid Tatiana.
When Tatiana returns from Brazil
at
 the end of summer, Podder stalks
and stabbed her to death.
Responsibilities of Nurses to their Practice
 Ethical Principles:
▪ Human life is inviolable.
▪ Quality and excellence in the care of
patients.
▪ Accurate documentation – nursing
accountability
▪ Optimum standard of safe nursing
practice
▪ Be morally and legally responsible.
▪ Patient’s record is considered to be
confidential.
 Guidelines to be Observed:
▪ Know the definition and scope of
nursing practice.
▪ Be aware of duties and responsibilities.
▪ Acquire and develop competence in
knowledge, skills and attitude.
Responsibilities of Nurses to other Colleagues
 Ethical Principles:
▪ Work in solidarity with other members
of the healthcare team.
▪ Maintains collegial and collaborative
working relationships.
 Guidelines to be Observed:
▪ Maintain professional identity.
▪ Conform with group activities.
▪ Contribute to professional growth.
▪ Actively participate in professional
organizations.
▪ Respect rights of co-workers.
 Nurses shall adjust themselves to the
organization and know its policies and
procedures.
 They shall establish good working
relationships with co-workers.
 If one has grievance, this should be brought to
the attention of the proper authority rather than
talk about it with others who may not be able
to help.
Responsibilities of Nurses to Society and
Environment
 Ethical Principles:
▪ Preservation of life, respect for human
rights and promotion of a healthy
environment.
▪ Establishment of linkages.
 Guidelines to be Observed:
▪ Be conscious of obligations as citizens.
▪ Equipped with knowledge of health
resources within the community.
▪ Actively participate in programs,
projects and activities.
▪ Right conduct and proper decorum.
▪ Project image that will uplift nursing
profession.
Responsibilities of Nurses to the Profession
 Ethical Principles:
▪ Maintain loyalty.
▪ Compliance with by laws of accredited
professional organizations.
▪ Commitment to continual learning.
▪ Contribute to the improvement of the
socio-economic conditions and welfare
of nurses.
 Guidelines to be Observed:
▪ Be members of Accredited
Professional Organizations – PNA
▪ Strictly adhere to nursing standards.
▪ Strive to secure equitable working
conditions through appropriate
legislation and other means.
▪ Assert for the implementation of labor
and work standards.
Responsibilities of Nurses to themselves
 A nurse should be zealous in her professional
growth by keeping abreast with the latest
trends in nursing science.
 A nurse must not perform any act or
transaction that may discredit himself or
herself or the profession and to bring to the
attention of proper authorities an unethical
conduct of any registered nurse.