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Republic of the Philippines

TARLACSTATEUNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Binauganan, Tarlac City Philippines
Tel.no.: 4931865 Fax: (045) 982-0110 website: www.tsu.edu.ph
Accredited Level 3 status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines, Inc. (AACCUP)

NCM 108- HEALTHCARE ETHICS

Theories and Principles of Health Ethics:

Principle of Stewardship and the Role of Nurses as Stewards
Principle of Totality and its Integrity

OTHER RELEVANT ETHICAL PRINCIPLES

Bioethics represents a particular branch of ethics within the field of health care. Bioethics narrows
ethical enquiry of moral thought of those who work as professionals in clinical practice, basic research,
or any professional education institutions. It affects all the health professionals who seek knowledge to
improve their skills; at times, they are trapped in legal and ethical issues and their minds are in an
ethical dilemma regarding taking any decisions concerning the ethical issues involved in the bioethics.
Therefore, it is important for a nurse to learn and practice bioethical issues and management.

Principles of Bioethics

Murphy and Murphy (1976) Approach to Ethical Problem Solving

1. Identify the problem.

2. Identify why the problem is an ethical problem.
3. Identify the people involved in the ultimate decision.
4. Identify the role of the decision maker.
5. Consider the short- and long-term consequences of each alternative.
6. Make the decision.
7. Compare the decision with the decision maker’s philosophy of ethics.
8. Follow up on the results of the decision to establish a baseline for future decision making.

A. Principle of Stewardship

● Stewardship requires us to appreciate the two great gifts that a wise and loving God has
given: the earth, with all its natural resources and our own human nature, with its biological,
psychological, social, and spiritual capacities.
● The pr inciple is grounded in the presupposition that God has absolute Dominion over
creation, and that in so far as human beings are made in God9s image and likeness, we have
been given a limited dominion over creation and are responsible for its care.
● Stewardship refers to the expression of one9s responsibility to take care , nurture and
cultivate what has been entrusted to him.
● In healthcare practice, stewardship refers to the execution of responsibility of the health care
practitioners to look after, provide necessary health care services, and promote the health and
life of those entrusted to their care.
● Traditional Definitions of Stewardship
○ The parable of ‘talents’ in the New Testament describes another aspect of stewardship
in which a master divides his worldly goods between his three servants. The moral
portrayed here is that when one is entrusted with something of value, there is an
obligation to improve it.
● State-Oriented Definitions of Stewardship
○ The broad definition of state-oriented stewardship is that the function of government is
that it is responsible for the welfare and interests of the population, especially the trust
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and legitimacy with which its activities are viewed by the general public.

● The Metaphor of a Steward

○ “A steward is characterized as a person who preserves and promotes what is intrinsically
valuable.”
○ In the eleventh century, the English word ‘steward’ developed from the term
stigwaerd, meaning warden of the house.

○ To be a steward is to devote a substantial percentage of one’s thoughts and efforts to

maintain or enhance the conditions of some thing(s), person(s), and not primarily for
one’s sake’. It was suggested that stewards are motivated to act as they develop
character disposition(s), including self-discipline and courage.
● Nurse Leaders as Stewards
○ Stewards, as well as practicing nurses who seek to preserve and promote values at
the point of service, may influence managers in their decision about who ought to
receive what services and how, and thus influence change in health care
organizations.
○ Nurses leaders are ‘engaged to others and work collaboratively to establish and
achieve a vision and purpose9 that affects the well-being of a system or
organization rather than promote their self-interest.
○ Leaders are either self-oriented or system-oriented.
■ Self-oriented leaders perceive themselves as the decision makers and
others as implementers
■ System-oriented leaders, who hold as their priority the well-being of the
organization, show respect to all its members. The system -oriented leaders
in healthcare organizations will hold the point of service as their priority and
seek the input of nurses in setting collective value.
■ In short, Oriented to self leaders - reflect the value of individualism while
Oriented to the organization or system leaders - reflect the value of
collectivism.
○ In order for nurses to influence decision making at the point of service, there is a
need to invigorate nursing leadership. Nurses are urged to establish moral
communities where ‘ethical values are made explicit and shared, where ethical
values direct action, and where individuals feel safe to be heard’.
○ Nursing practices ought to be grounded in respect for persons’ dignity and self-
determination, as well as equity and fairness.

Role of Nurses as Stewards

Stewards of Self: To meet the concept of lifelong learning, nurse leaders or stewards will need to use
mentors and personal coaches to assist them in refining skills and improving competencies. Health
nurse leader stewards will thus become visible and sound role models within their institutions to
maintain the balance between self and professional fulfilment.

● Personal
○ According to a Communitarian theorist, MacIntyre states that a person is a narrative
self who seeks purpose, or good for the self, through interpretations of everyday
experiences. Together with these experiences are virtues that are central because
they affect perceptual judgments about what is relevant in an experience. A virtue is
defined as ‘a quality which enables an individual to move towards the achievement of
a specific human goal’.
○ Character or identity is cultivated as virtues are habitually exercised.
○ In cultivating a character, a person acts without knowing the exact outcome of his or
her actions; rather, he or she acts in the belief that the action will be worthwhile.
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○ A nurse who exercises stewardship at the point of service in accordance with

MacIntyre9s theory of virtue ethics will facilitate nurses9 justification of their shared
value priorities within professional setting as the American Nurses Association code of
ethics. Thus, stewards and nurses may preserve and promote what is intrinsically
valuable in nursing practice.
○ The potential for improving and enhancing policy outcomes is the predominant
positive potential of stewardship.
● Social
○ Healthcare has long been part of our lives and access to healthcare has become a
basic human right - but for some countries, it is a privilege. Receiving healthcare is
important because without it, people will be put at risk of infections and diseases.
○ Nurses play a central role in delivering healthcare. They advocate for health
promotion, educate the public about disease prevention, provide holistic care to the
patients, and participate in rehabilitation.
○ The n u r s e s also help the people and their families understand the
different experiences they encounter in dealing with their health and illnesses, like
how to cope, deal, and if necessary, live with it. In the hospital, nurses provide
ongoing assessment of people's health.
○ Nurses do more than care for individuals. They are not merely caregivers but they
also have other roles and functions, such as being a client advocate, a counselor,
and an educator among others.
● Ecological
○ Nurses have many roles, and this includes waste management since the healthcare
sector generates a lot of waste contributing to environmental issues, such as air and
water pollution which may cause problems if not properly managed.
○ Poor medical waste management unquestionably exposes healthcare workers,
waste handlers, and the community to infections, toxic effects, and injuries.
○ Nurses have the ability to use their trusted skill sets and lead the way for
sustainable, healthy communities and environments in which they serve.
■ By unifying and engaging staff through shared governance models,
nurses can reduce the overhead costs associated with waste
management.
■ Being aware of current healthcare waste disposal methods. Is it doing the job?
Or do we need to make changes to better the system? If ever, nurses should
take action if they can see that there are problems.
■ Nurses comprise the largest profession in health care and are adept at
educating, researching, and leading in waste reduction.
● Biomedical
○ Most crucial role of nurses as stewards because nurses deal with lives. With one
wrong move, it may cause certain problems, or even compromise the patient.
○ For this reason, nurses may be exposed to criminal charges due to improper
treatment.
■ For example, withholding nutrition can constitute nursing neglect
and expose the nurse to criminal charges of negligence or
conspiracy to commit suicide.

B. Principle of Totality and its Integrity

The principle of totality states that all decisions in medical ethics must prioritize the good of the entire
person, including physical, psychological and spiritual factors.

● Background
○ This principle derives from the works of the medieval philosopher St. Thomas
Aquinas, who synthesized the philosophy of Aristotle with the theology of the
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Catholic Church.
○ The principle of totality is used as an ethical guideline by Catholic healthcare
institutions.
● Integrity
○ Refers to each individual's duty to “preserve a view of the whole human person in
which the values of the intellect, will, conscience, and fraternity are pre-eminent.”
● Totality
○ According to the philosopher Thomas Aquinas, all of the organs and other parts of
the body exist for the sake of the whole person.
○ Because the purpose of the part is to serve the whole, any action that damages a part
of the body or prevents it from fulfilling its purpose violates the natural order and is
morally wrong. This is called the “principle of totality.”
○ However, a single part may be sacrificed if the loss is necessary for the good of the
whole person.
■ For example, the principle of totality would justify the amputation of a
gangrenous limb, because the person could die if the gangrene spread.
● Conditions
○ The action must be morally good or neutral in itself.
■ Providing medicine to a sick patient meets this requirement.
○ The bad results cannot be the means for achieving the good results.
■ Negative side effects don't cause the medicine to work more effectively.
○ The motivation for carrying out the action must be solely to achieve the good results.
■ Doctors prescribe medicine to help their patients, not to expose them to side effects.
○ The good result must be at least as significant as the bad.
■ Prescribing medication with side-effects is acceptable if the health benefits to the
patient will be at least as significant as the harm from the side-effects.

Ethico-moral Responsibility of Nurses in Surgery

Supporting Patient Rights and Choices
○ Nurses are obligated to morally respect the dignity and worth of individual patients
wherein nursing care must be provided in a manner that preserves and protects
patient autonomy and human rights
○ The nurse, as a moral agent for the patient, must be ready and able to advocate for
the patient's rights and needs whenever necessary while providing care. Assuming
such a stance involves acting on ethical principles and values
Respect for Others
○ Not only must nurses recognize the individuality of their patients, they also must
recognize the individuality of their colleagues and others.
○ Nurses must be able to interact with a variety of other professionals and ancillary
providers in the perioperative environment
○ The nurse recognizes the contributions of each member of the health care team and
collaborates to achieve quality patient care.
Treating Patients Equally
○ Perioperative nursing care should be provided in a non- prejudicial manner that
preserves and protects patient free will, choice, and human rights.
○ When providing patient care, nurses must take into consideration a patient's
values, religious beliefs, and lifestyle choices
■ Age specific care:
• perioperative nurses must act ethically with regard to age‐specific care and
treatment
■ Changing face of culture
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• nurses provide nursing care directed to meet the comprehensive needs of

all patients, taking into consideration aspects of culture, language,
perception of pain, significant others, values, and beliefs
Recognize Ethical Dilemmas
• Nurses have the responsibility to recognize and identify ethical issues that
affect staff and patients and make the best possible decisions

Sterilization/Mutilation
● Sterilization
○ Sterilization involves both genders and pertains to surgical procedures that leaves
either a male or female unable to reproduce. Sterilization then in other words is the
removal of a procreative member or element of the human in order to prevent
procreation.
■ Indirect (Therapeutic) – required for the survival and health of a person, sexual
organs, integrating parts which must yield to the good of the whole. Licit if:
● Sickness is grave, diagnosed and definitive that offsets the evils of
sterilization.
● Necessary is it is the only possibly effective remedy.
● Exclusively curative. Intention is important.
■ Direct – immediate effect is to render procreation impossible.
○ Types:
■ Eugenic – to avoid transmission of hereditary defects.
■ Hedonistic – to evade the complications and responsibilities of procreation
without giving up the sexual pleasure.
■ Demographic – to control the birth rate.

○ Procedures Involved:
■ Vasectomy (Males) – the cutting and closing of the vasa deferentia which are
tubes that connect the testicles to the prostate. Prevents sperm produced in the
testicles to enter the ejaculated semen.
■ Tubal ligation (Females) – is a procedure that involves severing and tying the
fallopian tubes. This generally involves an anesthetic and a laparotomy or
laparoscopic approach to cut, clip, or cauterize the fallopian tubes which essentially
carry sperm to the ova.
■ Hysterectomy – the surgical removal of the uterus thus permanently preventing
pregnancy and maybe even some diseases such as cancer
■ Castration (male & female) –is any action, surgical, chemical, or otherwise, by
which an individual loses use of the gonads: For males this procedure is called a
Gonadectomy. For females this involves the removal of the ovaries, otherwise
known as Oophorectomy.

The Ethical Issues Surrounding Sterilization:

■ The Catholic Church
− Strongly condemns all artificial methods of contraception - a position also held by most
protestant churches up to 1930 when the Anglican church coted for change.
− Indirect sterilization, resulting from the cure of some pathological condition, has always been
allowed.
− The church disapproves direct sterilization because: it separates unnaturally the dual purpose of
the marital act, contradicts the nature of man and woman and their intimate relationship, and
oversteps the dominion a person has over his or her generative faculties.
− Includes other means of contraception such as birth control pills or condoms and the
aforementioned surgical methods of sterilization.

Sterilization in Relation to the Principle of Totality:

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■ Medical perspective of Totality - all the parts of the human body, as parts, are
meant to exist and function for the good of the whole body, and are thus naturally
subordinated to the good of the whole body.
■ Totality - points to the duty to preserve intact the physical component of that
integrated whole.
■ Sterilization without a medical purpose relevant to the preservation of the
=whole= of an individuals body is then considered as a violation of the
Principle of Totality.
Mutilation
● Mutilation or maiming is an act of physical injury that degrades the appearance or
function of the human body, usually without causing death.
● This term is usually used to describe the victims of accidents, torture, physical
assault, or certain premodern forms of punishment.
● Types:
○ Direct – willed in itself, as end or means, intended and caused intrinsically
wrong. This offends human dignity and the individual does not have the right
mutilate himself, much less does society
○ Indirect (Therapeutic) – mutilation necessary for the survival of the patient or to
free him of proportional sufferings or infirmities.

The Importance of Aristotle's View on the Principle of Totality in Relation to Mutilation:

■ Totum quam parte, prius esse necesse est. – The principle of totality presupposes that "parts
exist for the whole. The good of the part is subordinated to the good of the whole; the whole is
the determining factor for the part and can dispose of its own interest.
■ Aristotle’s explanation on the Part/s
1. A part denotes any portion of a quantum into which it can "be divided, for that which is
taken from a quantum qua quantum" remains always a part of it.
Ex. Two can be named "in a sense a part of three."
There are two types of meaning for it. In the first place, part means "only those which
measure the whole," which includes only two. In another sense a part cannot be
considered as a "part of three."
2. Part can be understood as the constituent element of a dividable kind "apart from
the quantity. Ex. Species are part of the genus

3. Whole, which includes a part, can be divided. Here Aristotle uses the term
'whole' in the sense of "form or that which has form."
Ex. A bronze sphere or bronze cube which is from bronze or it can denote a portion of
material body which gives form to that.

4. The constituent "elements in the definition which explain a thing are also parts
of the whole." Here, too, Aristotle gives the example of genus and species to
substantiate his point. In this understanding "genus is called a part of the
species," in another understanding "the species is part of the genus.
■ Aristotle’s explanation in the Whole
a. That from which is absent none of the parts of which it is said to be naturally a whole,
and
b. That which so contains the things it contains that they form a unity; and this in two senses -
either as being each severally one single thing, or as making up the unity between them."
■ St. Thomas Aquinas’ simplification of Aristotles explanation of the whole:
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a. The perfection of the whole be integrated from the parts of which it is constituted;"
b. That these parts form a unity.
The Principle of Totality and the Justification of Mutilation by Thomas Aquinas
○ St. Thomas Aquinas brings the principle of totality under the topic "injuries to
the person."
Two perspectives: Penal and Medical
a. Medical mutilation
● mutilation is elicit when it is necessary for the good of the entire body
b. Penal Amputation
● involves amputation as punishment for performing wrong acts such as the
penal sentence of amputating a man9s hand for stealing practiced in Iran
● Thomas never justifies mutilation against innocent persons
■ Three basic elements that justify mutilation in the teachings of Thomas
1. Mutilation is justified for the well-being of the whole body.
2. It is not against the role of the human person as the protector of his/her
body. This is done on the basis of a human person's limited power over
his/her body for the betterment of the whole body.
3. Mutilation in the form of a penalty for a crime can be done by the state.

Preservation of Bodily Functional Integrity

● Bodily Integrity:
○ is the inviolability of the physical body and emphasizes the importance of personal
autonomy, self-ownership, and self-determination of human beings over their own
bodies.
○ the only person with the right to make a decision about one’s body is oneself- no one
else.
○ Bodily Integrity pertains to the respect for a certain wholeness.
● Double Meaning
○ Integrum - wholeness, unity, intactness
○ In-tangere - not touching, not hurting.
● Issue of Bodily Integrity
○ Practices that violate a person9s bodily integrity can range from piercing a baby girl9s
ears being exposed to toxic chemicals without one9s knowledge to rape and medical
treatment administered against a patient9s wishes.
○ Children are disproportionately vulnerable to violations of their bodily integrity
because most violations happen at very young age when a person is unable to
speak up for and defend themselves, or give4or refuse4consent.
● Problem of Bodily Integrity
○ Forced treatment as opposed to the right to physical integrity (and the ethical duty
of respect for autonomy)
○ A number of these practices are irreversible and due to their surgical nature carry
inevitable health risks. These range from infection and scarring to disfigurement,
amputation, and even death.
● Solution of Bodily Integrity
○ The right to bodily integrity is pivotal in any health-related context and should not be
lightly disregarded.
○ The decision about one9s body should rest only with the person in question and
be taken by them to give their free, prior and informed consent4or to refuse it.
○ The only exception is when an intervention is medically necessary to save the
person from serious, urgent and irreparable harm.
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Issues on Organ Donation

● WHAT IS ORGAN DONATION?
○ A person may will to dispose of his body and to desire it to ends that are useful,
morally irreproachable, and even noble among them, the desire to aid the sick and
suffering.
○ It is a process of surgically removing an organ or tissue from one person (the donor)
and placing it into another person (the recipient).
● Criteria:
○ Theres a serious need on the part of the recipient that cannot be fulfilled in any
other way.
○ The functional integrity of the donor with a human person will not be impaired even
though anatomical integrity may suffer.
○ The risk taken by the donor as an act of charity is proportionate to the good
resulting to the recipient.
○ The donors consent is free and informed.
○ The recipients for the scarce organs are selected justly.
● Ethical Issues
○ Examining ones values and beliefs
○ Death and the dead donor rule
■ Brain death/Higher brain death
■ Non heart beating death
○ Informed consent
○ Voluntary Consent
○ Donations, Not Sales
Role of the nurse in organ donation and transplant
○ Registered professional nurses are often the primary caregivers for patients
approaching the final stage of life.
○ Facilitates the coping of the patient and their families. Work is anchored on
counseling and facilitating the process for organ or tissue donation by educating and
guiding to the donor families.
○ Stays with the patients and helps the family understand the organ donation
process, which includes keeping the brain-dead patient9s body functioning until the
organ has been collected.
○ As a transplant coordinator:
○ The nurse must have deep knowledge regarding the following aspects:
■ What is organ donation and why it is needed?
■ How does organ donation help patient with organ failure?
■ What body parts can be donated?
■ Who can be potential donors?
■ Document required for the donor and for the recipients.
■ Why become an organ donor and how to get registered?
■ How does the family of the deceased organ donor cope with their loss.
○ Follows the ethics of organ donation.
■ The nurse’s first obligation is the well-being of the patient entrusted to our care.
■ An act procuring organs should never be the cause of a person9s death.
■ The decision to donate the organ is based on the strict medical criteria and law.
■ Nurses understand the good of organ donation itself.
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C. PRINCIPLE OF ORDINARY AND EXTRAORDINARY MEANS

− The principle of ordinary and extraordinary means is a concept in nursing bioethics that
guides healthcare professionals in making decisions about medical treatments and
interventions. It helps determine whether a particular treatment is considered necessary or
optional in a given situation.
Definition
− The principle of ordinary and extraordinary means states that healthcare professionals are
morally obligated to provide ordinary means of care to patients, but they are not obligated
to provide extraordinary means of care. Ordinary means refer to treatments and
interventions that are considered standard and reasonably expected in the given
circumstances. Extraordinary means, on the other hand, refer to treatments and
interventions that are considered excessive, burdensome, or disproportionate to the
expected benefits.
Example in Nursing Bioethics
− An example of the principle of ordinary and extraordinary means in nursing bioethics is the
use of life-sustaining treatments for terminally ill patients. In this scenario, ordinary means
of care may include providing pain management, hydration, and nutrition to ensure the
patient's comfort and dignity. These interventions are considered standard and expected
in the care of terminally ill patients.
− However, if the patient's condition deteriorates to the point where they require invasive
and aggressive interventions, such as mechanical ventilation or cardiopulmonary
resuscitation (CPR), these treatments may be considered extraordinary means. In such
cases, healthcare professionals may have the ethical discretion to withhold or withdraw
these treatments if they are deemed to be excessively burdensome or unlikely to provide
significant benefits to the patient.
− It is important to note that the determination of what constitutes ordinary and extraordinary
means can vary depending on the specific circumstances, cultural values, and individual
patient preferences. Healthcare professionals should engage in ethical discussions and
consult with the patient, their family, and the healthcare team to make informed decisions
that align with the principles of beneficence, autonomy, and non-maleficence.

D. PRINCIPLE OF PERSONALIZED SEXUALITY

− Principle of Personalized Sexuality
Sex is a social necessity for the procreation of children and their education in the
family so as to expand the human community and guarantee its future beyond the death
of individual members. Teaches that God created persons as male and female and
blessed their sexuality as a great and good gift.
− The significant and vital role that principle of personalized sexuality plays in an
individual's desire to be fully human has, to some extent, remained undisclosed,
dubious, and even sinful, primarily due to the culturally patterned negative attitude of
Filipinos towards human sexuality. Many still find an intellectually open and sane
discussion of the principle as a forbidden thing or a mortal sin. Traditional Filipino
sexuality attitudes, in other words, are conservative and strict. It is something
unmentionable or not to be discussed in public and seldom between the young and
their elders.
− The principle of personalized sexuality in nursing ethics recognizes that each individual
has unique sexual preferences, needs, and identities. It emphasizes the importance of
respecting and supporting patients' sexual autonomy, privacy, and dignity. This
principle can be applied in nursing ethics:
1). Informed Consent: Nurses should ensure that patients have the necessary information to
make informed decisions about their sexual health and well-being. This includes
discussing risks, benefits, and alternatives to various sexual practices or
interventions.
2). Non-Discrimination: Nurses should provide care without discrimination based on sexual
orientation, gender identity, or any other aspect of a patient's sexual identity. They
should create a safe and inclusive environment where patients feel comfortable
discussing their sexual concerns.
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3). Confidentiality: Nurses should maintain strict confidentiality regarding patients' sexual
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health information. This includes protecting their privacy and not disclosing any
sensitive information without their explicit consent.
4). Cultural Sensitivity: Nurses should be aware of and respect diverse cultural
beliefs and practices related to sexuality.
− They should provide care that is sensitive to patients' cultural backgrounds and values,
ensuring that their sexual needs and preferences are understood and respected.
5). Advocacy: Nurses should advocate for patients' rights to access appropriate sexual
health services and resources. This may involve addressing barriers to care, promoting
sexual health education, and supporting patients in making informed decisions about
their sexual health.
− By adhering to these principles, nurses can provide patient-centered care that respects
and supports individuals' unique sexual identities and needs. It is a social necessity for
the procreation of children and their education in the family so as to expand the human
community and guarantee its future beyond the death of individual members. Teaches
that God created persons as male and female and blessed their sexuality as a great
and good gift.