Ethical Considerations in

Spiritual Care
Learning Objectives
A. Balancing patients' religious beliefs with medical interventions and ethical
principles
B. Addressing conflicts and ethical dilemmas related to religious and
spiritual beliefs
C. Navigating end-of-life decisions and religious perspectives on death and
dying
D. Respecting patients' autonomy while considering their religious beliefs
 Activity 1 - Shipwreck
Eleven people have jumped into a lifeboat that only fits ten people, and the life-boat is also
starting to sink.

A.) What should the passengers do?

B.) Throw one person overboard and save ten lives or stick to the principle of "do not kill",
which means that everybody will drown?
 Activity 2 - Baby Theresa
Parents who have to decide what to do with their baby, who was born with one of the worst
genetic disorders.

A.) How do we put a value on human life?

B.) What should one do when there is a conflict between the law and one's own moral
position about an issue?
C.)If you were in a position to make the final decision in this case, what would it be and why?
 Ethical Principles
"Rights aren't rights if someone can take them away. They're privileges." - George Carlin, "It's Bad for
Ya," March 1, 2008.

Patient rights are a subset of human rights. Whereas the concept of human rights refers to
minimum standards for the ways persons can expect to be treated by others, the concept of ethics
refers to customary standards for the ways persons should treat others.

As such, rights and ethics are usually flip sides of the same coin, and behind every ‘patient right’ is
one or more ethical principles from which that right is derived.

Ethics is a branch of philosophy that is focused on understanding the moral principles of people and
how they make decisions based on what is considered morally right or wrong (Merriam-Webster,
2014). There are often ethical issues that can arise in the context of end-of-life care, particularly
when patients and families make decisions regarding the care they will accept or not accept.
 Ethical Principles
Establishing clearly defined patient rights helps standardize care across healthcare
fields and enables patients to have uniform expectations during their treatment.

According to the American Cancer Society, organizations should develop patient bills of
rights “to empower people to take an active role in improving their health, to strengthen
the relationships people have with their health care providers, [and] to establish
patients’ rights in dealing with insurance companies and other specific situations related
to health coverage.”
 Ethical Principles
Brief Overview of Medical Ethics & Human Rights:

Writings that specify ethical obligations (both in general and by physicians) predate by
millennia writings that specify human rights (both in general and for patients). The earliest
writings containing ethical principles date from the Old Kingdom of the Egyptians

We saw Ethics flourish as a scholarly discipline during the golden age of Greece (Socrates,
Plato, and Aristotle). In Ancient Egypt we see it on the tomb of Nenkh-Sekhmet “chief of
physicians” and the writings of the Hippocratic school of Cos. “Deontological or “duty” ethics.
Imposes on persons the obligation to preserve the rights and freedoms of others.
 Ethical Principles
Overview of Core Ethical Principles

The 4 basic ethical principles used to guide nurses and clinicians in care are Autonomy,
beneficence, nonmaleficence, and justice to help everyone make the right decision.
There are however, other terms that go with them such as Veracity & Fidelity,

● Autonomy
● Beneficence
● Nonmaleficence
● Justice
● Comparative Justice
● Veracity
● Fidelity
 Ethical Principles
Autonomy:

Autonomy is an American value. It is the ability to make decisions for oneself, also known as
self-government. We hold great respect for individual rights and equate freedom with
autonomy.
Respect for autonomy requires that patients be told the truth about their condition and be
informed about the risks and benefits of treatment in order for them to make informed
decisions. Under the law, they are permitted to refuse treatment even if the best and most
reliable information indicates that treatment would be beneficial, unless their action may have
a negative impact on the well-being of another individual. These conflicts set the stage for
ethical dilemmas.
 Ethical Principles
Beneficence:

is the act of being kind. The actions of the healthcare provider are designed to bring about a
positive outcome. Beneficence always raises the question of subjective and objective
determinations, of benefit versus harm. A beneficent decision can only be objective if the
same decision would be made regardless of who was making it.

Traditionally the ethical decision-making process and the ultimate decision were the
determination of the physician. This is no longer the case; the patient and other healthcare
providers, according to their specific expertise, are central to the decision-making process.
 Ethical Principles
Nonmaleficence

means doing no harm. Providers must ask themselves whether their actions may harm the patient
either by omission or commission. The guiding principle of primum non nocere, “First of all, do no
harm,” is found in the Hippocratic Oath. Actions or practices of a healthcare provider are “right” as
long as they are in the interest of the patient and avoid negative consequences.

Omission would be failing to raise the side rails on the patient’s hospital bed, upon which the patient
fell out and was injured. An act of Commission is something actually done that resulted in harm. An
example of an act of commission would be delivering a medication in the wrong dose or to the wrong
patient.
 Ethical Principles
Nonmaleficence

Case managers can be accused of maleficence by omission if they failed to coordinate a patient’s care correctly—for
example, discharging a patient to an inappropriate level of care or leaving a patient in a dangerous living situation. A
key role for the case manager is to be an advocate for the patient and neglecting this role could be maleficent. An
unethical act of commission could be breaking confidentiality by releasing information that becomes harmful to the
patient.
 Ethical Principles
Justice

speaks to equity and fairness in treatment. Hippocrates related ethical principles to the
individual relationship between the physician and the patient. Ethical practice today must
extend beyond individuals to the institutional and societal realms. This means that, in addition
to providing fairness in treatment to the patient, the institution and staff must also be treated
fairly.

For example, it is not fair if a patient cannot make payments and the institution has to pay for
the treatments already given for the patient’s benefit.
 Ethical Principles
Justice

There are two kinds of justice:

Distributive justice addresses the degree to which healthcare services are distributed
equitably throughout society. Within the logic of distributive justice, we should treat similar
cases similarly—but how can we determine if cases are indeed similar? Beauchamp &
Childress (2013) identify six material principles that must be considered, while recognizing
that there is little likelihood all six principles could be satisfied at the same time.
 Ethical Principles
Justice
To each person:

■ To each person an equal share

■ To each person according to need
■ To each person according to effort
■ To each person according to contribution
■ To each person according to merit
■ To each person according to free market exchanges
 Ethical Principles
Justice

Looking at the principles of justice as they relate to the delivery of healthcare, it is apparent that they
do conflict in many circumstances. For example, a real-life system that attempts to provide an equal
share to each person cannot distribute limited resources. There is a finite end to money and
resources within the budget of an organization. When good patient care demands more than the
system has allocated, there may be a need for adjustments within the marketplace.

An example would be when an insurance company has exhausted its allocated and contracted funds
to care for a hospitalized patient. The insurance company can then demand that the patient be
transferred to another facility of lesser cost. If, however, the acuity of the patient is too high to be
transferred, then the patient’s healthcare costs continue to exceed the budget, which is unequitable
for the insurance company.

Clearly, these are unfortunately real-life ethical and moral dilemmas. Who is most important?
 Ethical Principles
Justice

Comparative justice determines how healthcare is delivered at the individual level. It looks at
disparate treatment of patients on the basis of age, disability, gender, race, ethnicity, and religion. Of
particular interest are the disparities that occur because of age.

Bias as a result of age compared to gender and race discrimination is referred to the practice as
ageism (Chrisler et al., 2016). In our society, equal access to healthcare does not exist due to
variations in health insurance, third-party payers, socioeconomic levels, and even availability of
transportation to care facilities. There is valid concern about the distribution of resources,
particularly as the population ages and the demand for services increases.
 Ethical Principles
Veracity

(truthfulness) is not a foundational bioethical principle and is granted just a passing mention in most ethics
texts. It is at its core respect for all persons by being truthful.

Veracity is the opposite of the concept of paternalism, which assumes patients need to know only what their
physicians choose to reveal. Informed consent is only possible if patients have been well informed of options,
which then allows them to exercise autonomy with full knowledge.

There are times when the legal system and professional ethics agree that deception is legitimate and legal.
Therapeutic privilege is invoked when the healthcare team makes the decision to withhold information
believed to be detrimental to the patient. Such privilege is by its nature subject to challenge and is taken very
seriously by ethics committees.
 Ethical Principles
Fidelity

is loyalty. It speaks to the special relationship developed between patients and their
healthcare professionals. Each owes the other loyalty; although the greater burden is on the
provider to be worthy of the patient’s trust and loyalty (Beauchamp & Childress, 2013). Fidelity
often results in a dilemma, because a commitment made to a patient may not result in the
best outcome for that patient (Veatch, 2016).

At the root of fidelity is the importance of keeping a promise and being true to your word.
Individuals see this differently. Some are able to justify the importance of the promise at
almost any cost, and others are able to set aside the promise if an action could be detrimental
to the patient.
 Balancing patients' religious beliefs - ethically
Fidelity

For example, if a physician promises the patient they will always be there to care for them, yet
leaves the organization and joins another healthcare facility, the patient may feel the
physician betrayed their loyalty. The same may occur with a case manager who promises the
patient and family they will be available to help them, yet leaves the employment, which may
make the patient feel abandoned.
 Ethical Challenges & End Life Care Decisions
Challenges in End-of-life care:

Caring for patients nearing end of their life can often be a difficult be complicated and have
difficult questions for patients and families that must make surrounding many sensitive issues.
Although nurses have their own morals, values, and beliefs, they sometimes do not correspond
with the patients’ values, beliefs, or wishes, and an internal conflict for the nurse can ensue.
Regardless of the intervention or treatment, the nurse should focus on helping the patient weigh
the benefits and burdens of the intervention, rather than focus on the intervention itself
(Kennedy Swartz, 2001).

● Withholding/withdrawing of medical interventions

● Do Not Attempt Resuscitation (DANR)
● Allow Natural Death
● Medical Order for life sustaining treatment (MOLST)
● Hastening Death
● Terminal/Palliative Sedation
● Assisted Dying
 Ethical Challenges & End Life Care Decisions
Withholding/withdrawing of medical interventions

Sometimes these interventions range from minor, such as a non-life sustaining medication,
to more complex, such as mechanical ventilation. The rationale for stopping these
interventions is often based on the fact that the burdens are outweighing any benefits the
patient may get from it. Sometimes life-sustaining therapies may prolong suffering at the
cost of decreasing the patient’s quality of life.

One of the most heart-wrenching decisions that family members often have to make is about
withdrawing life sustaining treatments (life support) from patients.

Advance directives are documents that enable patients to make their decisions about
medical care known to their family and health care providers, in the event that they are
unable to make those decisions themselves (National Cancer Institute, 2013).
 Ethical Challenges & End Life Care Decisions
Do Not Attempt Resuscitation (DANR)

If a patient has an order for a DNR or DNAR, it means that the patient has elected for
cardiopulmonary resuscitation (CPR) to not be initiated or administered in the event of a cardiac
arrest. CPR could include the use of chest compressions, cardiac drugs, and the placement of a
breathing tube.

The success rate of CPR has been low, around 18%, among all hospitalized patients who arrest over
the past 50 years (Berry & Griffie, 2010), and it is well known that the percentage is even lower
among patients with advanced illnesses such as terminal cancer or end stage heart failure. A “do
not intubate” (DNI) order often accompanies a DNR order, which states that the patient elects not to
be intubated with a breathing tube if they go into cardiac arrest. Chest compressions and the use of
cardiac medications could still be used.
 Ethical Challenges & End Life Care Decisions
Allow Natural Death

Allow natural death is a more recent terminology some health care institutions have adopted
to use instead of the traditional DNR orders. An AND order simply allows the patient to
remain comfortable while not interfering with the natural dying process.
 Ethical Challenges & End Life Care Decisions
Medical order for life sustaining treatment (MOLST)

Sometimes also referred to as physician order to life-sustaining treatment (POLST), these

newer forms of advance directives were developed in order to improve the communication of
a patient’s wishes about life-sustaining treatments among healthcare providers and settings.
 Ethical Challenges & End Life Care Decisions
Hastening death (Principle of double effect)

The principle of “double effect” refers to some decisions that clinicians have that will produce
both desirable and undesirable effects (ELNEC, 2010).

Example: the nurse administers a pain medication in order to alleviate a patient’s pain and
suffering but this same intervention may also contribute to a hastened death, is also an
example of “double effect.” The medication will reduce the pain but also further reduce the
patient’s respiratory rate to a level that is inconsistent with life. In the case of double effect,
the nurse or clinician should always consider what the intended effect of the intervention is. Is
the pain medication being administered to reduce pain and suffering, or is it being given to
further reduce the patient’s respirations?
 Ethical Challenges & End Life Care Decisions
Terminal/palliative sedation

Terminal sedation (more recently called “palliative sedation”) is an intervention used in patients at
the end of life, usually as a last effort to relieve suffering (Knight & Espinosa, 2010). It involves
sedating the patient to a point in which refractory symptoms are controlled. The goal is to control
symptoms, and the patient is sedated to varying degrees of consciousness to achieve this. The intent
is not to cause or hasten death, but rather to relieve suffering that has not responded to any other
means.

● Patient has a terminal illness

● Severe symptoms present are not responsive to treatment and intolerable to patient
● A “do not resuscitate” order is in effect
● Death is imminent (hours to days)
 Ethical Challenges & End Life Care Decisions
Assisted dying

Assisted dying is defined as “an action in which an individual’s death is intentionally

hastened by the administration of a drug or other lethal substance” (Volker, 2010).
Under this general definition, there are two distinct subcategories that include assisted
suicide and active euthanasia. In assisted suicide, the patient is provided with the means
to carry out suicide, such as providing a lethal dose of a medication. In active
euthanasia, someone other than the patient is the one who carries out the action that
ends the patient’s life (Volker, 2010).
 Ethical Challenges & End Life Care Decisions
Assisted dying

Assisted dying is defined as “an action in which an individual’s death is intentionally

hastened by the administration of a drug or other lethal substance” (Volker, 2010).
Under this general definition, there are two distinct subcategories that include assisted
suicide and active euthanasia. In assisted suicide, the patient is provided with the means
to carry out suicide, such as providing a lethal dose of a medication. In active
euthanasia, someone other than the patient is the one who carries out the action that
ends the patient’s life (Volker, 2010).
 References
● Kkienerm. (n.d.). Integrity Ethics Teaching Guide: Table of Exercises.
https://www.unodc.org/e4j/en/integrity-ethics/teaching-guide/table-of-exercises.html
● 3. The Principles of Healthcare Ethics | ATrain Education. (n.d.).
https://www.atrainceu.com/content/3-principles-healthcare-ethics
● Olejarczyk, J. P. (2022, November 28). Patient rights and ethics. StatPearls - NCBI
Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK538279/
● Lowey, S. E. (2015, December 14). Ethical concerns in End-of-Life care. Pressbooks.
https://milnepublishing.geneseo.edu/nursingcare/chapter/ethical-concerns-in-end-of-life
-care/