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NCM 108 LEARNING OUTCOMES BIOETHICS Differentiate ethics form morality BIOETHICS - Study of the morality of human conduct Define bioethics in the context of hea...
NCM 108 LEARNING OUTCOMES BIOETHICS Differentiate ethics form morality BIOETHICS - Study of the morality of human conduct Define bioethics in the context of healthcare setting concerning human life in all its aspects from the moment of Describe the different ethical theories its conception to its natural end. Conception in science Analyze different ethical principles and its implication begins when the sperm fertilizes an egg cell forming a to the nursing practice zygote. Natural end means death without any human Integrate the different theories in explaining ethical interventions. dilemma experienced by nurses in the clinical setting - Its etymological root is derive from “bio” and “ethos”: ETHICS Bio = life - Science of the morality of human conduct or human act. Ethos = ethics - Goodness or badness of the rightness or wrongness of the human act. - Its is the philosophical discipline that deals with the morality of human conduct. Bioethics is the result of the WHAT MAKES GOOD, GOOD? collective efforts in philosophy, theology, law, and - As far as ethics being moral philosophy’s concern, an act medicine as it confronts the complex crisscrossing and is good when it is in agreement or in conformity with the inter joining of science and technology in the ambit of dictates of right reason. human life. WHAT MAKES REASON, RIGHT? - It is interested in the ins and purposes of life sciences, - Reason is considered right when it is in conformity with health care, meaning an implication of justice, death, pain, the truth. Meaning the truth is not that which is acceptable suffering, right, duties and responsibilities of the sick only to some but universally acceptable to all human person, his family, society and state. person regardless of time, space and culture. HEALTH ETHICS Truth - universally acceptable to all human person HEALTH ETHICS - Is a science that deals with the study ETHICS VS. MORALITY of the morality of human conduct concerning health and health care. Ethics - formal, systematic study of moral beliefs Morality - adherence to informal personal values - Its is employed to regulate human conduct in the practice of health care so that good may be done and evil may be RELATION OF ETHICS AND MORALITY avoided Both deal with human act or human conduct FILIPINO PRMARY PRINCIPLES OF BIOETHICS Ethics studies about morality Morality gives ethics a perspective of what to study Grouped into 3 main division: about that is the rectitude of whether an act is good or Goodness bad Beneficence Morality provides ethics with a quality that determines Family and distinguishes right conduct form wrong conduct form 1. Goodness DISTINCTION OF ETHICS AND MORALITY The primary principle of goodness is demonstrated through the practice of justice, respect for autonomy, Ethics pertains to the knowledge of what to study compassion, veracity, fidelity, and confidentiality. about-that is the goodness or evil of human act Filipino’s is true delicate and generous hospitality Morality pertains to the application of this knowledge which we are know for. in the performance of human act It is also shown in community sharing of goods Ethics provides learning about morality of a human including lending of money, materials, equipment, & conduct even human resources as seen in (bayanihan) Morality provides ways in practicing what is learned especially in times of disaster. Kababayan or (compatriots) when in a foreign land. In short: Utang na loob (indebtedness or gratitude) which runs - Ethics is the “word” through generations because of the belief that good - Morality is the “flesh” favors done to one member should be perpetuated in - Ethics indicates that “theory” act of gratefulness forever. - Morality indicates the “practice” NCM 108 Keeping secrets even if it would have been more - it states that people should adhere to their obligation charitable to reveal the secrets. (confrontive dialogues) and duties when engaged in decision making when are avoided because of the guise of being good and ethics are in play. It means that a person will follow his/her not hurting the feelings of others obligations to another individual or society because In bioethics, goodness is also veracity but telling the upholding one’s duty is what considered ethically correct. truth should be done with compassion & full of respect (appropriate timing and suitable occasion) Flaw of deontology Filipinos’ gift of pakiramdam (sensitivity) is a big - No rationale or logical basis for deciding an individual’s help. duties. In nursing, the primary principle of goodness should be - Puts focus on the rightness and wrongness of action, the motivating guideline in caring for patients therefore not interested on the consequences of those because goodness in health care means giving and actions. caring so that the patient will feel better. - Moral standard or principle exist independently of the ends or consequences 2. Beneficence No harm should be done to anyone The nurse has duty to act based on one relevant principle Contribute to welfare and growth or most relevant of several moral principles. Problem Connotes blessings, acts of mercy, kindness, charity, may arise when personal and cultural biases influence altruism, love, humanity the choice of the most primary moral principle. It connotes moral obligation to act for the benefit of others 2. TELEOLOGICAL ETHICS - Telos = end or purpose 3. Family - Logos = science It is a very important institution in Filipino culture. It is considered as a solid bank one can rely on where - Derives moral obligation from what is considered good withdrawal of help & support is endless and the or desirable as an end or purpose to be achieved. resource is never exhausted. - It judges the rightness and wrongness of decisions It is the source of all right conduct, ethics, morals, based on the outcomes or predicted outcomes. This is justice, autonomy, beneficence,. respect, and why it is called: goodness that flow in continuity among the children - “Consequence – oriented theory” from eldest down to the youngest. - Utilitarianism – most common form of Consequence Parents are looked up to as mature, respectable, – oriented reasoning. responsible adults where the younger one ask for - The focus is on the consequence of the act that is advises or enlightenment. executed by the agent premised on the purpose or The kind of our personhood often depends on the reason why the agent performs the act. If the result of nurturance, rearing, and breeding we have received the choices right then it follows that the choice is from the family. morally right, if it is contrary, then it is wrong. ”Kung ano ang puno ay siya ring bunga” it is one of the family’s responsibility to prepare the 3. UTILITARIANSIM offspirngs to become a good contributing “The greatest good for the greatest number” citizens in the future. - Choice that yields the greatest benefit to the most people is the one that is ethically correct. ETHICAL THEORIES - Primary motive happiness and/or pleasure in their highest degree to its greatest number of recipients. Each theory emphasizes different points, a different decision making style, or a decision rule such as predicting 2 TYPES OF UTILITARIANISM the outcome and following one’s duties to others. They are considered in making an ethically correct decision. In the 1. Act utilitarianism (eudaimonistic) – based on the absence of ethical theories, one is a clause in determining notion of happiness. morality of human acts or determining a sound moral - A person performs acts that benefit the most people assessment in relation to an action. regardless of personal feelings or societal constraints such as laws. 1. DEONTOLOGY (OR FORMALIST THEORY) - Derived from the Greek word; Disadvantage: one individual’s right may be Deon = obligation or duty infringed upon in order to benefit a greater number Logos = inquiry or study of people. It is not always concerned with justice, - coined by Charlie Dunbar Broad (1857-1971) beneficence or autonomy for an individual, if - means ethical study or ethical inquiry regarding duty NCM 108 oppressing the individual leads to the solution that benefit a majority of people. ARISTOTLE 2 KINDS OF VIRTUES: 2. Rule utilitarianism (hedonistic) – based on the a. Intellectual virtues – arise from teaching and notion of pleasure. through the reflection of theoretical moral - Takes into the account of law truths and the discovery of rational principles - Concerned with fairness that ought to control actions. - Seeks to benefit the most people but through fairest b. Moral virtues – arise as a consequence habit and most just means available. or of one’s habitual choice of action in - Values justice consonance with rational principles. - Include beneficence VIRTUES OF HEALTHCARE PROVIDERS Disadvantage: Use life experiences to attempt to predict outcomes but sometimes no one can In healthcare profession, nurses spontaneously and be certain that one’s prediction will be consistently show in their personal and professional life accurate. their wholehearted support in upholding applicable laws, code of ethics, policies, and promises entered into with clients/ patients. 4. VIRTUE ETHICS - Puts much weight on the moral character of the person CLINICAL VIRTUES rather than of what he/she has done. - Character traits that dispose nurses to provide - Character rather than the consequences of action is good care to patients, families, and communities. the focal point in drawing moral decisions. - Judges the person through his character by what he 1. Fidelity done. – steadfast faithfulness associated with pledge of - Judges by his/her character rather than by an action loyalty or the practice of keeping promises. that may deviate from his normal behavior. - Takes the person’s moral reputation and motivate into 2. Honesty account when rating an unusual and irregular behavior – quality of being honorable and upright in character that is considered unethical. and actions. - Virtue is usually construed as an act fitting to a man. 3. Integrity Disadvantage: it does not take into consideration a – implies more directly to character than to actions, person’s change in moral character. and it is the soundness of character and possession of very high standards of right and wrong. According to BEUCHAMP & WALTERS - Virtuous person is one whose inner self or character is 4. Humility always trained toward choosing and doing what is – meekness of heart; calls for submission, docility good. and courtesy. - A morally good person will more likely: 5. Respect a. Understood what should be done. – esteem or honor by which a person shows b. Perform required acts. recognition or high regard to self-worth, c. Form an act on moral ideals. self-respect with dignity, respect for authority, and respect for others with tolerance. TED CHAMBERS - A virtuous professional is: 6. Compassion a. One who can discern the right course of action in the – signifies sympathy; implies feeling for another’s situation without relying on principles and rules sorrow or hardship that leads to help or pity. b. One who desires to do what is right and avoid what is wrong. 7. Prudence – signifies carefulness, precaution, attentiveness, PLATO and good judgement as applied to action or 4 BASIC VIRTUES: conduct. a. Wisdom -arises in the rational soul. b. Courage -in the spiritual soul. 8. Courage c. Temperance – in the appetitive soul – signifies bravery and fearless. d. Justice- comes when there is an equilibrium among wisdom, courage, and temperance. 9. Bravery NCM 108 – applies to a kind of courage that is shown by bold, - Implies independence and firmness in one’s conviction, fearless, and daring action in the presence of perspective, or personal stance. danger. Health care providers are duty bound to: VICES OF THE HEALTH CARE PROVIDERS Acknowledge the autonomy of their patients Recognize and appreciate the views, decisions, - An evil fault, an imperfection, an immoral conduct, choices, beliefs, and values of their patients. tendency, practice or habit. o But autonomy is not absolute because if the choices want to jeopardize the health of others, 1. Fraud or disrupts and hampers the just distribution of – taking advantage over another misrepresentation, resources, the choice must be objected. false suggestion, or by suppression of truth. – It can be actual or constructive Patients’ rights o Actual fraud – consist in deceit, artifice, trick, - Moral and inviolable power vested in him as person to design and some direct and active operation. do, hold, or demand something as his own. o Constructive fraud – consists of act of - Every right involves corresponding duty in others to commission or omission contrary to legal and respect this right and not violate it. ethical duty, trust or confidence reposed. Types of patients’ right 2. Pride - The patient as an individual person has the moral right – high opinion of oneself that suggests neither to determine what is good for himself. proper self-respect nor personal dignity; suggests - Beauchamp and walter (1979) identified the four an unpleasantly assertive manner. rights/; 3. Greed 4 rights: – quality of wanting more than one’s share; a. Right to inform consent synonymous to avidity, avarice, cupidity, b. Right to inform decision covetousness. c. Right to inform choice d. Right to refusal of treatment. CORE VALUES OF PROFESSIONAL NURSES (The 6c’s of caring in nursing) RIGHT TO INFORMED CONSENT - Informed consent refers to the knowledge of Compassion – awareness of one’s relationship to others, necessary information a patient should know about in sharing their joys, sorrows, pain and accomplishments. order to be able to give consent base on his/her value system. Competence – having the knowledge, judgement, skills, - The patient has the right to receive all necessary energy, experience and motivation to respond information concerning diagnosis and treatment in adequately to others with in the demands of order to be able to give consent based on his/her professional responsibilities. values system. - The patient has the right to be informed about the Confidence – the quality that fosters trusting relationship possible alternative course of action to be taken comfort with self, client, and family. together with the possible consequences. Conscience – morals, ethics, and an informed sense of RIGHT TO INFORMED CHOICE right and wrong; awareness of personal responsibility. - A patient should know about the necessary information about medical treatment or experiment before it is Commitment – convergence between one’s desires and administered so that moral choice can be made. obligation and the deliberate choice to act in accordance with them. RIGHT TO INFORMED DECISION - Information and understanding are necessary for Comportment – appropriate bearing, demeanor, dress, genuine deliberation. and language, that are in harmony with a caring - Refers to the necessary information of and decision on presence. a medical treatment before the latter is carried out. ETHICAL PRINCIPLES 4 major elements of informed consent: 1. Respect for autonomy o Autos = self 1. Competence o Nomos = rule or law - Refers to the capacity of patient for decision making. - Refers to self-rule - Ability to make a choice free from external constraints One considered competent if: NCM 108 One has made a decision (can choose between 4. To refuse treatment to the extent permitted by law and alternatives) be informed of the medical consequences of his One has the capacity to justify one’s choice (give action. reason why that is the choice) and choice done in 5. To every consideration of his privacy concerning his reasonable manner. own medical care program (the issue here is one of privacy and simply courtesy) 2. Disclosure 6. To expect that all communication and records - Refers to the content of what a patient is told and pertaining to his care should be treated as confidential. informed about during the consent negotiation. 7. To expect that within its capacity, the hospital must provide a reasonable response to his/her request for 3. Comprehension services. - Refers to whether the information given has been 8. To obtain information regarding any relationship of his understood. hospital to other health care and educational institutions in so far as his care is concerned. 4. Voluntariness 9. To be advised if the hospital propose to engage in or - Means the consent must be voluntary; agree on his perform human experimentation affecting his/her care own volition; patient owns the decision, it is patient’s or treatment. The patient has the right to refuse to decision alone, has chosen the decision or option participate in such research projects. based on the information disclosed to him. 10. To expect reasonable continuity of care. The patient RIGHT TO REFUSAL OF TREATMENT has the right to know in advance what appointment - In conjuction with the statement on a patient’s beloved schedules &physician are available and where. rights as presented by American Hospital Association, The patient has the right to refuse treatment to the 11. To examine and receive an explanation of the hospital extent permitted by the law to be informed of the bill regardless of source of payment. medical consequences of his action. 12. To know what hospital rules & regulation apply to his LIMITATION OF A PATIENTS’ RIGHTS care/her conduct as a patient. 1. Patients’ rights do not include the right to be allowed to die. PROXY CONSENT/LEGALLY ACCEPTABLE 2. A patient in a moribund (dying) condition does not REPRESENTATIVE possess the necessary mental or emotional stability to make an informed choice. - the process by which people with legal right to 3. Patients’ rights are not absolute consent to medical treatment for themselves or for a minor or a ward delegate that right to another person. 2 types of informed consent a. Written consent – signed during admission 2 types of proxy consent for adults: b. Verbal consent – verbally signifies willingness to undergo medical treatment. 1. Power of attorney to consent to medical care - Usually used by patients who want medical care but Informed consent are concerned about who will consent if they rendered Emergency cases – do not need IC (informed consent): temporarily incompetent by the medical care. a. Comatose or obtunded patients - It delegates the right to consent b. Blind or illiterate patients c. Underaged patients or those unable to understand the 2. Living will circumstances. - a document that indicates a patient’s wishes d. Language barrier regarding their health care and how they want to be treated should they become seriously ill and unable to make or PATIENT’S BILL OF RIGHTS communicate a decision of their choice. - This contains legal instructions regarding The patient has the right: preferences for medical care if one is unable to make 1. To considerate and respectful care decisions for themselves. 2. To obtain from his physician complete current information concerning his diagnosis, treatment, ETHICAL PRINCIPLES prognosis in terms that the patient can be reasonably 1. AUTONOMY expected to understand. 3. To receive from his physician information necessary to 2. PRIVACY give informed consent prior to start of procedure or treatment. - refers to the right to be free from interference NCM 108 - privacy enables individuals to exert over their own lives - right entails a context of relation since it is a correlative which includes: duty. Deciding who should have access to personal - the true meaning of justice can only be achieved in the information ambiance of relation. When & how this information will be disclosed. - One can give each human person his/her due only in the context of relation. 3. CONFIDENTIALITY - Justice does not mean that everybody should be equal in all of life’s opportunities, concerned, and undertakings. - refers to the duty to protect privileged information & to Human beings can never be equal in all respects. The share entrusted information responsibly. enactment and promulgation on a numerable laws - It stems from the notion that a person’s wishes, decisions somehow impedes people to come to terms with equality. and personal information should be treated with respect. - This relates to the concept of privacy, information Two kinds of Justice: obtained from individual will not be disclosed unless it will benefit the person or there is direct threat to the social a. General legal justice good. - classified into equity and common legal justice. - refers to human person’s wishes and proper actions 4. VERACITY in consonance with the common good. - has affinity with laws since laws are made not only - Obligation to tell the truth and not lie or deceive others. for the good of certain individual but for the good of the whole community. Deception can take many forms: Intentional lying, Types of General legal justice: non-disclosure of information, or partial disclosure of information. Equity - human person judges, wills, & does what is right to others not necessarily from the injunction of - Veracity is often difficult to achieve, it may not be difficult the moral law but civil law. to tell the truth but it can be quite hard to decide how much truth to tell. Telling the truth is a personal communication Common legal justice - human person shows with patients, is another characteristics of actions that proclivity to will and do something for the good of many people believe as morally required reasons other others in accordance with the moral law or with the than just producing good consequences. prescription of civil law. - The nurse must assess whether communication is b. Particular justice honest. - classified into commutative justice and distributive justice. 5. FIDELITY - pertains to wishing and doing what is right in relation to another person who is accounted as an individual - means faithfulness and keeping promises with an inherent right to his/her own private good. - ethical foundation of nurse-client relationship - clients have an ethical right to expect nurses to act in Types of Particular Justice: their best interest. - when commitment are made to others, other things being Commutative justice - deals with fairness of equal most people recognized that there is moral exchange. obligations to keep those commitments. Failure to do so - exist in the relationship between individuals or could be a sign of lack of respect between entities like nations or corporations. Fidelity is demonstrated when nurses: Distributive justice - refers to a person’s will to share a. Represent the client’s viewpoint to other the goods which belong to a community or to individuals members of the health care team who are part of his/her community. b. Avoid letting their own personal values influence - sharing of nation’s wealth. It exist in the sharing their advocacy for clients. of love on the nation including natural resources and food to indigent and disadvantaged. - nurses supports the client’s decision even it conflicts with their preferences or choices. 7. BENEFICENCE 6. JUSTICE - duty to do good and active promotion of benevolent acts (goodness, kindness, charity) - derived from the Latin term; - guides the decision maker to do “what is good and right” Jus = right NCM 108 - stipulates that one should strive to achieve the greatest OTHER RELEVANT ETHICAL PRINCIPLES amount of good because people benefit from the most 1. PRINCIPLE OF DOUBLE EFFECT good - requires nurses to abstain from injuring patients - Introduced by Thomas Aquinas - taking care of the patient is a beneficent act - Often invoked to explain the permissibility of action - the principle of beneficence to be cherish and that causes serious harm such as: demonstrate by nurses to their patients. - The death of human being as a side effect of promoting some good end. Accrding to WILLLIAM FRANKENA there are: - Why double effect? Because one is good and the 4 Elements of beneficence: other is harmful. a. One ought not to inflict evil or harm - The principle allows the action as morally b. One ought to prevent evil or harm permissible where in harmful effect is not intended c. One ought remove evil or harm but a “side effect” of the action. d. One ought to do or promote good - As in act of self defense CHINESE - Morally justify actions that produced both good and evil effects. - believe that everyone shares the same nature hence, - This doctrine asked as to DISTUNGUISH INTENTED they assert that others are as human as they are. EFFECT from UNINTENDED EFFECT. - leads Kong Zi preach his signature “Golden Rule” - Has been used to justify the death of fetus under “Do unto others what you want others do unto you.” certain circumstances that threaten the life of the mother. “Do not do unto others what you do not want others do - For example, ovarian cancer sometimes must be unto you.” treated with full hysterectomy or the surgical BUDDHIST removal of the uterus, and such operation results in the death of the fetus. Note that the intention is to - one must inculcate the right thought (one of the 8 th fold save the mother not to kill the fetus. Note also that paths in Buddhism) which requires the mind to be free from it would be impermissible according to this doctrine impurities like harm, ill-will, cruelty, & lust. to perform abortion to save the mother from death. HINDUS It is permissible only if the procedure is an indirect cause of the death of the fetus. - they believe in “ahimsa” which means non hurting of all forms of life. Detractors felt that the unwanted effects of actions that are - it is clear that the mandate on preventing harm or evil to foreseen and still allowed within the course of treatment self and others as well as mandate on the promotion of become intended effects. good is a universal phenomenon. QUESTION: Under what effects can one be said to 8. NONMALEFICENCE act morally when some of the manifold foreseeable effects of that action are harmful? - understood as the overriding principle through which ANSWER: We have four criteria that points out how everyone is required to undertake the caring of the patient. the basic principles are considered almost common - capsulized in the phrase “do no harm” and intuitively correct. - principles of non maleficence injunct one’s avoidance of inflicting injury, harm, or pain to others. 4 Criteria of Double Effect END a. The action itself is good or morally neutral – meaning, not good nor bad. Learning Outcomes b. The agent sincerely intends the good and not the Describe other relevant ethical principles in bioethics evil effect – the evil effect maybe foreseen but is not Discuss the nurses’ role in every ethical principles intended. Explain how these principles influence or affect the c. The good effect is not achieved by means of the evil ethical decision of a nurse in responding to ethical effect issues or dilemma. d. The good must outweigh the harm. NCM 108 2. PRINCIPLE OF LEGITIMATE COOPERATION A person maybe morally excused if there is a - This principle is very sensitive especially in relation sufficiently grave reason. Like giving no approval of to the duties and responsibilities of healthcare the other person sinful act. It could be two types: providers. Immediate or Mediate - Cooperation indispensably needs prudence on the part of nurses. a. IMMEDIATE MATERIAL COOPERATION - They are mandated to pursue this principle only on Necessary to the sinful act matters that protect the integrity of the healthcare Any direct close cooperation in the sinful act providers and interest and welfare of their patients. of another while claiming not to embrace - So on matters requiring nurses’ cooperation which the evil intention will result to personal and integral scandal or It is always sinful immorality of the healthcare profession, the nurse A good example to this is a religious must dispense herself from such cooperation healthcare organization which provides a categorically. surgical team for a direct sterilization - Also in cases of abortion, the healthcare provider activity at the non-sectarian healthcare should refuse to cooperate because the patient organization. STERILIZATION refers to wants to hide the scandalous pregnancy. The nurses surgical contraception or tubal ligation or who stand firm to refuse cooperation has morally vasectomy. good and praiseworthy decision. The ---- healthcare providers who are determined to keep moral b. MEDIATE MATERIAL COOPERATION decisions on the right track. Refers to the cooperation in the sinful act of another by an act that is secondary and 2 TYPES OF LEGITIMATE COOPERATION subservient to the sinful act. 1. FORMAL COOPERATION A good example to this is the mediate Occurs when the sin of the other person is an involvement of a janitor in providing intrinsically evil act and cooperation is done by cleaning services at which sterilization is assisting in the act to attain its moral object performed. (immorality). It can occur by commission or by omission. 3. PRINCIPLE OF COMMON GOOD & SUBSIDIARITY Such cooperation is always immoral because as seen - COMMON GOOD – sum total of social conditions by definition, it is an intrinsically evil act. which allows people either as groups or as Commission individuals to reach their fulfilment more fully & Ex: An act of commission is done by a group of more easily (Vatican) voters taking part in the propaganda campaign in o It is about the progress of persons. This favor of law permitting abortion or euthanasia in defines the policy or action that most the country. Their acts constitute formal benefit the majority as morally correct. cooperation. - The principle of common good and subsidiarity can Omission be useful when issue involve or should involve the Ex: A nurse caring for a terminally ill patient and she overall picture or environment. knows that the patient commits suicide. The patient - It regards all individual as part of a larger obtain a pain medication that he can use to commit community. We share certain common conditions suicide by overdose. The nurse might cooperate and institutions upon which our welfare depends. formally with suicide by deciding to omit the - For society to thrive, we need to safeguard the scheduled visit to the patient’s room (to aid sustainability of the community for the good of all suicide) so that the overdose will not be detected including our weakest and most vulnerable until the patient is dead. members. - In nursing, the common good is a concept that may 1. MATERIAL COOPERATION have utility in analyzing moral and ethical issues Consist of an act other than the evil act itself but affecting the care of vulnerable patients groups. facilitates and contributes to its achievement. NCM 108 Nurses should regard themselves as the stewards of 4. PRINCIPLE OF APPROPRIATE DECENTRALIZATION life and the earth. - It has unique strength Nurses have responsibility of taking care of the - Only principle that addresses the issue of locus of environment (environmental sanitation) decision making. o Ex: Observing environmental sanitation - Strongly linked to human dignity, democracy, and 4. BIOMEDICAL STEWARDSHIP solidarity. - Is a responsibility of a healthcare practitioner nurses - Assist in reaching agreements on common good. to look after, provide necessary health care services - General aim: to guarantee a degree of and promote the health and life entrusted to their independence for lower authority in relation to a care. higher body, or for local authority in relation to central government. o An example to this is a mother allowing her 6. PRINCIPLE OF TOTALITY & ITS INTEGRITY daughter choose which clothes to wear. - It pursues the issue of the dignity of the whole o A municipal government unit lets residents person; decide whether to have a local lockdown or - In essence the integrity of human life. follow the national order in community - TOTALITY implies wholeness, completeness, and quarantine. entirety - It applies to any entity that is made up of parts that together constitute as a whole. 5. PRINCIPLE OF STEWARDSHIP - But this principle upholds that the whole is greater - This supports the role of nurses as stewards. than sum of its parts - STEWARDSHIP – is a practical recognition that man When this principle is applied to HUMAN PERSON, is not the absolute master of himself or of his “his/her whole physical body is more important and possessions. He has receive any grace and gift from valuable than any of its parts” god. It maybe ethical and legal to sacrifice a part of one’s - Humans are mere stewards or caretakers with body for the good of whole body. responsibility of protecting and cultivating spiritual and bodily functions. ETHICO MORAL RESPONSIBILITY OF NURSES IN STEWARDSHIP RESPONSIBILITY SURGERY Pertains to management Duty involved when one The principle of totality and its integrity is promoted and supervision of accepts the task of when the ethico moral responsibility of nurses in surgery another person management is observed, where: Entails concomitant This response is values and/or virtues of characterized by values of o Shared decision making – is the foundation responsibility and dependability, of a mutually respectful relationship accountability perseverance, initiative, between a health care provider & patient. and effort, and being o Nurses as enlightened patient advocates worthy and good servant. have an entrusted interest in fully understanding the legal and ethical considerations of the informed consent ROLE OF NURSES AS STEWARDS process. 1. PERSONAL o Role in the informed consent process. A nurse being a man or a person has to be a Educated nurses possess unique opportunity to facilitate steward of the gift of life along with other autonomy especially in the presence of special possessions of God has shared with him. circumstances such as: 2. SOCIAL a. Patients who refuse surgery As a social being, a nurse have responsibility to be b. Patients with limited mental capacity good and worthy to others. c. Patients with surrogate decision makers 3. ECOLOGICAL STEWARDSHIP NCM 108 The nurse ascertains the consent form has been signed before administering psychoactive medications because 2. CONTRACEPTIVE the consent may not be valid if it was obtained while the Intentional prevention of conception through patient was under the influence of medications that can sterilization, but these can be justified. affect judgment and decision making capacity. Each nurse has ethical and moral responsibility to JUSTIFICATIONS represent the patient’s interest, show humility, respect, a. Serious illness of either husband or wife (like in the and protect patient’s autonomy & preserve patient’s case of lepers, epileptic, syphilitics or with dignity (ICN, 2013). tubercular disorder to prevent conception of It is important to know that patients have their own offspring who might be affected by the disease. power of self-determination, and it is the nurse’s b. Probability of genetic abnormality (carriers of responsibility to have an understanding of it in a mutual defective genes opt to avail of this procedure) community. c. Severe financial burden (where the family is financially constraint to support another child) d. When child-bearing put one’s health in danger STERILIZATION & MUTILATION (example, a wife is sick and physically weak and As nurses, what is our stand in cases of sterilization and unable to bear a child) mutilation? STERELIZATION – is most common method of 3. EUGENIC AND SOCIAL STERILIZATION contraception among married couples. Performed for the purpose of hindering the - It is a mutilation of sexual power in a man or woman conception of undesirable and physically or so as to render conception impossible. mentally unfit offspring. - Sterilized individual can perform a conjugal act and can Some sort of social engineering to attain orgasm but cannot procreate. Design a society free from individuals with social diseases, mental defects TYPES OF STERILIZATION 1. BASED ON DECISION OR VIOLATION 2. PUNITIVE STERILIZATION Voluntary – the person will and requests that the Done as a punishment for crime or antisocial procedure be done on himself or herself. behavior, particularly rape and other sexual related Involuntary or compulsory – done by order of the offenses. public authority of the state. - This is usually part of the eugenic programs MUTILATION intended to prevent the reproduction of members Came from the Latin term “Mutilatus” – which of the population considered to be carriers of means to cut off or maim. defective genetic traits. This refers to the procedure that diminishes or destroys the functional integrity of the human body. 1. BASED ON PURPOSE OR ENDS o Example, we have the removal of the tonsils It could either be THERAPEUTIC, CONTRACEPTIVE, or tonsillectomy; rib resection; EUGENIC, or PUNITIVE. laryngectomy; or sex transplant. 1. THERAPEUTIC PRINCIPLE OF TOTALITY Removal of a Right to dispose of 2 TYPES OF MUTILATION reproductive organ his organs or 1. MAJOR MUTILATION or potion in order to Destroy their Refers to the procedure that destroys the functional Save one’s life or to capacity to function integrity of the human body so that it becomes Promote bodily only to the extent incapacitated of its natural functions. integrity that the Like the removal of the uterus where the woman Therapeutic General well-being of can no longer bear a child. promotes the the whole demands principle of totality it. 2. MINOR MUTILATION wherein an individual Procedure that diminishes but does not destroy the has a ⸻→ functional integrity of the human body. NCM 108 Like the removal of the tonsils; in the case of rib Organ transplantation is morally permissible in resection; blood donation; tooth extraction; or even proper circumstances but should not be done for circumcision. economic advantage. Eg. Organ donation 3 Conditions to Consider o The donation of one kidney is morally In considering the moral soundness of mutilation, we have permissible because one kidney can to observe these 3 conditions: perform the work of the two. Whenever 1. That the preservation or functioning of a particular diseased organs are removed, injuring organ provokes a serious damage or constitute a bodily and functional integrity is justified by threat to the complete organism (whole body). reason of the overall health of the body. 2. That this damage cannot be avoided or at least notably diminished, except by the amputation (or ORGAN TRANSPLANTATION mutilation) and that its efficacy is well assured. Transfer of an organ or tissue from its original state 3. That it can be reasonably foreseen that the negative to another part of the body or to another individual. effect (mutilation) and its consequences will be Eg. Kidney, corneal, & blood donation compensated by the positive effect. CLASSESS OF TISSUE TRANSPLANTATION FEMALE GENITAL CUTTING (FGC) 1. AUTOGRAFT Example of mutilation - Transplantation of one’s own tissue such as skin Also called Female Genital Mutilation or Female graft from the buttocks, putting them into leg. circumcision There is a partial or total removal of external 2. HOMOGRAFT genitalia or other injury to the female genital - Transplantation of tissue from one human body to (Clitoris) another. It could be cutting of clitoris or sewing of the 2 TYPES vagina. a. Homograft from the dead This presents a concern on safety and other - transplanting an organ from a dead person to a negative consequences of the procedure. The WHO living person. had efforts to end the practice, but because of: b. Homograft from living Traditional and religious impact, the practice - transplanting an organ from living to a living continues. person just in the case of blood donation or kidney transplantation. PRESERVATION OF BODILY FUNCTIONAL INTEGRITY (ORGAN DONATION) 3. HETEROGRAFT The principle prescribes assisting people to - Use of tissue or tissue derivatives from different integrate or balance the 4 dimensions of their species such as from the brute animal to a man. personalities in one way of describing health care o Example is getting liver extract and dedicated to the “whole person”. This is the manner estrogen from cattle. in which healthcare professional strives to fulfill their mission. Is tissue transplantation moral? Mission: to help people experience their own → In terms of autograft, there is no moral objection or dignity and value. question because the same body will endure the Moral obligation to preserve bodily and functional pain and enjoy the benefit of transplantation. integrity. → In case of homograft from the dead, it is morally upright if there is an: FUNCTIONAL INTEGRITY Informed consent of the relatives Ability of the body to function in a healthy manner. Dead is treated with respect It is not the same as anatomical integrity. Dead agreed while he is still alive or as stated in his (living will) NCM 108 The patient’s death is not hastened for This measures are artificially prolonging the life of the immediate tissue transplantation patient → In the case of homograft from the living, this form Give more burden and fatigue to the family and patient of mutilation has to be dealt according to its general Provide hindrance to letting the person go in peace and principles. maintain its dignity. → Not morally permissible if the functional integrity Subjecting patients to chemotherapy and hemodialysis of the human body of the donor is destroyed. when they are on the verge of death may become → Organ donation requires pure and right intention disproportionately extraordinary because of the burden → Meaning, out of good conscience. It should not be on the family’s weak body. The intervention will offer no used to establish personal enterprise or profit for his benefit to the patient and be force on the patient. own. What we can do as healthcare professionals is to help enlighten families on the futility of the actions and that 7. PRINCIPLES OF ORDINARY & EXTRA ORDINARY MEANS resources can be better used in other channels resulting - We are to deal here with its ETHICAL PERSPECTIVE: in more benefit to others. a. When are we morally obliged to start or continue a treatment? 8. PRINCIPLE OF PERSONALIZED SEXUALITY b. When are we morally obliged to refuse or Sex discontinue a treatment? - Sex is considered as social necessity for the procreation of children & their education in the ORDINARY MEANS family In the principle of ordinary means, the action is ethically - So as to expand human community indicated if there is a: - And guarantee its future beyond the death of Reasonable hope of benefit/success individual members. This principle teaches us that Not overly burdensome God created persons as male and female and blessed Does not present an excessive risk their sexuality as a great and good gift. God made us Financially manageable sexual, not only for the survival of our species but for Proportionate to the state of the patient the: It comprises provision of necessities of life - Complete expression of a married person’s mutual Usually pertains to food, normal respiration, and self-giving love to find complete fulfilment in elimination process (like giving of IV fluid; nasogastric children. tube feeding; insertion of indwelling catheter; administration of O2 therapy are considered necessary CONTRACEPTION measures and maybe sustained even if the case is In principle of personalized sexuality, contraception is: irreversible) Intrinsically wrong Can be sustained until the time of death Destroy the true meaning of sexual love Leads to serious personal & social evils EXTRAORDINARY MEANS In contrary to ordinary means, the condition in HUMANIZED SEXUALITY extraordinary means: The principle of personalized sexuality emphasized No reasonable hope of benefit/success humanized sexuality. Which: Overly burdensome Represent fulfilment of physical & sensual need Present excessive risk Evidenced with love & sacramental mystery Not financially manageable (they entail the use An example of this is a harmonized of aggressive modalities, -----, the financial married couple relationship which capabilities of the family.) conquers life challenges by its There is no obligation to use it foundation and love, and respect for Therefore, it is morally optional the sanctity of marriage Families who can afford hook patients to respirators in giving 3rd generation drugs which provide no benefit to --------------------------------END-------------------------------------- patient. The act done is to ease the guilt of the family and feel that they need everything they could. NCM 108 108 – BIOETHICS – WEEK 3 Obtained true inform consent in writing Learning Outcomes Reliance on legal guardian - Explain the ethical standards as bases for understanding State compliance with declaration ethics in research - Discuss the significance of ethics in EBP THERAPEUTIC RESEARCH – direct benefit for the patient. - Determine the ethico-moral role of nurse in the NON-THERAPEUTIC RESEARCH – advancement of knowledge implementation of EBP for the benefit of future patients. - Explain the good clinical practice guidelines ETHICAL STANDARDS IN NURSING RESEARCG - Act of moral principle which the researcher has to follow Premise allowing Non-therapeutic researchers: while conducting nursing research. o Protects participants form harm - To ensure the rights and welfare of individuals, groups, or o Strong independent justification for exposing community under study are protected. healthy volunteer to substantial risk of harm just to gain new scientific information 3 ETHICAL STANDARDS o Protect the life and health of the participants 1. NUREMBERG CODE 3. BELMONT REPORT - Consider as most important document in the history of the - Publicity from Syphilis Study ethics of medical research - National Research Act of 1974 - The code was formulated 50 years ago (August 1946 in - National Commission for the protection of Human Subject Nuremberg Germany by American Judges setting of of Biomedical and Behavioral Research judgement of Nazi doctor accused of conducting - Basic ethical principle that should underlie the conduct of murderous and torturous human experimentation in biomedical and behavioral research the concentration camps. 3 PROGRAM: 3 ETHICAL PRINCIPLE Sterilization of racial enemies 1. BENEFICENCE Euthanasia of racially impure - Obligation to benefit others and maximize possible Medical experiment of racially valueless benefits - Freedom from any physical and Psychological Harm CODE STIPULATED - Freedom from exploitation Voluntary consent 2. RESPECT FOR PERSON/HUMAN DIGNITY Withdrawal of subject from study Right to be protected and respected: Protection of the subject form physical and mental Right to self determination suffering, injury, disability, and death. Right to full disclosure Balanced of benefits and risk. Right to privacy 3. JUSTICE 2. DECLARATION OF HELSINKI - Fair and equitable treatment before, during, and after the - World medical Association in 1964; updated in 2000 & study: 2004 Right to fair treatment – it means that the - Distinction between therapeutic and non-therapeutic selection of some groups like that of a research minority group should be done systematically - Focus on the obligations of physician-investigators to where all have a chance to selected as a study research subject. participants. It also relates to researchers treat in those clients to participate in the BASIC PRINCIPLE Conform to accepted scientific principle study fairly without any prejudice. Design formulated in experimental protocol, review by Anonymity and confidentiality – It means IRC. that there is no way for anyone including the Conducted by qualified and trained person researcher to personally identify the Importance in proportion to inherent risk. participants in the study. This means that no Assessment of risk vs. Benefit’s personally identifying information can be Safeguard subjects integrity (privacy) collected in an anonymous study personally Abstain unless hazard are predictable identifying information includes but is not Preserve accuracy when publishing limited names, addresses, email addresses, Adequately inform or right to withdraw phone numbers, government issues ID’s/numbers, photographs and IP addresses. NCM 108 This also means that study conducted face to ROLE OF NURSES IN EBP face or over the phone cannot be consider Each client get possible services anonymous. Next term is confidentiality Update knowledge which means that the participants can be Provide clinical judgement identified but their identities are not revealed Improvement care provided to anyone outside of the study. In other Saves lives words only the researcher knows the The researchers must adhere to the following: identities of the participants and measured in a. Standards of Declaration of Helsinki put in place to ensure that the participant b. Conduct of clinical research as per identities are not revealed to anyone else. Declaration of Helsinki protocols Right to intellectual property – it ensure that c. Ethics of clinical practice dictated by financial the researchers benefits from his work it will and circumstantial considerations protect him from unfair use by others or the researcher cannot use the data they gathered ETHICO-MORAL RESPONSIBILITIES OF NURSE IN EBP from the participants or another study 1. There is a sound basis of the intervention done to the without the consent of the said participants. patient and it is carried out in an ethically appropriate manner. ETHICS VS EVIDENCE BASED RESEARCH 2. Ethical guidelines are followed in the conduct of ETHICS evidence-based practice. - Professional values 3. Observed that nobody will be hurt in the process of - Every human being follow ethical practices implementation. - Research work within the proven evidence, either 4. The rights of the patient will be observed at all times scientific or based on experience. during the implementation of EBP. EVIDENCE GOOD CLINICAL PRACTICE (GCP) - Responsibility to follow the ethical practices - International ethical and scientific quality standards for - Positive and negative evidences are published in the designing, conducting, recording, and reporting trials that journal involved the participation of human subject. - Accessible to the public - Compliance with this standards provides public assurance - Required by Declaration of Helsinki that: EVIDENCE BASED PRACTICE Rights, safety, and well-being of the trial - is an integration of clinical expertise, patient values, and subject are protected best research evidence into the decision making process Consistent with the principle of Declaration for patient care. of Helsinki Clinical trials are credible GOAL OF EVIDENCE BASED PRACTICE (EBP) To provide practicing nurse the evidence-based data Objectives of this guidelines: to deliver effective care. To provide a unified standard for the European Union Resolve problem in clinical setting (EU), Japan and the United State to facilitate the Achieve excellence in care delivery mutual acceptance of clinical data by the regulatory Reduce the variation s in nursing care and assist with authorities in this jurisdiction. efficient and effective decision making. EBP SEVEN LEVELS EVIDENCE GOOD CLINICAL PRACTICE 1. Systematic reviews - metanalysis and metasynthesis – - Develop in consideration of the current good clinical highest evidence practices of EU, Japan, US, as well as Australia, Canada, 2. Single RCT the Nordic countries and WHO. 3. Systematic review of correlational/observational - Can be applied to other clinical investigation that may studies have an impact on safety and well-being of the human 4. Single correlation/observational studies subjects. 5. Systematic review of Guidelines of GOOD CLINICAL PRACTICE: descriptive/qualitative/physiologic studies Conduct clinical trial with an ethical eye 6. Single descriptive/qualitative/physiologic studies Subject protection is the paramount priority 7. Opinions of authorities and expert committees NCM 108 Have a well-designed plan, and stick to it! operations without anesthesia, or exposing them to Select qualified study staff hypothermia studies. Documentation is essential Code stipulated: a) Importance of voluntary consent of the subjects of research. NCM 108 – WEEK 3 BIOETHICS b) Right of the subjects to withdrawal from the subjects from study anytime they feel there is a threat to their Learning Outcomes: 1. Explain the ethical standards as bases for understanding life. ethics in research. c) Protection of the subjects from the possible harm of the 2. Discuss the significance of ethics in EBP. study. 3. Determine the ethico-morale role of nurses in the d) Protection of subjects from physical and mental implementation of EBP. suffering, injury, disability, and death. 4. Explain the good clinical practice guidelines. e) Balance of benefits and risk brought about by the study. ETHICAL STANDARDS IN NURSING RESEARCH B. DECLARATION OF HELSINKI act of moral principles which the researcher has to This was adapted by the World Medical Association in follow while conducting nursing research. 1964: updated in 2000 & 2004. to ensure the rights & welfare of individuals, groups, or It introduce distinction between therapeutic and community under study are protected. non-therapeutic research. The Nuremberg Code focuses on the human right of 3 ETHICAL STANDARDS IN NURSING RESEARCH research subjects A. Nuremberg Code The declaration of helsinski focus on the obligations of B. Declaration of Helsinki physician-investigators to research subjects and C. Belmont Report emphasizes obligations of research institutions who receive the funds. A. NUREMBERG CODE most important document in the history of the ethics of The declaration stipulated that the research should follow this medical research. BASIC PRINCIPLES: the code was formulated 50 years ago – August 1946 Conform to accepted scientific principles. in Nuremberg Germany Design formulated in experimental protocol, reviewed by by American judges sitting in judgment International Ethics Commission (IEC). of Nazi doctors accused of conducting murderous and Conducted by qualified and trained persons. torturous human experimentation in the concentration Importance in proportion to inherent risk. camps. Assessment of risks vs. benefits. focuses on the human rights of research subjects. Safeguard subject’s integrity (privacy). formulation of Nuremberg Code was to protect subjects Subjects may abstain unless hazards are predictable. under 3 programs: Preserve accuracy when publishing. Adequately inform or right to withdraw. 3 Programs: Obtain true informed consent in writing. a) Sterilization of racial enemies Reliance on legal guardian. - like the Jews, who were considered by the Nazis as State compliance with declaration. threats to German’s pure blood. b) Euthanasia of racially impure Therapeutic research – direct benefit for patient. - for people who are insane or with congenital defects. Nontherapeutic research – advancement of knowledge for the benefit of future patients. A study that does not have direct benefit c) Medical experiments of racially valueless to the study participants. - the prisoners, who are subjects for research then. - they were injected of small pox virus for vaccine Premise allowing Nontherapeutic Research: trials, exposing them to high altitude, performing Protect participants from harm. NCM 108 Strong independent justification for exposing healthy also relates to researchers rating those who volunteer to substantial risk of harm just to gain new declined to participate in the study fairly scientific information. without any prejudice. Protect the life and health of the participants. 2. Anonymity and confidentiality On International –-- in 1999, Declaration of Helsinki was when describing data collection and data revised to address the use of placebos. Placebo is not ethical management procedures for human in virtually all studies that involve diseases with proven participants, these two rights needs to be treatment. They --- ethical in trials where no proven discussed. treatment is seen. The revision was due to controversy over the use of placebos in attempting to find easy or cheap way to reduce HIV perinatal transmission. The study was conducted i. Anonymity in Ivory Coast, Uganda and Thailand, where HIV positive there is no way for anyone, including the pregnant women are given either placebo or shorter course researcher to personally identify of AZT. participants in the study. This means that no personally identifying C. BELMONT REPORT information can be collected in an due to the publicity from Syphilis Study anonymous study. National Research Act of 1974 was passed Personally identifying information includes, created National Commission for the protection of but is not limited to names, addresses, email Human Subjects of Biomedical and Behavioral Research addresses, phone numbers, government “Belmont Report” was the title of the report published by issued ID numbers, photographs and IP the National Commission Human Subjects of Biomedical addresses. and Behavioral Research which basic ethical principles This also means that any study conducted that should underlie the conduct of biomedical and face-to-face or over the phone can be behavioral research, which identified basic ethical considered anonymous. principles that should underline the conduct of biomedical and behavioral research. ii. Confidentiality this means that the participants can be 3 Ethical Principles: identified but their identities are not 1. Beneficence revealed to anyone outside of the study. In obligation to benefit others and maximize possible other words, only the researchers knows benefits the identities of the participants and in research, subject should enjoy freedom from any measures are put in place to make sure that physical and psychological harm participant’s identities are not revealed to freedom from exploitation anyone else. 2. Respect For Human Dignity Rights of those involved in the study must be 3. Right to intellectual property protected and respected: this ensures that the researcher benefits from his i. Right to self determination work. It will protect him unfair use by others. ii. Right to full disclosure or the researcher cannot use the data gathered iii. Right to privacy from the participants for another study without 3. Justice the consent of the said participants. fair and equitable treatment before, during, and after the study: EVIDENCE BASED RESEARCH 1. Right to fair treatment ETHICS VS EVIDENCE BASED RESEARCH the selection of some groups (like that of a Is there a conflict? minority group) should be done systematically where all have the chance at being selected as Ethics a philosophical term for professional values. a study participant. NCM 108 Every human being is supposed to follow ethical c. Ethics of clinical practice dictated by financial and practices in every walk of life. circumstantial considerations Research are also supposed to work within the gambit of like with the funds and resources are utilized proven evidence, either scientific or based on optimally. experience. The source of the funds has no rested interest on the results of the study. EVIDENCE BASED RESEARCH scientific researchers have a greater responsibility to Ethico-moral Responsibilities of Nurses in EBP: follow the ethical practices, as their positive and 1. There is a sound basis of the intervention done to the negative reporting are followed by billions. patient and it is carried out by an ethically appropriate positive and negative evidences are published in the manner. journal to make it accessible to the public as required by 2. Ethical guidelines are followed in the conduct of Declaration of Helsinki. evidence-based practice. an integration of clinical expertise, patient values, and 3. Observe that nobody will be hurt in the process of best research evidence into the decision making process implementation. for patient care. 4. The rights of the patients will be observes at all times during the implementation of EBP. Goal of EPB: a. Provide practicing nurse the evidence-based data to GOOD CLINICAL PRACTICE (GCP) deliver effective care. international ethical and scientific quality standard for b. Resolve problem in clinical setting. designing, conducting, recording, and reporting trials that c. Achieve excellence in care delivery. involve the participation of human subjects. d. Reduce the variations in nursing care and assist with efficient and effective decision making. Compliance with this standard provides public assurance that: rights, safety, and well-being of the trial subjects are EBP is the product of Seven (7) Levels of Evidence (provides the protected highest evidence, down to the opinionated studies created by the consistent with the principles of Declaration of Helsinki authorities and expert committees (discussed in Nursing clinical trials are credible. Research): a. Systematic Reviews – Metanalysis & Metasynthesis – Objective of this guideline: highest evidence provide a unified standard for the European Union (EU), b. Single RCT Japan and the United States to facilitate the mutual c. Systematic review of correlational/observational studies acceptance of clinical data by the regulatory authorities d. Single correlational/observational studies in these jurisdictions. e. Systematic review of descriptive/qualitative/physiologic Developed in consideration of the current good clinical studies practices of European Union, Japan, US, as well as f. Opinions of authorities & expert committees Australia, Canada, the Nordic countries and WHO. Can be applied to other clinical investigations that may Role of Nurses in EBP have an impact on safety & well-being of the human Each client get possible services subjects. Update knowledge – essential for lifelong learning Provide clinical judgement Guidelines of Good Clinical Practice: Improvement care provided Conduct clinical trials with an ethical eye. Save lives Subject protection is the paramount priority. Have a well-designed plan, and stick to it. With the benefit of having ethics in EBP utilization, Select qualified study staff. The researchers must adhere to the following: Documentation is essential. a. Standards of Declaration of Helsinki b. Conduct of clinical research as per Declaration of Update on EBP: Helsinki protocols where both the positive and negative results Evaluating Nurses’ Understanding and Participation in the are published. Informed C
