NCM108
HEALTHCARE ETHICS
MODULE 1 - C
TOPIC: ETHICAL PRINCIPLES
PROFESSOR: Dr. Ma. Virginia Bautista Camarinta
TOPIC OBJECTIVES:
o Identify the ethical principles applied in the nursing profession;
o Demonstrate knowledge and skills of ethical principles that nurses must adhere;
o Recognize ethical dilemmas and take appropriate actions; and
o Evaluate ethical outcomes of intervention to promote ethical practice;
We have learned in the previous module 1-A and B about the concept on Ethics.
Ethics is simply defined as, the principle that describe what is expected in terms what is right and
correct and wrong in terms of behavior; Ethics employs the marvelous faculty of human reason upon
the supremely important question of what is upright life is and must be.
The study of ethics seeks to provide means of formulating answers to questions and so guide
questions. It provides a framework for dealing with issues, problems, and dilemmas. An understanding
of ethical and moral theories helps a person to decide on an appropriate line of action. The broad
understanding of what is right or wrong in human conduct is taught to us by our families, religion,
national culture, and legal structure.
Ethics is that part of philosophy that deals with systematic approaches to questions of morality. It
provides an intellectual framework that allows us to analyze and make decisions in regard to moral
choices.
We commonly associate ethics to customs, morals, and etiquette, and even used them
interchangeably.
Customs are acts approved by a group or society; while,
Etiquette is a social observance required by good breeding and in a composed manner. i.e. table
manners, dress codes, etiquette on talking, etc.
The Objectives of Ethics are to:
1. make clear to us why one act is better than another;
2. live in an orderly social life;
3. appraise and criticize intelligently the moral conduct and ethical system; and
4. seek the true value of life.
The Parts of Ethics are:
1. General Ethics which deals with the basic principles which are the morality of human acts; and
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2. Social Ethics which tackles on the basic principles in the life of a man as member of the society.
Professional ethics is a branch of moral science that the treats of the obligations which a member of a
profession owes to the public, to his profession, and to his clients.
The most occurring ethical issues and concerns in healthcare include the allocation of scarce resources
and end life issues.
Bioethics is the term used to describe the application of ethics to biological sciences, medicine, and
related fields; a systematic study of moral conduct in life sciences and medicine; For M.T. Reich, it is a
systematic study of human behavior, specifically, in the fields of life sciences and healthcare, as
examined in the light of moral values and principles. Bioethics is a subcategory of ethics. Bioethics
addresses ethical concerns like those that occur as a result of advancing science and technological
advances.
Some of the most common, current bioethical issues revolve around stem cells, cloning, and genetic
engineering.
There are two major classifications of Ethical Theories:
1. Deontology is an ethical school of thought that requires both the means and end goals must be moral
and ethical; it is patient-centered; on the other hand,
2. Utilitarianism thought states that the end goal justifies the means even when the means are not
moral; it is leaning towards the benefit of the many;
The Ethical Principles that Nurses must adhere to are the:
o Principle of Justice
o Beneficence
o Non-maleficence
o Accountability
o Fidelity
o Autonomy
o Veracity
Principle of Justice.
Nurses must fair when distributing care. Care must be fairly, justly, and equitably distributed among a
group of patients. The maintenance of this ethical principle is seemingly very simple in the abstract and
complex in application, as it looks at the concepts of fairness, just deserts, and entitlements. We factor
in considerations and measurements to confront distribution problems (including goods and services)
and what is due to an individual.
i.e. several methods of distribution of goods and services, at an attempt in some measure to provide a
system in which individual receive their due share.
1. to each, an equal share (e.g. primary, elementary, and tertiary education)
2. to each, according to the need (e.g. aid the needy and programs such as food stamps, rations,
Social Amelioration Program)
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3. to each, according to effort (e.g. unemployment benefits)
4. to each, according to contribution (e.g. retirement benefits)
5. to each, according to merit (e.g. jobs and promotions)
6. to each, according to ability to pay (e.g. free market exchange)
Cases to decide on reflecting on the principle of justice.
Should an elderly be provided the same level of health care as that provided to children?
Who shall be denied on lifesaving treatments when there is not enough for all?
Principle of Beneficence.
Doing good and right thing for the patient. Acts of mercy and charity, to include any action that benefits
another.
Statements on Beneficence. All the statements of beneficence involve action toward preventing, or
removing harm, and promoting the good.
1. one ought to prevent harm
2. one ought to remove harm
3. one ought to do or promote good
The technology of modern healthcare and therapeutics has made this principle a most difficult principle
to follow, because much of what we do has unfortunate secondary or side effects.
e.g. administration of steroids to patients with asthma, to relax the smooth muscles of the airway, while
developing side effects of Cushing Syndrome (weight gain, high blood pressure, slow wound healing,
and acne)
administration of morphine sulfate for pain, may lead to suppression of respiration.
In an attempt to explain the principle of Non-maleficence, practitioners have explained their actions
through the *principle of double effect. With this concept, the secondary effects may be foreseen, but
can never be an intended outcome. Good intentions outweigh harmful effects.
Guiding elements for the principle of double effect.
The course chosen must be good or at least morally neutral.
The good must not follow as a consequence of the secondary harmful effects.
The harm must never be intended but merely tolerated as casually connected with the good intended.
The good must outweigh the harm.
Principle of Non-maleficence.
Doing no harm, as stated in the Hippocratic Oath statement “I will never use treatment to injure or
wrong the sick”. In some way, this seems to very similar to the duty of beneficence, where the
practitioner works to maximize the good for the patient and to minimize the harm.
Accountability.
Accepting responsibility for one’s own actions. Nurses are accountable for their nursing care and other
actions. Nurses must accept all the professional and personal consequences that can occur as a result
of their actions.
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Fidelity.
Keeping one’s promises. The nurse must be faithful and true to their professional promises and
responsibilities by providing quality, safe care in a competent manner. Practice faithfully your nursing
profession.
Autonomy and patient self-determination.
Upheld when the nurse accepts the client as a unique person who has innate right to have their own
opinions, perspectives, values, and beliefs. Nurses encourage patients to make their decisions without
judgements or coercion from the nurse. The patient has the right to reject all the treatment.
Patients’ Rights.
1. The Right to Appropriate Medical care and Humane Treatment.
Every person has the right to health and medical care corresponding to his state of health, without any
discrimination and within the limits of the resources, manpower, and competence. In the course of
such, his human dignity, convictions, integrity, individual needs and culture shall be respected. If any
person cannot immediately be given treatment that is medically necessary he shall, depending on his
state of health, either be directed to wait for care, or be referred or sent for treatment elsewhere, where
the appropriate care can be provided. If the patient has to wait for care, he shall be informed of the
reason for the delay. Patients in emergency shall be extended immediate medical care and treatment
without any deposit, pledge, mortgage or any form of advance payment for treatment.
2. Right to Informed Consent.
The patient has a right to a clear, truthful and substantial explanation, in a manner and language
understandable to the patient, of all proposed procedures, whether diagnostic, preventive, curative,
rehabilitative or therapeutic, wherein the person who will perform the said procedure shall provide his
name and credentials to the patient, possibilities of any risk of mortality or serious side effects,
problems related to recuperation, and probability of success and reasonable risks involved:
Provided, That the patient will not be subjected to any procedure without his written informed
consent, except in the following cases:
a) in emergency cases, when the patient is at imminent risk of physical injury, decline Of death if
treatment is withheld or postponed. In such cases, the physician can perform any diagnostic or
treatment procedure as good practice of medicine dictates without such consent;
b) when the health of the population is dependent on the adoption of a mass health program to control
epidemic;
c) when the law makes it compulsory for everyone to submit a procedure;
d) When the patient is either a minor, or legally incompetent, in which case. a third party consent Is
required;
e) when disclosure of material information to patient will jeopardize the success of treatment, in
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which case, third party disclosure and consent shall be in order;
f) When the patient waives his right in writing.
Informed consent shall be obtained from a patient concerned if he is of legal age and of sound mind. In
case the patient is incapable of giving consent and a third party consent is required.
The following persons in the order of priority stated hereunder, may give consent:
i. spouse;
ii. son or daughter of legal age;
iii. either parent;
iv. brother or sister of legal age, or
v. guardian
If a patient is a minor, consent shall be obtained from his parents or legal guardian. If next of kin,
parents or legal guardians refuse to give consent to a medical or surgical procedure necessary to
save the life or limb of a minor or a patient incapable of giving consent, courts, upon the petition of the
physician or any person interested in the welfare of the patient, in a summary proceeding, may issue an
order giving consent.
3. Right to Privacy and Confidentiality. - The privacy of the patients must be assured at all stages of
his treatment. The patient has the right to be free from unwarranted public exposure, except in the
following cases: a) when his mental or physical condition is in controversy and the appropriate court, in
its discretion, order him to submit to a physical or mental examination by a physician; b) when the
public health and safety so demand; and c) when the patient waives this right in writing.
The patient has the right to demand that all information, communication and records pertaining to his
care be treated as confidential. Any health care provider or practitioner involved in the treatment of a
patient and all those who have legitimate access to the patient's record is not authorized to divulge any
information to a third party who has no concern with the care and welfare of the patient without
his consent, except: a) when such disclosure will benefit public health and safety; b) when it is in the
interest of justice and upon the order of a competent court; and c) when the patients waives in writing
the confidential nature of such information; d) when it is needed for continued medical treatment
or advancement of medical science subject to de-identification of patient and shared medical
confidentiality for those who have access to the information.
Informing the spouse or the family to the first degree of the patient's medical condition may be allowed;
Provided That the patient of legal age shall have the right to choose on whom to inform. In case the
patient is not of legal age or is mentally incapacitated, such information shall be given to the parents,
legal guardian or his next of kin.
4. Right to Information. - In the course of his/her treatment and hospital care, the patient or his/her
legal guardian has a right to be informed of the result of the evaluation of the nature and extent of
his/her disease, any other additional or further contemplated medical treatment on surgical
procedure or procedures, including any other additional medicines to be administered and their generic
counterpart including the possible complications and other pertinent facts, statistics or studies,
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regarding his/her illness, any change in the plan of care before the change is made, the
person's participation in the plan of care and necessary changes before its implementation, the
extent to which payment maybe expected from Philhealth or any payor and any charges for which the
patient may be liable, the disciplines of health care practitioners who will furnish the care and the
frequency of services that are proposed to be furnished.
The patient or his legal guardian has the right to examine and be given an itemized bill of the hospital
and medical services rendered in the facility or by his/her physician and other health care providers,
regardless of the manner and source of payment. He is entitled to a thorough explanation of such bill.
The patient or his/her legal guardian has the right to be informed by the physician or his/her
delegate of his/her continuing health care requirements following discharge, including instructions about
home medications, diet, physical activity and all other pertinent information to promote health and well-
being.
At the end of his/her confinement, the patient is entitled to a brief, written summary of the course of
his/her illness which shall include at least the history, physical examination, diagnosis, medications,
surgical procedure, ancillary and laboratory procedures, and the plan of further treatment, and which
shall be provided by the attending physician. He/she is likewise entitled to the explanation of, and to
view, the contents of medical record of his/her confinement but with the presence of his/her attending
physician or in the absence of the attending physician, the hospital's representative.
Notwithstanding that he/she may not be able to settle his accounts by reason of financial
incapacity, he/she is entitled to reproduction, at his/her expense, the pertinent part or parts of
the medical record the purpose or purposes of which he shall indicate in his/her written
request for reproduction. The patient shall likewise be entitled to medical certificate, free of
charge, with respect to his/her previous confinement.
5. The Right to Choose Healthcare Provider and Facility. - The patient is free to choose the health care
provider to serve him as well as the facility except when he is under the care of a service facility or
when public health and safety so demands or when the patient expressly waives this right in writing.
The patient has the right to discuss his condition with a consultant specialist, at the patient's request
and expense. He also has the right to seek for a second opinion and subsequent opinions, if
appropriate, from another health care provider/practitioner.
6. Right to Self-Determination. - The patient has the right to avail himself/herself of any recommended
diagnostic and treatment procedures. Any person of legal age and of sound mind may make an
advance written directive for physicians to administer terminal care when he/she suffers from the
terminal phase of a terminal illness: Provided That:
a) he is informed of the medical consequences of his choice; b) he releases those involved in his care
from any obligation relative to the consequences of his decision; c) his decision will not prejudice public
health and safety.
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7. Right to Religious Belief. - The patient has the right to refuse medical treatment or procedures
which may be contrary to his religious beliefs, subject to the limitations described in the preceding
subsection: Provided, That such a right shall not be imposed by parents upon their children who have
not reached the legal age in a life threatening situation as determined by the attending physician or the
medical director of the facility.
8. Right to Medical Records. - The patient is entitled to a summary of his medical history and condition.
He has the right to view the contents of his medical records, except psychiatric notes and other
incriminatory information obtained about third parties, with the attending physician explaining contents
thereof. At his expense and upon discharge of the patient, he may obtain from the health care
institution a reproduction of the same record whether or not he has fully settled his financial obligation
with the physician or institution concerned.
The health care institution shall safeguard the confidentiality of the medical records and to likewise
ensure the integrity and authenticity of the medical records and shall keep the same within a
reasonable time as may be determined by the Department of Health.
The health care institution shall issue a medical certificate to the patient upon request. Any other
document that the patient may require for insurance claims shall also be made available to him within
forty-five (45) days from request.
9. Right to Leave. - The patient has the right to leave hospital or any other health care institution
regardless of his physical condition: Provided. That a) he/she is informed of the medical
consequences of his/her decision b) he / she releases those involved in his/her care from any
obligation relative to the consequences of his decision; c) his/her decision will not prejudice public
health and safety.
No patient shall be detained against his/her will in any health care institution on the sole basis of his
failure to fully settle his financial obligations. However, he/she shall only be allowed to leave the
hospital provided appropriate arrangements have been made to settle the unpaid bills: Provided.
further, That unpaid bills of patients shall be considered as loss income by the hospital and health care
provider/practitioner and shall be deducted from gross income as income loss only on that particular
year.
10. Right to Refuse Participation in Medical Research. - The patient has the right to be advised if the
health care provider plans to involve him in medical research, including but not limited to human
experimentation which may be performed only with the written informed consent of the patient:
Provided, That, an institutional review board or ethical review board in accordance with the guidelines
set in the Declaration of Helsinki be established for research involving human experimentation:
Provided, further, That the Department of Health shall safeguard the continuing training and
education of future health care provider/practitioner to ensure the development of the health care
delivery in the country: Provided, furthermore, That the patient involved in the human experimentation
shall be made aware of the provisions of the Declaration of Helsinki and its respective guidelines.
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11. Right to Correspondence and to Receive Visitors. - The patient has the right to communicate with
relatives and other persons and to receive visitors subject to reasonable limits prescribed by the rules
and regulations of the health care institution.
12. Right to Express Grievances. - The patient has the right to express complaints and grievances
about the care and services received without fear of discrimination or reprisal and to know about the
disposition of such complaints. Such a system shall afford all parties concerned with the opportunity to
settle amicably all grievances.
13. Right to be Informed of His Rights and Obligations as a Patient. - Every person has the right to be
informed of his rights and obligations as a patient. The Department of Health, in coordination with
heath care providers, professional and civic groups, the media, health insurance corporations, people's
organizations, local government organizations, shall launch and sustain a nationwide information and
education campaign to make known to people their rights as patients, as declared in this Act
Such rights and obligations of patients shall be posted in a bulletin board conspicuously placed in a
health care institution.
It shall be the duty of health care institutions to inform of their rights as well as of the institution's rules
and regulations that apply to the conduct of the patient while in the care of such institution.
Additional Notes
Informed Consent.
Defined as the patient's choice to have a treatment or procedure which is based on their full
understanding of the treatment or procedure, its benefits, its risks, and any alternatives to the particular
treatment or procedure. All clients have the legal right to autonomy and self-determination to accept or
reject all treatments and interventions.
Advance Directive.
Advance Directives are integrated into the client's plan of care by nurses and other healthcare
professionals. Any and all information about advance directives is also documented and communicated
with other members of the healthcare team so that all of these client's choices are upheld in all aspects
of care and all clients should be encouraged to initiate advance directives whenever they have failed to
generate these important documents in the past.
The ultimate purpose of advance directives is to guide professional decision making and direct the
client's care and treatments at the end of life. Advance directives also provide the legal basis for all
clients to accept or reject care as they wish because they have the innate right to autonomous decision
making without coercion and self-determination even when they are no longer competent to do so.
Nurses must review and verify the patient's advance directive status with their first patient contact
because an emergency life threatening situation like a cardiac or respiratory arrest can occur at any
time with little or no time to review these documents at that time. If, for example, the patient has an
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advance directive to NOT have CPR, the nurse may administer CPR because they have failed to
review the client's advance directive. This CPR, then, is contrary to the patient's wishes.
References:
Printed Materials:
Edge, Raymond S. and Groves, John Randall (1999) Ethics of Health Care: A Guide for Clinical
Practice. Second Edition. Delmars Publications. Pp. 39-51
Ciabal, Laura (2001). Health Ethics: A Guide for Health Allied Professions. First Edition. Educational
Publishing House.
Rumbold, Graham (2001). Ethics in Nursing Practice. Third edition. Bailliere Tindall Publishing.
Published in Association with the Royal College of Nursing.
Online Materials:
https://www.registerednursing.org/nclex/ethical-practice
https://samch.doh.gov.ph/index.php/patients-and-visitors-corner/patients-rights
