BIOETHICS WEEK 2 ETHICS AND VALUES oValues Enduring beliefs or attitudes about the worth of a person, object, idea,

a, or action. These are important because they influence decisions and actions, including nurses ethical decision making. oValue Transmission Values are learned through observation and experience. As a result, they are heavily influenced by a persons socio-cultural environment that is by societal traditions; by cultural, ethnic, and religious groups; and by family and peer groups. For example, if a parent consistently demonstrates honesty in dealing with others, the child will probably begin to value honesty. Nurses should keep in mind the influence of values in health, For example, some cultures value treatment by a folk healer over that of a physician. oValues Clarification This is a process by which people identify, examine, and develop their own individual values. A principle of values clarification is that no set of values is right for everyone. Values clarification promotes personal growth by fostering awareness, empathy, and insight. This process is an important step for nurses to take in dealing with ethical problems. One widely used theory of values clarification was developed by Raths, Harmin, and Simon (1978). They described a valuing process of thinking, feeling, and behaviour that they termed as choosing, prizing, and acting. VALUES CLARIFICATION 1. Choosing (cognitive) beliefs are chosen Freely, without outside pressure From among alternatives After reflecting and considering consequences Example: A person learns bout energy resources, production, and consumption; the greenhouse effect; and other environmental issues,including ways to minimize use of and recycle limited resources. 2. Prizing (affective) chosen beliefs are prized and cherished. Example: The person is proud of the belief that he or she has an obligation to participate in reducing environmental waste. 3. Acting(behavioral) chosen beliefs are: Affirmed the others Incorporated into ones behavior Repeated constantly in ones life Example: The person participates in the city recycling program for household waste, uses public transportation rather than driving a personal car when possible, helps organize recycling in the workplace, and is active in legislative and political activities related to environment. Clarifying Nurses Values Nurses and nursing students need to examine the values they hold about life, death, health, and illness. One strategy for gaining awareness of personal values is to consider ones attitudes about specific issues such as abortion, euthanasia, asking: 1. Can I accept this, or live with this? 2. Why does this bother me? 3. What would I do or what do I want to do in this situation? Nurses must understand that values are individual rather than universal; therefore, nurse should not impose their own values on patients. Clarifying Clients Values To plan effective care, nurses need to identify clients values as they influence and relate to particular health problems. When clients hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as intervention. The following process may help clients clarify their values: 1.List alternatives - make sure that the client is aware of all alternative actions. Ask, Are you

considering other courses of action? Tell me about them. 2.Examine possible consequences of choices- make sure the client has thought about possible results of each action. Ask, what do you think you will gain from doing that? What benefits do you foresee from doing that? 3.Choose freely - to determine whether the client choose freely, ask Do you have any participation in the decision-making? Or Do you have a choice? 4.Feel good about the choice - to determine how the client feels; ask how do you feel about that decision (or action)? 5.Affirm the choice - ask how will you discuss this with others (family or friends)? 6.Act on the choice - to determine whether the client is prepared to act on the decision, ask for example, Will it be difficult to tell your wife about this? 7.Act with a pattern - to determine whether the client consistently behaves in a certain way, ask How many times have you done that before? or Would you act that way again? oPersonal Values These are internalized values derived from society and their individual subgroups. These societal values are needed in order to feel accepted and have a sense of individuality. Example:honesty, compassion, acceptance, preservation of integrity towards others. oProfessional Values Nurses professional values are acquired during socialization into nursing from code of ethics, nursing experiences, teachers, and peers. Example: respect for human dignity, respect for the rights of others, wholeness of character, maintenance of competence ESSENTIAL NURSING BEHAVIORS AND VALUES oValues Altruism It is concern for the welfare and well-being of others, in professional practice. This is reflected by the nurses concern for the welfare of patients, other nurses, and other health care providers. Autonomy Is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients rights to make decisions about their health care. Human dignity Is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues. Integrity Is acting in accordance with an appropriate code of ethics and acceptable standards of practice. Integrity is reflected in professional practice when the nurse is honest and provides care, based on an ethical framework that is accepted within the profession Social Justice Is upholding moral, legal, and humanistic principles. This value is reflected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality health care. oProfessional Behaviours Demonstrates understanding of cultures, beliefs, and perspectives of others. Example: When caring for a patient whose beliefs does not permit him to undergo certain medical treatments. Advocates for patient, particularly the most vulnerable. Example: When a patient is incapable of evaluating the risks involved when included in an investigative study, the nurse can speak for the patient. Takes risks on behalf of patients and colleagues. Nurses can act as a third person in an investigative study because of the possible danger or injury on the subject. Mentors other professionals. Example: A young nurse asked for mentorship on certain educational endeavour such as adviser for a

research project. Plans care in partnership with patients. Example: The nurse and the patient and his family must plan together in the management care of care. Honours the right of patients and families to make decisions about health care. Example: The nurses primary task is to inform the patient and the family with all the information about the available options or care, including cost, procedures, benefits, and risks, and the patient and the family who shall make the voluntary choice and decision. Provides information so patients can make informed choices. Example: The nurse provides the correct, clear, and accurate information of the treatment including the side effects, and after effects of the treatment, and possible complications. Provides culturally competent and sensitive care. Example: The nurse must consider the religious beliefs and practices of the patient in rendering nursing care. Protects patients privacy. Example: The nurse must keep all information,communication and records of care of the patient except in the interest of justice. Preserves the confidentiality of patients and health care providers. Example: Any information gathered by the nurse during the course of caring for the patient must be treated confidential. This duty extends even after the patients death. Designs care with sensitivity to individual patient needs. Example: Care planned for a diabetic patient considers the needs of the patient as to age, gender, and religion. Provides honest information to patients and the public. Example: Any medical findings and treatment, etc. relative to the care of the patient must be accurately relayed to the patient and his significant others Documents care accurately and honestly. Example: This is done in proper charting of any care done by health care team. Seeks to remedy errors made by self or others. Example: When medication error is done, report right away the error with honesty and truthfulness in order to have immediate remedy. Demonstrates accountability for own actions. The nurse is responsible and accountable for individual nursing practice and determines appropriate delegation of tasks. Supports fairness and non-discrimination in the delivery of care. The nurse takes appropriate action to safeguard the proper and equal distribution of health services to all sectors of society. Promotes universal access to health care. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the people. She collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs. Encourages legislation and policy consistent with the advancement of nursing care and health care As a health care professional, the nurse has the expertise to be an advocate for the health care needs in the community. The nurse can contact the congressional representatives in support of legislation that benefits health care and the nursing profession. The nurse can also offer to serve on health policy task forces and committees. ETHICS AND MORALITY oMorality This refers to private, personal standards of what is right and wrong in conduct, character or attitude. oMoral Development Theories

Jean Piagets Stages of Moral Development Amoral phase (ages 0-2) The child is totally self-centered. Egocentric stage (ages 2-7) They are particularly interested in or concerned with rules. Play is on fun not on the observation of rules. Heteronomous stage (ages 7-12) They enter the period of morality of constraint. At this stage, rules are taken very seriously, and they tend to view behaviour as right or wrong Kohlbergs Stages of Moral Reasoning Pre-conventional Morality (ages 2-7) Although children are essentially amoral, very young children are moral rather in a primitive way, which Kolhberg described by the 2 pre-conventional stages. Stage 1: Reward and Punishment. During this stage children do not have yet understanding of values and accept the authority of others. They assume that powerful individuals in their lives have the right to hand down a fixed set of rules, which they must obey. Issues of good or bad depend on the physical consequences. Stage 2: Individualism and Exchange Children begin to recognize that other individuals have their own interests which need to be taken into account. This is the Ill scratch your back if you scratch mine phrase, a time of simple exchange and reciprocity. Human relations are viewed in the pragmatic terms of the marketplace rather than in consideration of loyalty or justice. Conventional Morality (ages 7-12) As children approach elementary school age, they are usually capable of conventional morality, in which they conform to the societal expectations of family or group in order to win the approval of authority figures. Post-conventional Morality (ages12 and beyond) The focus at this stage is the development of social contract and autonomous decision making apart from outside authorities. The level allows the individual to rise above morality based on authority to one based on reason. Stage 5: Social Contract and Individual rights At this stage the individual explores the idea that the creation of the good society requires a social contract into which people freely enter to work for the benefit of all. A good society protects the rights of its citizens, and where injustice are found, allows changes to be made through the use of democratic processes. Stage 6: Universal Principles This is the highest level of moral development, a time when the individual makes a personal commitment to the universal principles of equal rights, social justice, and respect for the basic dignity of all people. When there is a conflict between these values and social contract, the contract takes a back seat to the basic principles. The individual becomes an autonomous agent following the dictates of personal conscience. Stage 3: Good Boy/Good Girl At this stage, the child seeks to conform to the expected social conventions. Good behaviour pleases or helps others; one earns approval by being nice or having good intentions. Children often adhere to a concrete version of the Golden Rule. Stage 4: Law and Order The focus here is fixed on rules, social order,and respect for authority. Right conduct consists of doing ones duty. The value system exemplified by Boy Scout and Girl Scouts would have real meaning at this level of development. Gilligans Stages of Moral Reasoning According to her theory, moral development proceeds through three levels and two transitions, with each level representing a more complex understanding of the relationship of self and others and each transition resulting in a crucial re-evaluation of the conflict between selfishness and responsibility. Stage 1: Caring for oneself a. At this stage the individual is concerned only in caring for the self. She feels isolated,alone, and unconnected to others. b. There is no concern or conflict with the need of others because the focus is on self. c. The focus of this stage is survival.

d. The transition of this stage occurs when the individual begins to view this approach as selfishness and moves toward responsibility. The person begins to realize a need for relationships and connections with other people. Masseys Value Cohorts The major current generation clusters identified by Massey are broken down into four broad categories of worldview value differences: 1.Traditionalists a. They have been shaped to believe in a set of prescribed codes of action that determine how a person behaves on the job, at home, and socially. b. For the traditionalist, society is best structured with everyone knowing, and being in, his or her appropriate place. Stage 2: Caring for others a. During this stage the individual recognizes the selfishness of earlier behaviour and begins to understand the need for caring relationships. b. She approaches relationships with a focus of not hurting others, causing her to be more responsive and submissive to others needs, excluding any thoughts of meeting ones own needs. c. A transition from goodness to truth occurs when there is recognition that this approach can cause difficulties with relationships because of the lack of balance between caring for oneself and caring for others. d. The woman makes decisions on personal intentions and consequences of actions rather than on how she thinks others will react. Stage 3: Caring for self and others a. The person sees the need for a balance between caring for others and caring for self. b. The concept of responsibility includes responsibility for self and other people. c. Care remains the focus on which decisions is made. However, the person recognizes the interconnections between the self and others and realizes that if ones own needs are not met, other people may also suffer. 2.In-Betweeners a. They recognize and accept regulations and make calculating assessments in regard to their personal needs. b. At work, they often appear more like the traditionalist, conforming to standard dress codes and protocol, while in their private lives they may lead very individualistic and informal lifestyles. 3.Challengers a. They are program medina period of permissiveness, when individuality was prized above team play. b. They appear to challenge standards unless conformity benefits their own personal requirements. c. In organizations ,they expect and demand participation and personal consideration. 4.Synthesizers a. They are more conservative than challengers, yet more cynical and skeptical than traditionalist and inbetweeners. b. They perceive a finite and perhaps a shrinking world where the future may well hold less for them in both quality and quantity. c. They see the system as both the problem and the solution. d. They appear to accept the role of adapting to change and the creation of new systems that both provide and sustain. Note: Massey in some sense subscribes to ethical relativism, a view that holds that there are no universal or absolute principles that bind human beings, and that the standards of right and wrong are always relative to the society or culture.

BIOETHIS- WEEK 3

oMoral Frameworks The four types of moral theories discussed below are frameworks for nurses in developing explanations or ethical actions or explanations in health care settings. These moral frameworks guide moral decisions but they do not determine the outcome. Consequence-based (teleological) theories 1. Look at the outcomes (consequences) of action in judging whether that action is right or wrong 2. Utilitarianism, a form of a consequential theory, views a good act as one that brings the most good and the least harm for the greatest number of people (also called the principle of utility) 3. This approach is often used in making decisions about the funding and delivery of health care. 4. These theories focus on issues of justice (fairness). Principle-based (deontological) theories 1. Involve logical and formal processes and emphasize individual rights, duties, and obligations. 2. The morality of an action is determined not by its consequences, but by whether it is done according to an important objective principle. For example, on the rule: do not lie, a nurse might believe she should tell the truth to a dying client, even though the physician has given the instruction not to do so. 3. Deontological theories justify the rules of acceptable behavior differently. Relationship-based (caring) theories 1. Stress commitment, courage, generosity, and the need to nurture and maintain relationships. 2. Caring theories judge actions according to a perspective of caring and responsibility, stressing individual rights that promote the common good or the welfare of the group. Divine Mandate Theory 1. Used in ethical debate. 2. The idea is a simple, believing that there is a divine being who has set down a finite series of rules that adherents claim can provide guidance to most, if not all moral decisions. 3. From the Judeo-Christian traditions,the ten commandments includes moral prohibitions common to most cultures, as well as some specific rules set down to exact adherence to a particular region, providing rules against stealing, adultery, murder, and so on. oMoral Principles These are statements about broad, general, philosophical concepts such as autonomy and justices. They provide the foundation for moral values, which are specific prescriptions for actions. They are useful in ethical discussions because even if people disagree about which action is right in a situation, they maybe able to agree on principles that apply. For example, most people would agree on the principle that nurses are obligated to respect their clients, even if they disagree as to whether the nurse should deceive a particular client about her prognosis. The Different Moral Principles Principle of Autonomy comes from the Greek word autos meaning self andnomos meaning governance. 1.The right to make ones own decisions. a. Nurses who follow this principle recognize that each client is unique, has the right to be what that person is, and has the right to choose personal goals. b. People have inward autonomy if they have the ability to make choices; they have outward autonomy if their choices are not limited or imposed on them. 2.Honoring the principle of autonomy - means that the nurse respects a clients right to make decisions even when those choices seem to the nurse not to be in the clients best interest. 3.Respect for autonomy - means that people should not be treated as an impersonal source of knowledge or training. This principle comes into play, for example, in the requirement that clients provide informed

consent before tests, procedures, or participating as a research subject can be carried out. Principle of Nonmaleficence 1. This is the duty to do no harm. Harm can mean intentionally causing no harm, placing someone at risk of harm, and unintentionally causing harm. 2. Example of nonmaleficence is not assisting in or performing abortion, not assisting persons to commit suicide or not performing euthanasia Principle of Beneficence 1. Beneficence means doing good. Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons. 2. This principle promotes doing acts of kindness and mercy that directly benefit the patient. 3. These acts promote the health of the patient, prevent illness or complications, alleviate suffering, and assist towards peaceful death if the inevitable comes. Principle of Justice 1. In health care, this refers to the right to demand to be treated justly, fairly, and equally. 2. This is often referred to as fairness. Nurses often face decisions in which sense of justice should prevail. For example, a nurse making home visits finds one client depressed and crying, and she knows she could help bystaying for 30 minutes to talk. However, that would take time for her next client who is a diabetic who needs a great deal of teaching and observation. Thus the nurse needs to weigh the facts carefully in order to divide time justly among her clients. Principle of Fidelity Fidelity means to be faithful to agreements and promises, Nurses have responsibilities to clients, employers, government, and society such as the observance of code of ethics. Principle of Veracity This refers to telling the truth. Although this seems straightforward, in practice choices are not always clear. Should a nurse tell the truth when it is known that it will cause harm? Does a nurse tell when it is known that the lie will relieve anxiety and fear? Lying to a sick or dying is rarely justified. The loss of trust in the nurse and the anxiety caused by not knowing the truth, for example, usually outweigh any benefits derived from lying. Nurses must also have professional accountability and responsibility. According to the Code of Ethics for Nurses (ANA, 2001): 1.Accountability - means answerable to oneself and others for ones actions 2.Responsibility - refers to the specific accountability or liability associated with the performance of duties of a particular role, as in the case of a young married man who has AIDS, requests not to tell his diagnosis to his wife. In this case, telling the wife would be more advantageous so that she can be examined, protected or treated. She would also be able to use precautionary measures, understand her husbands condition, and participate in his care. ETHICAL THOUGHTS oKantianism Advocated by Immanuel Kant, a German philosopher of the 18th century. Attempted to define a person as a rational human being with freedom and moral worth. A person is morally good and admirable if actions are done from a sense of duty. Stated that people ought to follow a universal framework of maxims or rules to guide right actions and duties because it is only through dutiful actions that people have moral worth. He emphasized that people should regard everyone with dignity and respect, and when they do not, individuals feel used and demoralized. According to Kant, there are 2 types of duties: Hypothetical Imperatives 1. These are duties or rules that people ought to observe if certain ends are to be achieved. 2. They are sometimes called the if-then imperatives, which are conditional. 3. Example: If I want to show compassion to my patient, then I should perform a compassionate action for my patient.

Categorical Imperatives 1. These are moral actions based on reason. 2. Where moral actions are concerned, duties and laws are absolute, unconditional, and universal. 3. The acting according to a categorical imperative, would ask: If I perform this action, should it become a universal law? 4. No action can ever be judged as right, if the action cannot have a potential to become a binding law for all people. According to Kant, suicide is never acceptable. A person when committing suicide cannot rationally wish that all people should feel free to commit suicide; the world would become chaotic. Kants contributions summarize the ethics of respect for persons such as: principle of autonomy, principle of fidelity, principle of veracity, formalism, the positive rights and negative rights. Principle of Autonomy 1. Comes from the Greek wordautos (self) andnomos (governance) 2. Synonymous with self-determination 3. In health care this means personal liberty, where the individual is free to choose and implement her own decisions, free from deceit, duress, constraint, or coercion. Elements involved in autonomy are: a.the ability to decide b.the power to act on your decisions c.a respect for the individual autonomy of others Application of Autonomy a.Informed consent Derives its rules from autonomy. Health workers are obliged to seek a valid consent because the consenting party is an autonomous person. Respect for autonomy of the patient means that the patient has the capacity to act intentionally ,with understanding, and without controlling influences that would act against a free and voluntary act such as coercion or undue influence. Therefore, nurses do not provide advice or recommendations as to what course of action the patient and his family must resort to, instead, the nurse primary task is to inform them with all the information, there is about the options available, including their cost, procedure, benefits, and risks and it is the patient and his family who shall make their own decision And patients decision must be complied with even if the health care provider disagrees with him or her. Autonomy is not absolute for the law has set forth certain limitations. For example, a person in the acute stage of contagious disease must be isolated, even against his will, in order to prevent the spread of the disease and for the protection of the greater public. b.Standards of Disclosure for Consent to be Adequately Informed What standard should be used in deciding how much information must be transferred for consent to be adequately informed? There are three (3) standards to be considered: i.The Professional Standard -this is the traditional standard which requires a physician to disclose what colleagues similarly situated would have disclosed in similar circumstances. This standard appears to be built on the premise that deciding how much information to disclose is something that only professionals can know, which is related to the Hippocratic ideology. The physicians duty is to keep confidence with certain exceptions, including when the physician believes that it is in the patients interest to disclose. ii.The Reasonable Person Standard - it requires that the physician must disclose what a reasonable patient would want to be told or find significant, even if none of the physician colleagues would agree. iii.The Subjective Standard - the goal is to give the information the patient wants personallymeaningful, in that case it is based on the actual subjective interests of the patient, not to those other persons. In order to do this, the health care provider mustlearn allofthe patients idiosyncratic interests and tastes, lifestyles and preferences. In the case of a nurse who is requested by the children of an aged mother who is suffering from metastatic cancer request not totell her diagnosis and instead proceed with the chemotherapy. c. Paternalism In health care, the concept of paternalism is applied when health care givers, especially physicians,

assume the authority to make decisions for the patients. Paternalism is often thought of as a violation of patients autonomy or the right to make his own decisions ,in instances where patients have diminished decision making capacity wherein the patient is mentally incompetent, delirious ,unconscious, or under the influence of substances,nurses can make the decision for the patient to promote patients well being or to protect patient from harm or injury. d.Standard of Best Interest This pertains to health care providers making decisions about a clients health care when they are unable to make informed decisions about their own care. In this situation, the health care provider decides the best course of action for the patient to be carried out Principle of Fidelity This refers to the obligation of a person to be faithful to agreements, responsibilities, and commitments that he has made to himself and to others. This principle supports the concept of accountability of nurses and other professionals. Principle of Veracity 1. This principle holds that actions or rules are morally right in so far as they involve communicating truthfully and avoiding dishonesty. 2. Veracity binds both the health practitioner and the patient. The patient must tell the truth in order to provide appropriate care. The practitioner needs to disclose factual information so that the patient can exercise personal autonomy. 3. In nursing, veracity is applied in the nurses responsibility never to mislead or deceive the patient. Formalism This theory states that actions or rules are morally right as long as they conform to a specified form rather than being based on the consequences they create. For example, if one person has a right to refuse medical treatment, but the physician has the duty to treat, in this case, that person has the right to be left alone when he refuses treatment. Positive and Negative Rights Rights come in two (2) different forms: 1.Positive Right - implies not only to act autonomously but also to have access to the means necessary to carry out ones actions. 2.Negative Right - the right to be left alone, to be free from the interference of others to act autonomously. In a country where abortion is legal, when a woman decides to have an abortion, she has the negative right meaning she is legally free to pursue an abortion using whatever means available within the constraints of the law. If she can find a physician and has enough money to pay for the procedure, she has the autonomy to arrange and undergo abortion without the state interference. oSocial Justice Theory Advocated by John Rawls, an American philosopher. Proposed that fairness and equality be evaluated under a veil of ignorance, which means that if people had a veil to shield them from their own or others economic, social, and class standing, each person would be more likely to make justice-based decisions from a position free from all biases. His theory examines of how justice in distribution should be related to maximizing social utility. Definition of Social Justice Virtue that guides in creating those organized human interactions we call institutions. In turn, social institutions when justly organized provide access to what is good for the person, both individually and in association with others. Social justice also imposes personal responsibility to work with others to design and continually perfect institutions as tools for personal and social development. Rawlss Contributions to Political and Moral Philosophy Two Principles of Equality and Justice: 1. That everyone should be given equal liberty no matter what adversities exist for people.

2. That difference among people should be recognized by making sure that the least-advantaged people be given what they deserve or their share for improvement. Application to Health Care 1. It could support a practice of paying high salaries to physicians, but only if it were necessary as an incentive to get physicians to expend effort to help those patients who are considered indigent. 2. It could justify shifting some resources to healthier patients if that were the only to way to benefit the indigent patients Standards to be Applied or Considered When Distributions Are Made: 1. Distribute according to market - that is, to those who can afford to pay. 2. Distribute according to social merit - may be according to position in the society or standard of living. 3. Distribute according to medical need - that is to those who have greater need of medical attention. 4. Distribute according to age - that is to the older and younger age groups who are more susceptible to diseases. 5. Distribute according to queuing, or first come, first served. 6. Distribute according to random selection - that is, to select unsystematically without standards or rules to follow. Theory of the Inviolability of an Individual Rawls maintains that all men are inviolable. That is, an individual should not be used as a means in order to attain what is good for others. In this case, all men should be considered of equal worth. Tolerable-Erroneous Theory Principle This is a case of choose-the lesser-evil principle. An act of injustice can be tolerated if only if, it is necessary to avoid an even greater act of injustice. In the case of this principle, it is the only available at hand, and so reason dictates that it must be carried out for the sake of those who are supposed to be benefit or affected by it. oChristian Ethics Advocated by St. Thomas of Aquinas Teaches that there exists a natural moral law, which is manifested by the natural light of human reason, demanding the preservation of the natural order and forbidding its violation. The source of the moral law is reason itself, which guides us to do good and avoid evil. The Christian ethics otherwise known as natural law ethics are: Voice of Reason or Voice of Conscience -directs one to do good and avoid evil. The natural ethicists say that one cannot run away from ones conscience. The following situations further expound the above principle: 1. We know that we are acting rightly, if we heed the voice of reason; we know we are acting wrongly, if we act against it. 2. I know I am doing the right thing, if and when I follow the voice of conscience; otherwise, I feel a sense of guilt, selfreproach, or remorse. 3. What is the good? It is that which is suitable to and proper to human nature. When an act is suitable to human nature, then it is good and it must be done; whenever it is not proper for human nature, it is bad and it must be avoided. 4. How does one know that a particular act is or is not suitable to human nature? By means of whether or not one is following and obeying the voice of reason (conscience), or acting contrary to it. Three (3) Natural Inclinations The natural inclination urges us to care for our health, not to harm or kill ourselves, or put ourselves in danger. The three inclinations are self-preservation, just dealings with others, and propagation of our species. 1.Self-preservation a. It is natural for man to preserve his life, which urges man to care for his health, not to harm or kill himself, or to put others in danger. b. Any act that violates this basic inclination is wrong because it contradicts the Creators very purpose for human nature. c. Acts such as suicide, self-immolation, mercy killing or easy death, smoking, habitual drinking, and putting oneself in unnecessary jeopardy are by nature evil. d. On the other hand, acts that promote health, vim, vigor, and vitality are by nature good.

2. Just dealings with others a. Nature leads us to treat others with the same dignity and respect that we accord ourselves. This is the basis of justice which arises out of human relations. b. Any act of injustice, such as subjecting others to indignities, degradations, and inhumanities, is against nature. c. All forms of mans inhumanity to man, such as exploitation, sexploitation , oppression, seduction, abduction, swindling, cheating, kidnapping for ransom, murder, rape, harassment, and intimidation are by nature evil. 3.Propagation of Life (Species) a. The propagation of our species is viewed as a natural good. We are obliged not to pervert or thwart the natural design of the human nature. b. Any alterations, interventions that will stifle the very purpose for which each member of the human organism is unnatural, and hence is evil. The three (3) moral principles of Christian ethics which are very relevant in the health care profession, are principle of double effect, principle of totality, and the precept a good end does not justify an evil means. 1.Principle of Double Effect This applies to a situation in which a good effect and an evil effect (which is permitted to occur but not directly intended) will result from a good cause.Important distinctions to consider in the discussion of the principle of double effect: a. First, performances of various acts are followed by various effects, some of which we desire, others of which we do not desire but merely allow or tolerate. b. Second, sin is an act of the will. Any act done whetherwilled or intended and what is tolerated or merely permitted enters at times into moral judgments. c. Thirdly, there is a difference between performing a good act, which has both good and evil effects, and performing an evil act in order that good may result. For example, a woman has an ectopic pregnancy which endangers her life if her pregnancy continues. In the medical context, only surgical removal of the fetus can save the mothers life. It would be unreasonable not to remove the fetus and let both human lives perish. Four (4) Conditions Under the Principle of Double Effect Under the principle of double effect, the following basic principles or conditions must be fulfilled to justify an action that has both a good and bad effect. a. The course taken must be good or at least morally neutral; b. The good effect of the action must not come from an evil effect but must come from the action itself directly; c. The foreseen effect must not be intended or approved but merely permitted to occur; d. The good must outweigh the harm, or there must be a sufficient reason for allowing the evil effect to occur while performing the action. Example: A mother has an ectopic pregnancy, which puts her in danger. In medical parlance, only surgical removal of the fetus can save the mothers life. Right reason dictates that it is better to save one life than to let both human lives perish. The above example applies the four conditions to justify the action: 1. The fallopian tube is in a pathologic condition; therefore it is moral to remove it. 2. The purpose of the procedure is to remove a pathologic organ which is a threat to the life of the mother. 3. The death of the fetus is unintended and merely tolerated. To be a complete human being is not merely to have the higher level of functioning, but to have all the basic human functions in harmonious order. This order requires other parts of the body to function in order to support the whole bodys well being, but this also forbids their sacrifice. Nor can this dependence be supplied by some external means. For example, the ability to produce test tube babies does not itself justify the elimination of the reproductive system. Body feelings like movements, eating, sexuality, and manipulation of the environment develop ones self-awareness and relation to the community. Thus, if a child was conceived in a test tube and raised in a laboratory, it is doubtful that baby can have essential human experiences.

The following norms pertain to human integrity: i Primarily, human health is not merely a matter of organs but of capacities to humanly function; ii Generally, any particular human functional capacity can be diminished when necessary for the good of the whole person, iii Secondary functions can always be sacrificed for more basic ones. For example, a finger can be removed to save the use of the hand because the capacity of one finger to function is secondary in relation to the capacity given by the hand as a whole. iv. Primary or basic functional capacities, however, cannot be destroyed to promote even more important capacities except when it is the only way to preserve life. Example: A young lady was diagnosed to have cancer of the right leg. After series of examinations, surgical intervention is advised to in order to preserve her life. Under Christian ethics, it is our natural obligation not only to preserve our lives but also to preserve the integrity of our bodies. It further teaches that no matter how good an end maybe, we may not employ any evil means to attain it. oW.D. Rosss Seven Prima Facie Duties He believed in two moral principles - rightness and goodness. This theory is rule-based in nature which considers the value of consequences of actions. Aprima facie duty - is one that dictates what I should do when other relevant factors in a situation are not considered. These are Morally significant duties as they relate to individual circumstances at first sight. These are not absolute but are conditional Actual duties are those real duties that a person is obligated to perform. In the performance of ones responsibility, two duties may come into conflict; however, only one duty can become the actual duty. Sometimes conflict between prima facie duty to keep a promise and a promise to assist someone in need. Example: A duty to assist can override to keep a promise in certain nursing duties and priorities. Suppose that Phoebe, a cardiac rehabilitation nurse, promised to assist her patient, Ms. Santos, with her post-operative ambulation in 15 minutes. Mr. Elgin, one of her patients had a seizure that needed Ms. Phoebes immediate attention. When Ms. Phoebe returned to Ms. Santoss room after two hours, she explained what had transpired. She did the right thing by breaking her promise to Ms. Santos to help another patient in an emergency situation. W.D. Rosss - described a set of moral rules that should guide a persons universal principles. These are called prima facie duties: Duties of fidelity - telling the truth, keeping actual and implicit promises. Duties of reparation - righting the wrongs we have done to others. Duties of gratitude - recognizing the services others have done for us. Duties of justice - preventing a distribution of pleasure or happiness that is not in keeping with the merit of the people involved. Duties of beneficence providing help to improve the condition of others. Duties of self-improvement - bettering ourselves with respect to virtue and intelligence. Duties of nonmaleficence - avoiding or preventing an injury to others. oPrinciple of the Totality of the Human Person To promote human dignity in community, every person must develop, use, care for and preserve all of his physical and psychic functions. This principle makes explicit another aspect of human dignity by requiring self-respect as well as respect for others. This principle establishes a norm for setting priorities when one human value must be subordinate to another. There is hierarchy of human values in terms of biological, psychological, social and spiritual dimensions of human personality. The spiritual and social values have higher priority than the biological and psychological, but priority must not be understood dualistically, as if the lower can be sacrificed to the higher values. o Principle of Creative Stewardship The multidimensional human nature and its natural environment should be used with profound respect for their intrinsic teleology and the gift of human creativity should be used for cultivate nature and environment with care set by the limits of actual knowledge and the risk of destroying these gifts. This principle requires us to appreciate the two (2) great gifts that a wise and loving God has given us the earth and everything in it, and our human nature with will, intelligence embodied with biological, psychological, ethical, and physical capacities. These two should not therefore be subjected to

exploitation, destruction, and the like, but mans gifts coupled with creativity must be cultivated, conserved, and developed. Man is the steward of these God-given gifts, thus mans creativity should be used as co- creativity with the Creator. oPrinciple for Christian Hope In health care, this sense of hope is the source of healing, thereby constantly affirming the possibility of turning suffering into a victory over disease and death. Three (3) ethical norms relate in particular way to Christian hope. Our hope enables us not only to courageously endure the sufferings of life, but to grow as a person through these experiences (principle of growth through suffering). Hope also enables Christians to entrust themselves to another in the lifelong commitment of marriage and to look forward to sharing this gift of life and love with a family and the future(principle of personalized sexuality). Moreover, not only do we have hopes for our family but for the whole humanity and society and the earth which our home(principle of creative stewardship). oPrinciple of Growth through Suffering Bodily pleasure should be sought only as the fruit of the satisfaction of the basic needs of the total person suffering, so suffering and even bodily death when endured with courage can and should be used to promote personal growth in both private and communal living. In teleological ethics the ultimate criterion of morality is true happiness. An action is morally good because it leads to happiness for persons. People sometimes fail to take into account, that in reality, not all that appears to be happiness is really so. This is quite possible, because people think they are happy because they have achieved goals that are partial, superficial and unstable. The real authentic happiness is one that satisfies the whole person in his deepest and most ultimate needs and does so permanently. From an ethical point of view, it is essential to understand that true happiness, cannot be measured merely by pleasure, comfort,or freedom from anxiety, tension, and guilt. These are just the consequences and the signs of the achievement of human goals and the fulfillment of needs. Relevant to ethical queries, people need to look at the deeper and more total need and not to measure good and bad merely in terms of pleasure and pain. Authentic fulfillment must be seen in intensifying deeper spiritual pleasures along with moderate bodily pleasures and by realizing that one is able to develop as a person through suffering. oPrinciple of Personalized Sexuality This principle is based on an understanding of sexuality as one of the basic aspect of a person that must be developed (personalized) in ways consistent with an enhancing human dignity. Human sexual life is not merely a matter of animal instinct but this requires free decisions that sometimes raise serious ethical decisions. The survival of the human race, as well as the maturation and fulfillment of the individual depends in a notable way on the right use of the gift of sex. Sexuality is a complex of many values that are recognized in every ethical theory; however, the interrelation and priority are subject to disagreements. The generally recognized sexuality values are summarized into four (4) categories: Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic tension. Sex is a search for the completion of the human person through an intimate personal union of love expressed by bodily union. Sex is a social necessity for the procreation of children and their education in the family so as to expand the human community and guarantee its future beyond the death of individual members. Sex is a symbolic (sacramental) mystery, somehow revealing the cosmic order. All great religions and philosophies in life recognized these values. However, secular humanist argue that we are free to combine and separate these different values according to own purposes and preferences. It seems entirely reasonable to use sex purely for the sake of pleasure apart from any relation to love or family; sometimes to use it to reproduce (making test tube babies) without any reference to pleasure or love; sometimes an expression of unselfish love, but without any relation to family or marriage. Sex morality is reduced to two (2) fundamental norms: Laws or social attitudes that hinder human freedom to achieve these values in ways individual desires are unjust and progressive; Sexual behavior at least among consenting adults is entirely a private matter to be determined by

personal choice, free from any moral guilt. Biblical teachings clearly teach that sexuality is a gift of the creator. Any use of sex outside marriage is ethically wrong because: It is a selfish pursuit of pleasure apart from love, as in prostitution, masturbation, casual or promiscuous relations; Or it express love but not a committed love involving true self-giving, as in adultery or premarital sex; It is a commitment but practiced in a way contradictory to its natural fulfillment in the family, as in contraception or the relations of committed homosexuals These are in contradictory to the intrinsic value and meaning of sexuality as designed by the creator and blessed by him. Human culture and customs have undergone revolutionary changes, but such changes cannot alter the basic human nature without destroying humanity itself. O Respect for Autonomy In Greek, auto means ones own and nomos stand for rule, principle, or law. Thus autonomy would mean living or acting according to ones own rule, principle, or law. This principle refers to a persons choosing and acting on the basis of his/her own values, principles, or ideals of conduct, goals and purposes. This principle when correctly stated is - whatever professionals suggest people have the right to have their own choices respected in health care in as far as these choices are about themselves as individuals. This is in contrast with the doctor knows best approach from previous decades. Every individual is autonomous in which case one should choose what one wishes to be and should take responsibility for that choice. In as much as every person is autonomous, one should make moral decisions for and by oneself. For example, once informed about the nature of his ailment as well as the respective treatment (example: surgical intervention or otherwise), the patient has to decide on whether to undergo or not. It is assumed that respecting someones autonomy yields satisfaction for that person directly, while interference with it yields a form of anxiety, pain or suffering. To maximize values and well being, decisions of capable peoples choices must be avoided. (Note: In addition to the above explanation review the above topic under Kantianism) oThe Principle of Beneficence The practice of doing acts of kindness, goodness and charity. The beneficence principle in health care ethics maybe stated: Do no harm and produce the good or Do good and do no harm. This prescribes the avoidance and prevention of harm and the production of good. As much as possible, health care professionals should take care not to compound or aggravate the ill patients condition by causing further injury. This principle has two (2) complimentary aspects: positive aspect - is the production of the good negative aspect - is the avoidance of harm. oPrinciple of Non-maleficence Nonmaleficence means to do no harm and is the other side of the coin of beneficence. In health care practice, one ought not to inflict evil or harm. These include avoiding negligence and harmful care and making decisions regarding withholding or withdrawing treatment and whether or not to provide extraordinary or heroic treatment. oPrinciple of Justice and Fairness Justice means rendering what is due or merited. A health care professional acts justly if and when the rights of the patients are respected; on the other hand, an act of injustice is done whenever ones duty to the patient is neglected. The principle of justice that interests health care professionals includes the equal distribution of harm and benefits, of burdens and comforts, of goods and services among those who need them. This refers to the principle of equity, which prescribes fairness and impartiality regarding equal access to health care and the allocation of scarce medical resources between two (2) individuals or to a group of persons who are in dire need. In the health care profession, justices are of two (2) kinds namely: comparative and noncomparative justice. Comparative justice - is one in which what an individual patient or group receives is determined by balancing the competing claims of other individuals or groups. That is to say, what a particular patient receives is

determined by the gravity of the condition or need. Thus, one patient may need a kidney transplant more than the other patient because Patient A is dying of renal failure, while Patient B has just been diagnosed as having a kidney problem.The crucial point here then is the balancing of the needs of the patient. Noncomparative justice - is one in which the distribution of medical goods or resources is determined by a certain standard rather than by the needs or claims of the individuals. In other words, medical treatment is determined by principle (rule or policy), not by need. A principle of treatment or policy of distribution is formulated which prescribes a strict numerical equality of treatment, irrespective of the needs of an individual. When medical resources are scarce or limited, certain procedures or systems to be followed in distributing treatment is thus made. To cope with the problem, certain policy may be devised such as First come first served, Senior citizen first or pregnant women first, and the like. BIOETHICS WEEK 7 THE CODE OF ETHICS FOR NURSES IN THE PHILIPPINES O Code of Ethics of Filipino Nurses The Philippine Nurses Association (PNA) Special Committee, headed by Dean Emeritus Julita Sotejo, has developed a Code of Ethics for the Filipino Nurses in 1982 that was approved by the House of Delegates of the PNA. However, it was not implemented. Back then, the ethical guidelines used by the nursing profession of this country was the Code of Ethics of the American Nurses Association (ANA). In 1984, the Board of Nursing officially adopted the International Council of Nurses (ICN) Code of Ethics and added a fifth commitment which is promotion of spiritual environment when it is passed as Board Resolution No. 633. This code was in effect for succeeding five years. In 1989, the PRC approved the Amended Code of Ethics and it was approved by the general assembly of the PNA during a convention held in 1990. O Brief History of the Philippine Nursing Law The first law that had to do with the practice of nursing was contained in Act No. 2493 of 1915 which regulated the practice of medicine. This act provided for the examination and registration of nurses in the Philippine Islands. During that time, the applicants needed to be only twenty years old, of good physical health, and of good moral character. Graduates of the intermediate courses of public schools could enter the school of nursing which then requires only two years and a half of instruction. These graduates were called first-class nurses. Those who desired to be secondclass nurses filed an application with the district health officer in the district where they resided. In 1919, Act 2808 was passed. This was known as the First True Nursing Law. It created among others, a board of examiners for nurses. However, it was in 1920 that the first board examination in the Philippines was given. Congress enacted the Philippine Nursing Law, otherwise known as Republic Act 877, on June 19, 1953. Provisions included the organization of the Board of Examiners for nurses, provisions regarding nursing schools and colleges, examination, registration of nurses including miscellaneous provisions relative to the practice of nursing. In June 18, 1966, Republic Act 4704 amended certain portions of R.A. 877. Several attempts were made to amend the Philippine Nursing Law and proposals were submitted to the Batasang Pambansa. Parliamentary Bill 446 proposed one professional program in nursing and the widening scope of nursing practice (Philippine Nursing Act of 1976). Republic Act 7164, codified and revised all the laws regulating the practice of nursing in the Philippines, It was known as the Philippine Nursing Act of 1991. In 2002, the Philippine Nursing Act of 2002 (RA 9173) was enacted. This law empowered and ordered the Board of Nursing to promulgate a Code of Ethics for Registered Nurses in coordination and consultation with the accredited professional organization. In the formulation of the Code of Ethics for Registered Nurses, the Code of Good Governance for the

Professions in the Philippines was utilized as the principal basis with all the principles under the said Code are adopted and integrated into the Code of Ethics as they apply to the nursing profession. On October 23, 2003 in Iloilo City, the Board of Nursing (BON), after consultation with the accredited professional organization of registered nurses, the Philippine Nurses Association, Inc. (PNA), and other affiliate organizations of registered nurses, has decided to adopt the new Code of Ethics. Pursuant to the powers vested upon it by Republic Act No. 877, otherwise known as the Philippine Nursing Law, as amended by Presidential Decree No. 233, the Board of Nursing, with the approval of the Professional Regulation Commission hereby adopts the new code containing the rules and regulations necessary for the maintenance of an efficient, ethical, technical, moral, and professional standards in the practice of nursing in the Philippines. O The Amended Code of Ethics for Registered Nurses in the Philippines Pursuant to Section 3 of Republic Act No. 877, known as the Philippine Nursing Law, and Section 6 of presidential Decree No. 223, the amended Code of Ethics for Nurses recommended and endorsed by the Philippine Nurses Association was adopted to govern the practice of nursing in the Philippines. A new Code of Ethics for Registered Nurses has been promulgated by the Board of Nursing, in coordination and in consultation with the accredited Professional Organization (PNA). In its formulation, the Code of Good Governance for the Professions was adopted and integrated as they apply to the Nursing Profession. After consultation on October 23, 2003 at Iloilo City with the accredited professional organization of registered nurses, the PNA, and other affiliated organizations of registered nurses, the Code was adopted under Republic Act 9173 and promulgated by the Board of Nursing under Resolution No. 220 Series of 2004 last July 14, 2004.

THE HUMAN PERSON o One is human by virtue of ones genetic code, while a person is a member of a moral community. To better understand man as a person the following elements are to be considered: The Personhood Being a member of a moral community, a person has characteristics which are recognized by the community as grounded in moral status and is someone acknowledged with rights. The various characteristics central to personhood are: consciousness of objects and events; the ability to feel pain; the ability to reason; self-motivated activity; the capacity to communicate; and ones concept of the self. The clear understanding of personhood are of vital importance to the study of bioethics because most of the focus of ethical thought is the person, the being who bears personal rights and responsibilities. The following are the elements of the personhood: A Subject A Biblical understanding of personhood starts with the acknowledgment that human beings exists as creatures, which are under the rule of God, the Creator. They are subjects to His authority. Our personhood therefore resides principally in our relationship with God. Embodied Subject As subjects, human beings are also defined by having a human body. Historically, philosophers have tried to separate body from the mind and spirit. However, contemporary Christian theologians agree that these elements are intrinsically united. Part of the Material World God created the world, took dust, and formed man and breathed life into it. Inter-relational with Persons God recognizes that Adam is insufficient on his own and created a companion for him. The rest of the story in the Bible relates on the way that relationships between different people develop. An Interdependent Social Being

Personhood expresses itself in the way that we relate as social beings. An interdependent society recognizes the need to care for each other. Christian theologians believe that Jesus is the perfect human being and point out that, when on earth he did the things that God the Father wanted, and was supported in his actions by the Holy Spirit. Therefore, Jesus showed us an interdependent concept of relationship. Historical Individual people exist within a historical framework and are intrinsically interested in their ancestors. Our personhood expresses itself within cultural historical contexts. Equal but Unique Each person has equal rights, despite economic, educational, or psychological differences yet we are not all the same. Theologians point out to their understanding of God as a single being composed of three equals through different persons Father, Son and Holy Spirit. Called to Know and Worship God One feature of a person is his ability to know and respond to God. Biblical revelation speaks that man is made in the image of God (Genesis 1:27; 5:1; 9:6). Man has the capacity to love, to feel pain, to reason, to excel, and with capacities or gifts/talents to be of benefit to the community. Thus humans have lives that are of worth. BIOETHICS- WEEK 9 THE CALLING OF THE HEALTH PROVIDER O The Health Care Profession -treats and tends to patients who are injured, sick, disabled, or infirm. The delivery of modern health care depends on an expanding interdisciplinary team of trained professionals. o A health care provider or health professional - is an organization or person who delivers proper health care in a systematic way professionally to any individual in need of health care services. O The Client the care that clients or patients receive is determined by the competence of nurses giving that care. Being members of the health care team, nurses are responsible for the quality ofperformance of their duties. O Patients Right Patients rights means the moral and inviolable power vested in a patient as a person to do, hold, or demands something as his own. Every right in a patient involves a corresponding duty in a nurse to respect this right and not to violate it. Any violation of a right is morally wrong and this is a form of injustice committed against the patient. The International Council of Nurses Code of Ethics provides that, Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, color, creed, culture, disability or illness, gender, nationality, politics, or social status. Likewise, the same provision in essence is emphasized in the American Nurses Association Code of Ethics: The nurse in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social, or economic status, personal attributes, or the nature of health problems. In the Amended Code of Ethics for Nurses, likewise provision give emphasis on the worth and dignity of each human being . . ., uphold the rights of individuals . . ., respect the Patients Bill of Rights in the delivery of nursing care, uphold the patients rights when conflict arises regarding management of their care. Clients come to a health agency believing that health care professionals will help them solve their health problems help to solve their health problems will be provided by health care professionals. These patients have rights which, when violated, may subject the nurses to legal problems.

The Patients Right are the following: Right to competent care patients have the right to expect that the kind of nursing care given to them will help them regain or maintain their health. To provide competent care, the nurse must: 1. Have the necessary education, training and experience 2. Personality to carry out the services for which they are responsible. Lacking those, nurses maybe charged with incompetence. Nurses may be sued for negligence or malpractice because of incompetent care. Negligence refers to the commission or omission of an act pursuant to a duty, that reasonably prudent (careful, cautious or sensible) person in the same or similar circumstance would or would not do, and acting or the nonacting of which is the proximate cause of injury to another person or property. The Elements of Professional Negligence are: a. The existence of a duty on the part of the health care professional in-charged to the patient, to use due care under circumstances; b. Failure to meet the standard of due care; c. The foreseeability of harm resulting from failure to meet the standard, and d. The fact that the breach of this standard resulted in an injury to the plaintiff. Malpractice a. The negligent acts of persons engaged in the professions or occupations in which highly technical or professional skills are employed; b. Also denotes stepping beyond ones authority; the idea of improper or unskilful care of a patient by a nurse; and c. A term for negligence or carelessness of professional personnel. Common acts of negligence are: Burns resulting in the application of hot water bags, vaporizers, heat lamps Objects left inside the patients body such as sponges, catheters, suction tips Loose dentures lodged in the patients trachea Falls of children or unconscious or weak patients Failure to observe and take appropriate action for emergency situations Examples of malpractice: Administering of anesthesia by a nurse Prescribing medication by a nurse Intravenous (IV) catheterization by an unlicensed IV Nurse

Freedom from harm 1. There should be an appropriate balance between potential benefits of the patients medical regimen and the risks assumed by the patient. This is called the risk-benefit ratio, where the benefits should outweigh the harm. 2. Minimal risk is defined as exposure to the possibility of injury going beyond everyday situation. 3. Medications are toxic and should be monitored for therapeutic as well as side effects. Without proper monitoring, patients may acquire prolonged treatment and or hospitalization. Right to Withdraw from Participation although a consent has been signed, the patient (and in the case of a minor, incompetent or unconscious patient, the guardian/parent) may withdraw from whatever he has consented to because he or she does not have enough information about what is to be done prior to the consent. Right to Confidentiality of Information data given to members of the health team are given in trust and good faith. The patient and his family believe such information may help in the diagnosis or treatment of the clients condition. This is privileged communication. Confidential information maybe revealed when /to: 1. The patient himself permits such revelation as in claimsfor hospitalization or sickness benefits;

2. The case is medico-legal in nature such as gunshot wounds, attempted suicide or accidents which have to be reported to the police or NBI; 3. The patient is ill with communicable disease where public safety maybe jeopardized; or 4. To members of the health team if such information is relevant to his care. Right to Self-determination this is related to the principle of autonomy which states that a patient, as an autonomous individual, has the moral right to determine what is good for himself, usually upon the advice of a health care professional. One is free to determine whatever one likes about his life as long as it is suitable to and proper for ones nature. The following are the patients rights under self-determination: 1.Right to Informed Consent the patient has the right to receive all the necessary information concerning diagnosis and treatment in order to be able to give consent based on his sense of values. Informed consent refers to the knowledge information about, and the consent to a particular form of medical treatment, before that treatment is administered. The information should include the risks, expenses, and the advantages of any medical treatment that concerns the patient. 2.Right to Informed Decision information and understanding are necessary for genuine deliberation for without these two elements, the patient cannot make a moral decision. Informed decision refers to the necessary information of, and decision on, a medical treatment before it is to be carried out. The patient must be informed about the whole process and must understand what this information pertains to so that an appropriate moral decision can be arrived at. 3.Right to Informed Choice refers to the necessary information a patient should know about a medical treatment or experiment so that a moral choice can be made. The patient has the right to be informed about all possible alternative courses of action (or other forms of treatment) to be taken, together with the possible consequences. 4.Right to Refusal of Treatment the patient has the right to refuse treatment because his religious convictions prohibit him from doing so. Many regard the right to refuse treatment as fundamental in a free society, especially among those who advocate the freedom or the right to die if and when the prevailing circumstances warrant it. Moreover, the invasion of a patients body without valid consent is an assault and health care professionals may be subjected to legal sanctions. Limitations of a Patients Right Patients rights do not include the right to be allowed to die under the concept of paternalism, the physician may make the moral decision for an in behalf of the patient who is no longer mentally competent to make the decision, as in the case of a comatose patient. In light of the value of life principle of health care ethics, it is a sworn duty to attending physician to do whatever is medically possible to save the patients life. A patient in a declining condition does not possess the necessary mental capacity or emotional stability to make an informed choice a dying patient, or one who lapses into unconsciousness, becomes mentally incompetent to make a decision. The attending physician, in such a situation, may perform a paternalistic act for the well being of the patient. Patients rights are not absolute paternalistic concern limits the competent or capable patients freedom of choice (example: refusal of treatment) for his own good in order to prevent harm from befalling that patient. The Magna Carta of Patients Rights In the past, we have been using as reference of patients rights the Patients Bill of Rights adopted by the American Physicians Association (APA) or the American Hospital Association (AHA). Recently, lawmakers have taken noticed of the necessity of creating a law to prevent malpractice suits against professional health workers and health facilities. Senate Bill No. 588 entitled Magna Carta of Patients Rights, if passed into law aims to recognize and

promote patients rights. The Patients Bill of Rights within the scope of the proposed Magna Carta of Patients Rights For purposes of additional information, below is the Patients Bill of Rights adopted by the American Medical Association. They are the humanizing elements of health care ethics. Obligations of Patients just as the agency and the staff are expected to inform the patients of their rights, they are also expected to inform patients about their responsibilities which include the following: Since nurses are the closest caregivers, they are the most logical guardians of the patients rights. It shall also be part of their duties to inform patients and their relatives of the responsibilities expected of them upon admission. The Dying Patients Bill of Rights Note:Please refer to the student handout for the complete American Hospital Associations version of the Patients Bill of Rights and Patients Duties and Responsibilities, The Dying Patients Bill of Rights, and the unabridged version of the Magna Carta for Patients Rights. oThe Health Care Provider The Rights A right is something owed to an individual according to just claims, legal guarantees, or moral and ethical principles. Nurses Bill of Rights The following Nurses Bill of Rights was adopted by the American Nurses Association (ANA) Board of Directors on June 26, 2001. oBill of Rights and Responsibilities for Students of Nursing The Bill of Rights of student nurses was adopted by the National Student Nurses Association (NSNA) of America in 1991. Note :Please refer to the student handout for the Nurses Bill of Rights and the copy of Bills of Rights and Responsibilities of Student Nurses oThe Health Care Provider-Client Relationship It must always be in the minds of the health care providers that the goal is to render service to humanity. Modern health care is a team practice. The nurse being a part of the team plays different roles and there exist different forms of relationships between the nurse as a health care provider and the patient. Below are the proposed hypothetical models used for the examination of the physician-patient relationship which could also be of importance in nurse-patient relationship: Engineering Model in this pattern, the physician acts as a scientist who deals only with facts. 1. The physician gathers the information, explains the material to the patient, and then divorces himself from the decision. 2. The patient is allowed to make decision, and follows the dictates of his choice. Although this model allows for a higher level of patients autonomy, it permits no professional determinism. 3. The health care provider would not be allowed to exercise personal values, and if called upon would perform duties that might possibly be personally abhorrent. Priest Model this is a highly paternalistic model, where the physician operates from the moral position of knowing what is best for the patient. The patient is made to believe that her opinion is not of the same value as that of the physician. Collegial Model this model suggests that the physician and the patient should see themselves as colleagues solving the common problem of eliminating illness.

Contractual Model this is a share decision-making model in which the patient is accorded the right to make decisions and to have control over his own life whenever significant decisions are to be made. Once the decision is made, the patient relies on the technical experience and skills of the health care team for most of the decisions in regard to care. This model allows both parties to interact in an atmosphere of both obligations and expected benefits.