PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City

NURSING PROGRAM

Right
Wrong

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 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
NURSING PROGRAM

DISCLAIMER

This is to certify that this Module and its contents were adapted and compiled by the teacher
exclusively for classroom usage and application for the Bachelor of Science in Nursing Program,
Tertiary Education Department, Pilar College of Zamboanga City, Inc. for NCM 108 Health Care
Ethics course, first semester AY 2021-2022. The contents attributes and refer exclusively to the
legitimate author.

April Joy D. Villanueva, RN

Helen Grace A. Bawi, RN
Maria Victoria C. Alegre, RN
BSN Faculty

Approved by:

S. Maria Divina Consejo Billanes, RVM

BSN Program Dean

© 2022 І All rights reserved.

No part of this module may be reproduced, stored in a retrieval system or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise, without the prior written consent of the
Author and Pilar College.

MODULE 2
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Bioethics and its Application in Various
Health Care Situations

TOPIC TITLE DURATION

1 Sexuality and Human Reproduction 1 hr & 30 mins.

2 Dignity in Death and Dying 1 hr & 45 mins.

3 Nursing Roles and Responsibilities 1 hr

4 Ethical Decision-Making Process 1 hr & 15 mins.

Instructional Objectives:
At the end of this module, you must be able to:
 To outline the nature of a variety of ethical issues surrounding human reproduction,
including the conflict between the pro-life (anti-abortion) position and the pro-choice
position (not necessarily pro-abortion, but against legislation outlawing abortion)
 To understand the various arguments used and the types of patients involved in end of
life decisions.
 Deepen understanding on the importance of ethical decision making and the nursing
roles and responsibilities in health care ethics.

I have read and understand the study course guide and hereby
consented to the academic integrity policy of the school. I also
acknowledge any disciplinary action due once the policy has
been violated by any means.

____________________________
Signature over Printed Name

2 1 hour &
30 mins.

Topic 1: Sexuality and Human Reproduction

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 At the end of the lesson, the students will be able to:
 Outline the distinction between “human” and “person”, and the dispute regarding
personhood criteria.
 List the basic facts of fetal development.
 Explain the process of in vitro fertilization and list the ethical issues involved.
 Provide pro and con arguments for the issue of surrogacy.

Overview

Bioethics is an applied ethical study dealing with moral issues. What is a moral issue? It is a
case problem, situation, or subject matter of great interest and crucial significance that demands a
moral decision; it may also be understood as that which involves the rightness or wrongness of an
action.

One of the toughest challenges that we as health care professional face are the different
ethical issues such as abortion, contraception and sterilization, euthanasia and many others. This are
some of the discussions we’ll go through as we venture in this module.

Let’s begin our journey by doing the activity below.

Activity 1:
From this pool of letters, search for ten (10) words in relation to ethical
issues and dilemma common in our society.

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In relation to your activity “Word Search”, we will now uncover insights into the
different ethical issues involving sexuality and reproduction.

THE MORAL QUESTION: WHEN DOES LIFE BEGIN?

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 When does life begin? Learn about the science of embryonic and fetal development, and how
that impacts the moral question. Learn about the various and confusing terms people use: life, human
life, potential life, and personhood.

Science and Morality: When Does Life Begin?

Few issues generate the kind of passion that the debate regarding abortion does. When it
comes to matters of factual truth, science is usually the answer to our questions. However, the issue
of when life begins is as much a moral question as a scientific one. Let's take a closer look at the
science.

The development of human life goes

something like this: a sperm fertilizes an egg,
combining their genetic information, and creating
something called a zygote that will grow into a
human being. Pregnancy officially begins on the
first day of a woman's menstrual cycle -
fertilization occurs during week three, the zygote
implants in the uterus in week four, and the baby's
major systems and structures (including the brain)
develop in week five. During weeks six and seven,
arms, legs, eyes, and ears begin to form, and the
heart beats regularly. Hands, feet, lungs, nipples, Human embryo at 6-7 weeks
toes, hair follicles, and all organs form in weeks
eight and nine.

By week 14, the baby's face is well-formed, limbs are long and thin, nails and genitals have
appeared, the liver is working, and the baby can make a fist. By week 18, the baby can move,
stretch, and suck, and it has hardening bones. No later than week 21, the baby can hear and swallow.
By week 30, practically every feature of the baby is present and developing, the baby can
indisputably respond to the outside world, and the brain is now growing rapidly. In the final 10
weeks of pregnancy, the baby gains fat and muscle, stores nutrients, establishes consistent sleeping
patterns, and develops lungs ready for the birth and the outside world.

So at what point in this process does life really begin? When does a fetus or baby have
enough value to be protected? Let's start by looking at some important terminology.

What is a Person?
At the heart of the question of when life begins, is the definition of personhood. We protect
people by outlawing murder and assault, so at what point should this protection begin?

While the definition of life is debated, it's usually said that life generally can grow, can
maintain homeostasis, has organization, has a metabolism, can respond to stimuli, can reproduce,
and can evolve. There are exceptions to this definition, and it is still hotly debated, but this is
generally considered to be the best definition we have. Based on this definition, most scientists
would consider even sperm and eggs to be alive, and so a zygote or fetus certainly is.

However, life is not automatically the same as human

life. Some argue that a fetus is only potential human life, not
actual human life. But what is a human life? When most
people talk about human life, they're referring to genetically
unique and complete human beings. Therefore, most
commonly, human life is considered to be a life form that
contains the 46 chromosomes that genetically define a human
being. A sperm or egg contains 23, and when fertilization
occurs, they combined together to form 46. So while this
definition is also debated, most scientists would argue that
What is life? human life begins at fertilization.

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 However human life is not the same as personhood. This is where science makes way for
morality. What defines a human person? Is human life always a human person? Does personhood
begin at birth? Or does personhood develop along with your personality as you grow after your
birth? Some argue for the latter, yet it is been shown that stimuli from outside the womb can affect
aspects of the personality of a child. For example, the foods that a mother eats while pregnant have a
direct effect on the food tastes of the child, and babies
recognize their mother's voice after leaving the womb.
Geneticists might argue that a unique individual human
is indeed created at conception. And still others argue
that it is about agency and self-awareness, and this
happens sometime during late pregnancy.

For now, the question is unanswerable - it's an

issue of moral value.
What makes us human?

Moral Value
When does a human being have moral value and deserve protection? That is the key
question. Many argue that the value in human life is created by us. From that point of view, life only
has value through our experiences after birth, and through those who love us. In that case, abortion
would be morally acceptable and a matter for personal choice.

However religious people (particularly monotheists) often argue that human life is sacred,
and is a gift from God. Actively ending a human life, even shortly after conception, could therefore
be considered morally wrong. Even if a person's religious text does not say when life begins, they
might argue that it is too great a risk to take. After all, if it turned out that that God considers
abortion to be equivalent to murder, the moral consequences for society would be stark indeed.
Religious people argue that since the consequences are so huge, the merest possibility that abortion
is morally wrong is enough reason not to allow it.

On the other side of the moral argument, people make the point that forcing somebody to
make a certain choice when the morality of the situation is unclear, violates their rights. They also
note the various issues surrounding pregnancy: the risk to a mother's life that can occur, the financial
cost of looking after children, and the lack of societal support for the poor.

While there might not be any single answer, one thing is clear: nothing is as simple as people
on either side claim. Through our scientific understanding of how humans develop, it is clearly a
gradual process. Any attempt to say that personhood begins at a particular point seems to be flawed.
If personhood begins at fertilization, then a large proportion of humans (30-70%) are lost through
natural miscarriages. If personhood begins at birth, then that means that babies that could survive
perfectly fine independently and without their mother have no value. If personhood begins at the
point where we have the technology to keep a baby alive, then the definition of personhood would be
constantly changing. None of these options seem entirely correct.

THE ETHICS OF ASSISTED REPRODUCTION PRACTICES

Imagine this...dreaming about having a baby and being told it’s not possible. Well, at least
not in the conventional way. What other options are there? In this lesson, learn about just some of
the reproductive technologies we have to help women become pregnant.

Lights, camera, action!

Fade to image 1. A little girl playing dress up with her doll, she changes its diaper and rocks
it to sleep. Image 2. The girl has grown and is taking care of her brothers and sisters. Image 3. A
wedding, a happy couple. Image 4. A negative pregnancy test, and another one, and another one.
Disappointment for the happy couple.

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 Sadly this is the scene for millions of people. Impaired fecundity, the inability to conceive
and/or carry a fetus to full term, affects almost 7 million women in the US alone. For women this
can be one of the most stressful times in their life. The cause? It could be something as simple as
removing estrogens like soy from your diet or as complicated as poor egg development or even a
hostile uterus!! Yes girls, your uterus can be hostile... the environment created by it might actually
be killing all the sperm before they can reach the egg! Or it may not be ideal for implantation of the
egg. But, there is hope!

What can we do about it? Well advances is medical research have created ART, or Assisted
Reproductive Technologies. These are procedures aimed at helping women obtain pregnancy. They
are usually considered after 6-12 months of unsuccessful attempts to conceive. The main types of
ART are: IUI, IVF, and third party assistance.

ART: IUI
1. Intrauterine Insemination (IUI) is when the male's sperm is placed inside the female's
uterus using a long tube. This might help you remember. Intra means inside while uterine refers to
the uterus, where a fetus develops inside the mother. So intrauterine means 'inside the uterus', that's
where the sperm are placed. But why? Well, the main job of sperm is to reach and fertilize the
women's egg. But sometimes they have trouble getting there they may need a little help. Some may
not swim very well, the male may not be able to form an erection, or if the female has scarring on

her cervix, the entrance to the uterus. Any of these conditions could impair the sperm's ability to
reach the egg.

ART: IVF
2. In Vitro Fertilization (IVF) is
when both the egg and sperm are removed
from the reproductive organs of the female
and male. For males this is pretty easy, but
for females it's a little trickier. First, the
development of eggs is stimulated through
hormones, then the doctor retrieves them
from the female. This is useful when a
women has trouble releasing eggs on her
own. The eggs and sperm are placed in a
dish so fertilization can occur. Doctors
watch over the eggs until they become
embryos, fertilized eggs that have started
cell division but have not developed any
organs yet. The embryos are placed into
the female's uterus. Remember how we In IUI the sperm are injected directly into the uterus using a long tube
talked about that hostile uterus?! Well, if needed the doctor can help make the uterine environment a
little more friendly before implanting the embryos.

Sounds pretty cool right? But there are some potential problems, every embryo has the
potential to develop into a baby if implanted, however, not all embryos are implanted. Extra embryos
are destroyed or frozen. So the question is, are those embryos alive? If they are, would destroying
them be considered murder? The answers to these questions are for each person to decide on their
own. Some people believe that life begins at fertilization, and if that is the case then yes, they are
alive. But others believe that life doesn't begin until later and so the destruction of the embryos isn't
ending a life.

ART: Third Party Assisted

3. Donation of egg or sperm is another option for those whose eggs or sperm are not healthy
enough to produce a baby. It's similar to IVF but the egg and/or sperm can be obtained from a donor.
The embryo is then be placed inside the mother or a surrogate.

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 Surrogacy is when a female other than the mother carries the baby. Maybe the mother is
unable to carry due to problems with her uterus, hormones or other health reasons. But as
you may imagine, things don't always end well. In one case a woman, Mary Beth
Whitehead agreed to be a surrogate for the Stern family. Mrs. Stern had multiple sclerosis
and couldn't carry a baby. Mary was inseminated with the sperm of Mr. Stern and was
paid to carry the baby to term at which time she would release the baby to the Sterns.
However, Mary changed her mind once the baby, called Baby M, was born. The ensuing
legal battle over Baby M brought up many ethical questions about surrogacy.

How would you feel if you had carried a baby for 9 months and then had to give it up? Or
what if you waited 9 months for your biological baby and then were

told you could not have him/her? Who does the baby belong to? The biological parents or the
woman who carried it?

Some believe surrogacy is against God's will. If you were meant to carry a baby you would
be able to do so naturally. Others may feel that being a surrogate is like selling your body, well…
your uterus. Does this take advantage of poorer women who need money? Should it be allowed?

And did you know that there are no official US laws pertaining to surrogacy? Some states
have banned surrogacy all together, while others have banned paying for surrogate services. In all
cases it's recommended that legal services be obtained to help prevent problems similar to those
encountered with the Baby M.

IS IT ETHICAL TO CLONE A HUMAN?

Human cloning is a controversial topic and there are many ethical considerations surrounding
it. In this lesson we'll discuss human cloning, as well as the pros and cons associated with it.

Even identical twins, who have the exact

What is Cloning? same DNA, have different personalities.
If you're like me, you sometimes wish you could be in
several different places at once, or just have a little more of you to
go around. Wouldn't it be nice to have someone else clean the
house, walk the dog, make dinner, do the laundry, and do just about
everything else for you? One way you might think to accomplish
this would be to clone yourself. That way, you could literally do
several things and be in several places at once! But before you get
ahead of yourself (hopefully still just your one self!), we should
talk about what cloning actually is. Yes, your DNA would be
exactly the same, but identical twins have the exact same DNA,
too, and I've yet to meet a pair that doesn't have distinctly different
personalities.

With cloning, there are two types to be familiar with. The

first is reproductive cloning, which involves creating a genetic
duplicate using somatic cells. Somatic cells are all the cells in your
body except your sex cells, which I know is confusing, because I
just told you that this type of cloning is called 'reproductive' cloning. The reproductive part comes in
when that newly created embryo is placed back into a uterus to develop like it would if it had been
formed through normal fertilization.

The second type of cloning is therapeutic cloning. Here, instead of letting the new embryo
grow, stem cells are removed and the embryo is not given a chance to develop. These stem cells can
then be used for a multitude of different medical therapies and treatments, hence the use of the word
'therapeutic' to describe this type of cloning.

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Ethics of Reproductive Cloning
It's true that reproductive cloning can be used for good. Imagine a couple that has fertility
problems and therefore has difficulty having their own children. Cloning could help this couple
overcome this challenge. Likewise, couples that know they have a high risk of passing on a genetic
disease could utilize cloning in order to produce healthy children. Or, say that a couple has lost a
child due to accident or sudden illness. Cloning this child could replace that lost family member for
them. But many view this as 'playing God' and therefore oppose it.

Additionally, as we see with identical twins, even when they have the same DNA, no two
people are exactly alike. Cloning your lost child will not bring back that child. It will simply create a
new child that looks like your previous child. And how would you feel if you were that cloned
sibling? Would you feel as loved, knowing that you had been created to be someone else, instead of
your unique self? How would others view you as a cloned individual, even if you weren't created to
replace a lost sibling? Would they see you as less than human? And what if you don't live up to the
standards of the individual they had hoped to create?

There are scientific concerns as well. Cloning is still a relatively new technology, especially
for human purposes. We don't really know what will happen to these individuals later in life, and
there are likely biological issues that occur in cloned individuals that we are not even aware of yet.
Reproductive cloning is also not very efficient. Only a small percentage of cloned embryos actually
develop properly, so it is unlikely that cloning will be an option for many people.

Ethics of Therapeutic Cloning

Reproductive cloning is definitely
controversial, but because therapeutic cloning
involves allowing the embryo to die, this type
of cloning takes the cake in terms of ethical
issues. First, let's look at the benefits of
therapeutic cloning.
Those stem cells I mentioned before are really
important because they replace specialized
cells in your body. You have them as an adult,
but only in a limited supply, and they can only
replace certain types of cells. Embryonic stem
cells, on the other hand, can be grown in large
numbers and can be used to create all different
types of cells. Think about it -- when you were
an embryo, your cells were charged with
creating an entire functioning human. So all
those cells in that tiny embryo were able to The possible beneficial uses of stem cells in
divide and differentiate to eventually form a medicine are numerous
full-fledged human. Modern medicine has been able to utilize these stem cells harvested in the lab to
help treat diseases like Parkinson's, diabetes, Alzheimer's, and joint disorders, as well as generate
tissues and organs for transplant.

But there is much debate over the point at which 'life' begins, so many see the destruction of
an embryo as unethical, regardless of the purpose. The debate over embryonic stem cells is not just a
religious one either. It has been debated by politicians, scientists, and others, and will likely continue
to be debated for a long time to come.

There have also been recent advances in the use of cord blood stem cells, which come from
the umbilical cord of a newborn. Some may consider the source of these stem cells to be more
ethical than embryonic stem cells, and their use could reduce the controversy surrounding
therapeutic cloning in the future.

ETHICAL CONSIDERATIONS OF SURROGATE PREGNANCY

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 Having a baby without having to be pregnant? Sounds like a good option, right? Especially
for those who cannot get pregnant or cannot physically carry a baby. But there are many medical,
legal and ethical issues to consider.

Why Surrogacy?
Imagine hearing the heartbeat of an unborn child for the first time, seeing him/her on the
ultrasound, the excitement, the anticipation. Only it's not your hands holding the new baby to your
chest, it's not your eyes they look into for the first time, it's not your smile they see. Those heartbeats
you heard, the kicks you felt, the ultrasounds you saw. . . they weren't for your baby. Well, not your
biological baby. You see, you are a surrogate mother. Someone who carries the baby of another
because they cannot. The baby you carry is not biologically yours.

Surrogacy is one of many Assisted Reproductive Technologies (ART), techniques used to

help couples experiencing fertility issues have children. Specifically, it is third party assisted
reproduction because the couple experiencing fertility issues is seeking the assistance of an outside
party, in this case, the surrogate mother. Other examples are donation of sperm or egg from an
outside party.

Why would someone become a surrogate? Why go

through all that when it's not your child? Or, on the other
hand, why would someone use a surrogate instead of
carrying their own baby during pregnancy? Perhaps the
biological mother has a medical condition that would
make pregnancy difficult or impossible. Perhaps her body
cannot handle the toll of pregnancy, or her uterus, where
the fetus grows and develops, is unable to carry the fetus
successfully. Maybe her sister or good friend has
volunteered to carry the baby for her. There are many
medical reasons why a woman may seek out surrogacy.
But these are not the only reasons: surrogacy can also be
used for same sex couples who cannot have their own
children or, in some cases, some women simply do not
want to go through the process of being pregnant.
The uterus houses the growing fetus, or
baby, during pregnancy

Is it legal?
While this may sound like a great option for these couples paying for surrogacy services is
illegal in most states and countries. Many couples seeking commercial surrogacy travel to India or
other countries where it is legal.

The problem here is that, due to lack of proper legislation in some countries, poorer mothers
are often taken advantage of. They are persuaded to become surrogates by spouses or middlemen
who take most of the money that is not used for

medical services. Many of these women have no say over their own bodies. There is usually no
psychological screening or legal counseling, and they may be separated from their families for the
duration of the pregnancy. Not only that, should the pregnancy outcome be negative, the surrogates
are unlikely to be compensated for their services.

Legal issues can also arise for the biological parents. When the parents are from one country
and the surrogate from another, problems with the child's citizenship or bringing the child back to
the parents country can arise. In some cases, parents have even been given the wrong child. Many of
these problems come from lack of legislation and organization. Laws have been passed in the past
few years to help alleviate these problems, but both the laws and their enforcement vary by country.
Now this may sound like a potential horror story, but in the few US states and European countries
where non-commercial surrogacy is legal, there are laws in place to protect all parties involved,
including the baby.

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Ethical considerations
Legal or not, surrogacy comes with a host of ethical considerations. Other than potential
exploitation of the surrogate, other controversial problems may arise. What if the surrogate mother
becomes attached to the baby and doesn't want to give it up? Should she be allowed contact with the
baby as it grows up? Or what if the child is unwanted, as in the case of Baby Gammy, a Down's
Syndrome child left behind in Thailand by her Australian parents?

What about the baby? Similar to an adopted child, questions about their birth may arise. Do
you tell them about their surrogate mother or not? Do you allow them to contact their surrogate
mother? These are questions the parents will have to consider.

Despite increases in legislation to help alleviate some of the complications, surrogacy can
still carry with it a negative reputation. Many still see it as baby selling and feel that infertile couples
should adopt rather than hire a surrogate. Surrogacy is also frowned upon or even prohibited in some
religions.

What could go wrong?

Surrogacy can be a great option for some couples but anyone considering it needs to be
aware of all sides, both the ethical and the medical. To protect all parties a legal contract should be
set up. But what if that contract is breached? Breaches of contract might include voluntary abortion
of the baby without consent of the biological parents, or failure to abort if such an action is
recommended by a physician. Failure to follow behavioral, nutritional or medical guidelines set in
place by the parents or a physician can also be considered to be a breach of contract.

There are also medical complications to consider. What if the health of the surrogate mother
is at risk? Should the baby be aborted or taken out early? Who has the right to make that choice?
Similar to other forms of ART, in order to ensure or increase the chances of success multiple
embryos are often transferred to the surrogate mother. While the odds are that only one embryo will
implant, what happens if there are twins? triplets? or more? What if the biological parents only
wanted one child? What then? There are also the normal complications associated with multiple
births such as premature labor and miscarriage to consider as these can affect pregnancy outcome
and maternal health.

WHAT IS IN VITRO FERTILIZATION AND HOW DOES IT WORK?

This lesson introduces the concept of fertilization, and then uses that background information
to explain the details behind in vitro fertilization (or IVF). A summary and brief quiz are included at
the lesson's conclusion.

Overview of Fertilization
Most people are familiar with the concept of fertilization: the idea that sperm cells join egg
cells to produce zygotes, otherwise known as fertilized eggs. However, what people might be less
familiar with is how normal fertilization differs from in vitro fertilization (IVF). Each of these
processes can produce a healthy individual, but they differ in form and complexity. For example,
fertilization normally occurs when a sperm fuses with the mother's egg inside the uterus or fallopian
tube. This is how most fertilized eggs are produced and chances are, it's how you were created;
however, when people have difficulty conceiving a child naturally, they may choose to explore
another method of fertilization such as IVF.

In Vitro Fertilization
The primary difference between IVF and natural fertilization is that IVF involves removing
sperm and eggs from the parents' bodies for fertilization outside the body. The sperm is used to
fertilize an egg under controlled conditions within a laboratory setting. If successful, the fertilized
egg (zygote) further develops into an embryo, and then is implanted back into the mother's uterus to
undergo an otherwise normal development process. While this method of fertilization seems simple,
it is actually very complicated.

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 The initial step of in vitro fertilization involves the woman taking hormone supplements that
stimulate her ovaries to release multiple eggs, rather than the typical one egg per month. If the
stimulation is successful, these eggs are then carefully harvested. The timing of this harvest is
critical; too early or too late a harvest, and the eggs may not develop properly.

To harvest eggs, doctors use a hollow needle to collect the eggs directly from the ovarian
follicles. During the procedure, many women will receive pain medication, be mildly sedated, or
undergo full anesthesia. Upon retrieval, the eggs are mixed with the father's sperm and fertilization is
allowed to occur. Then, under clinical supervision, the fertilized eggs are allowed to develop for
several days.

After the eggs have grown and are ready,

doctors use a flexible tube to implant the
developing embryo back into the woman's uterus.
This procedure is simpler than egg retrieval and
typically involves no sedative or anesthesia.
However, this is where things become
considerably less controlled because there is no
guarantee that deposited embryos will survive. In
fact, the majority of embryos are unlikely to
remain viable following their introduction back
into the uterus. The success rate varies widely
depending on the mother's age, health, and other
factors; one study estimated that approximately
Developing embryo
25% of implanted embryos result in a live birth.

For this reason, most doctors recommend implanting multiple embryos, thus increasing the
likelihood of success for one of them. Yet, in some cases, multiple embryos do survive and develop
into healthy children. Therefore, IVF could help couples have one child or multiple children,
depending on how many embryos are implanted, and the success rate of the embryo implantation.
ETHICS OF IN VITRO FERTILIZATION (TEST-TUBE BABIES)
Did you know that modern medicine makes it possible for couples who cannot naturally
conceive a baby to become pregnant? However, not everyone agrees with the use of these methods.
Learn more about what IVF is and why some are concerned about its use.

Who was Louise Brown?

For many women, the birth of their first child may be the happiest day of their life. Can you
imagine, instead of parties and celebrations thrown in honor of your newborn daughter, receiving
hate mail from strangers? This was the experience of Lesley and John Brown after the birth of their
daughter Louise. What would spark such a response? Why would such outrage be directed at a
newborn baby?

While many women nowadays seek medical assistance to obtain pregnancy, Louise Brown
was the first baby born using in vitro fertilization (IVF) back in 1978. Her doctors, Patrick Steptoe
and Robert Edwards, are now seen as the pioneers of IVF. Back in the 1970s and 1980s, many
people, both religious and non-religious alike, saw this treatment as an abomination. They felt that
the doctors were messing with Mother Nature, or ''playing God''.

Why IVF?
IVF is one of many types of assisted reproductive technologies (ART), a group of medical
methods that are used to help women become pregnant. Did you know that according to a 2015
survey, around 7 million men and women in the US alone will seek treatment for infertility? Reasons
for infertility can vary from diet or lifestyle to medical reasons, and many causes of infertility can be
addressed using ART. In fact, that same survey found that the use of IVF has increased by around
65% since 2003.

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 By now you may be wondering ''what exactly is IVF?'' and ''why would somebody use it?''
Before we answer those questions, let's make sure you have a little refresher as to the basics of
reproduction. First up, the males. Guys, inside each of your testes, you are constantly making tiny,
and I mean like microscopically small, sperm. Millions of them! The key thing about sperm is they
have to be able to reach their target. That means they need to swim. But not all guys make good
swimmers. Sometimes, they need a little help.

And girls, well, each month you release an egg from one of your ovaries. That egg travels
down the uterine tube to the uterus. Normally, any nearby sperm would fertilize that egg, and the
fertilized egg would implant itself into the uterus. But, just like the guys, sometimes you need a little
help too. Maybe your ovaries have trouble releasing the egg, or maybe both the egg and sperm need
a little help completing fertilization. Perhaps the environment in the uterus isn't quite right. This is
where the doctors come in.

What is IVF?
In vitro fertilization is when eggs and sperm are removed from the reproductive organs and
are combined outside the body. This usually takes place in a laboratory dish - not the most romantic
setting in the world, but we all need a little help sometimes. Doctors can alter the environment the
eggs and sperm are kept in to make sure it is just right for fertilization. Then, they watch over the
fertilized eggs a week or so until they develop into embryos. Due to the cost and because chances of
success are not 100%, at least two embryos are placed into the mother's uterus to complete
development. From here, the mother's body takes over and, if all goes well, 9 months later the
parents will have their own baby!

Health concerns
Sounds like a miracle, right? A couple previously unable to have a child can now conceive!
But, like other advances in modern medicine or technology, there are some concerns. First let's look
at the physical concerns. Is IVF safe for the mother and for the baby?

Since IVF increases your chance of multiple births, the risks associated with this condition
should be considered. Primarily, multiple births and IVF babies in general run the risk of premature
labor, or early birth of the baby. This can be dangerous if the baby is born before their major systems
have finished developing or if their birthweight is too low, since low birthweight has been associated
with health complications in newborns. For the mother, IVF can lead to stress, pain in the ovaries if
they are overstimulated, or a condition called ectopic pregnancy where the fertilized egg implants
outside of the uterus.

Ethical concerns
The biggest ethical concern about IVF today is the destruction of unwanted embryos.
Remember how I told you the egg is fertilized outside the body? Well usually, to increase the
chances of success, multiple eggs are fertilized. However, not all of these are placed inside the
mother. The extra embryos are either frozen or discarded. See the problem yet?

All of the embryos have the potential to become a baby, if given the opportunity. Do these
embryos, having no ability to speak for themselves, have the right to life? Many religious groups and
non-religious individuals feel that the moment of life begins at fertilization, the moment that the egg
unites with the sperm and gains the potential to develop into a baby. If those extra embryos are
viewed as living, then destroying them would be a form of murder.

Another issue, though not as common as the first one, is the concept of ''playing God''. IVF
and other ART methods are taking fertilization and the ability to conceive a child out of
God's/Mother Nature's/biology's hands and putting it in our own. Essentially, we are circumventing
the natural order of things. Some individuals feel that if women were meant to conceive it would
happen naturally, and if it doesn't then perhaps God, or fate, didn't mean for her to conceive.
13
 On the other hand, we as humans have been given the intellect to create amazing medical and
technological advancements. Would God or fate have allowed us to do so if we weren't meant to use
them?

SUMMARY

The question of when life gains value is more moral than scientific. Science says that human
beings develop gradually over time. Sperm and eggs are alive even before conception and by most
accounts, human life begins at conception, since they are a unique and genetically complete human.
However human personhood is another matter entirely.

Humans develop their personhood gradually, their individuality impacted by experiences in

the womb, and with the outside world after born. It's more a question of moral value. If human life
only has moral value because we create it, then abortions are a matter of choice. However, to many
religious people, life is sacred and a gift from God. Even the possibility that an abortion may be the
ending of a human person is enough reason to prohibit it. Others argue that where there is doubt, a
mother's own rights are paramount. They would also point out that this is especially important in a
world where poverty still exists, and pregnancy can lead to a mother's death.

There are many resources available nowadays for couples who face difficulties obtaining
pregnancy. ART techniques include: IUI, when the male's sperm is placed inside the female's uterus
and IVF, where both the egg and sperm are removed from the reproductive organs and combined in
a lab. After fertilization the embryo is placed back into the female's uterus. If these or similar
techniques do not work surrogacy is also an option. This is when the baby develops inside a female
other than the mother.

Human cloning is a controversial topic because it involves the duplication of human DNA.
This may be done through reproductive cloning, which involves developing a duplicated embryo, or
through therapeutic cloning, which involves extracting stem cells from an embryo that is not allowed
to develop.

So, as you can see, there are many, many things to consider when looking at surrogacy.
Surrogacy can be an amazing and wonderful option for those who cannot have or cannot carry their
own children. But there are many legal, ethical and medical considerations.

The health and well-being of both the surrogate mother and child needs to be the first
priority. Legal contracts should be in place to protect all parties involved. Mothers should be
screened medically, psychologically and surrogacy should not exploit poorer women who have no
choice in the matter.

In conclusion, the ethical issues surrounding in vitro fertilization (IVF) and other assisted
reproductive technologies (ART) have valid points on both sides. There is no obvious right or wrong
answer: it is something each person has to decide for herself or himself. The ability of IVF
technology to fertilize a women's egg outside the uterus and later implant it inside the mother's
uterus to complete development is just one of many methods being used to treat infertility. As with
most medical procedures, IVF comes with its own set of risks, such as premature labor and ectopic
pregnancy.

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 2 1 hour &
45 mins.
Topic 2: Dignity in Death and Dying

At the end of the lesson, the students will be able to:

 Define dying with dignity.
 Understand why the terminally ill choose a form of assisted suicide.
 Differentiate between active and passive euthanasia.
 Summarize some of the arguments for and against euthanasia.

Overview

Of all the problems that can be considered life and death ethics, none causes more moral
anguish than the end of life issues of withholding/withdrawing life-support, euthanasia, and assisted
suicide.

Today, however, the practitioner is faced with the frustrating problem of available
technology that allows for life extension but cannot restore the patient to a life free of pain and
misery – or even, in some cases, to an awareness of the environment.

The practitioner’s duty to respect life and preserve it where possible may at times come into
direct conflict with the duty to alleviate pain and suffering. What is to be done when the care we
offer appears to have no value to the patient? What is to be done when the quality of life restored has
a negative value, when life itself appears to be an added injury?

15
 In relation to the Topic 1 of Module 2, we will now uncover insights into this idea
about dignity in death and dying, starting with...

ETHICAL ISSUES CONCERNING LIFE & DEATH: TERMS & DEFINITIONS

In this lesson, explore some of the ethical issues in the medical world concerning the
inducement of death and the prolonging of life.

Life and Death

When we think about morals, a lot of times we're talking about the best ways to live long,
happy lives. But that's not always the case. Sometimes we're talking about death. When is it best to
keep someone alive, and when is it best to let them die? That's a pretty heavy question, and while it
may not be the most cheerful ethical debate, it is important, especially in the world of healthcare.

Medical professionals have a unique set of moral duties to their patients, generally wrapped
up in the idea of do no harm. So, can it actually be harmful to keep someone alive? That's the debate
the medical world is facing today. It may not be the most upbeat topic, but there's no point in
avoiding it. Ethics aren't always just about long and happy lives.

Inducing Death
Can death be a more ethical choice than life? That's the question many medical professionals
are asking, specifically in terms of terminally ill patients. Currently, modern medicine treats terminal
illness, or sicknesses that cannot be cured and will result in death, in terms of making the patient as
comfortable as possible for the remainder of their lives. But sometimes this means keeping a patient
constantly sedated with drugs. Other times there simply is no way to avoid the pain that comes with
a deteriorating condition. So, in these scenarios, where there is no chance of a recovery, some people
are starting to argue that it is more humane, more ethical, to end a patient's life before suffering gets
worse.

The term for this is euthanasia, which just means intentionally ending a life to relieve pain or
suffering. Euthanasia is distinctly different than murder in that it is specifically focused on
preventing suffering.

Euthanasia is a complex debate, and it can be broken into various ideas. Although most
nations do not legally allow any form of euthanasia for human patients, the form that is gaining the
most support is doctor-assisted suicide, in which a medical professional oversees the end of life to
ensure that it is as painless and quick as possible.

The ideas of medical supervision and the voluntary consent of the patient are the two most
important components of presenting this as ethical. That makes it different from forms of euthanasia
in which the patient does not expressly ask for a termination of life. For example, the term mercy
killing is often applied to euthanasia

made without the knowledge of the patient or by someone outside of the medical profession.
Generally, this is just someone who feels pity for the victim. These are still largely considered
unethical, even amongst those who support doctor-assisted suicide.

However, there is even another form of mercy killing, which is simply letting someone die.
There are those who believe that if someone is in immense pain, and their lives will not be great
even after recovery, it may be more merciful to just let them die. Some people may support this on a
personal level, but the medical profession does not. In almost all cases, the medical ethical duty is to
provide care and prevent harm, which means not letting a patient die out of perceived mercy.

Prolonging Life

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 So, one side of this debate is focused on when it is best to let someone die. This ties directly
into the other alternative, prolonging life. When is it best to keep a patient alive, and when can even
this cross the line into unethical? Now, obviously, as long as the patient is conscious and recovering,
this is not even remotely a debate. Even for patients with severe conditions, medical professionals
will attempt to maintain the life of the patient for as long as there is hope of recovery. The issue
arises with patients in comas or similar states where it's not clear if they will ever be consciously
aware again. A patient with a prolonged state of unconsciousness and lack of response to external
stimuli is referred to as being in a vegetative state.

Very few people in vegetative states will ever recover, since these are generally brought on
by extreme head injury. Now, thanks to medical technology, it is technically possible to keep people
in this condition alive, although generally they will have no conscious awareness of being alive. So,
this raises another ethical question. Is it more humane to keep someone alive, knowing that they will
likely never be consciously aware again, or is it better to let them pass away?

One way that medical professionals draw the line is by looking for brain death, the
irreversible loss of brain function, which is a way to officially determine that a person has died. But
still, the question of attempting to artificially prolong life is tricky. Many times, this has just as much
to do with families of the patient as the patient themselves. The choice to prolong life, or to induce
death, can be something the family decides on in order to find closure and peace in an otherwise
difficult scenario.

ETHICAL ISSUES IN CRITICAL CARE NURSING

In this lesson, we will discuss a few of the common ethical issues that critical care nurses
deal with on a daily basis. We will also learn about legal documents that will help make decisions
should ethical issues arise.

Ethical Issues in Critical Care Nursing

Critical care nurses face ethical issues on a daily basis, whether involving professional ethics
or helping a patient or family sort out their own ethical issues. This lesson touches on a few of the
most commonly ethical issues in critical care nursing: palliative care, withdrawal of care, advance
directives, and medical power of attorney.

Let's say Patient J has suffered damage to his lungs and can no longer breathe on his own. He
will be attached to a ventilator for the rest of his life, and he needs to

be revived several times a month. However, Patient J is awake and oriented the majority of the time.
During one oriented period, he asks to be made a DNR, or do-not-resuscitate patient, meaning that if
his heart stops again, he doesn't want to be brought back.

Patient J's sister doesn't agree with this and tells the hospital her brother isn't competent. She
threatens to sue if the hospital allows her brother to become a DNR patient. She wants everything
done to keep him alive. The cycle of Patient J's heart stopping and being revived continues for
several months. Finally, the hospital is able to assemble an ethics committee to determine that
Patient J is competent and able to make his own decisions. He chooses to become a DNR patient and
dies peacefully within a few days.

Palliative Care & Withdrawing Care

In Patient J's situation, once he became a DNR, he didn't remove his ventilator; he chose
palliative care. Palliative care is caring for a patient to relieve pain and make the dying process as
peaceful as possible. Depending on patients' wishes, they're given food and hydration, but nothing
considered a life-saving measure, such as CPR, dialysis, or surgery, unless a surgery is to relieve
pain and not aimed at curing the patient.

Had Patient J decided that he wanted to remove the ventilator that was keeping him alive, he
would have been withdrawing care. This is seen a lot in patients who are brain dead, but their heart

17
is still beating. In this case, all life-saving components, such as the ventilator and any medications,
would be stopped, and the patient would be allowed to pass away.

Patient J's scenario is all too common in the intensive care unit. When a patient is dying, one
family member might want everything done to keep the patient alive, while other family members
(or the patient him or herself) might want a peaceful death. This is when an advance directive or
medical power of attorney is very useful. If the patient has neither, the hospital ethics committee
must determine what the appropriate action is.

Advance Directives
An advance directive is a statement that is written by the patient and signed by two witnesses
(not family members) that details how the patient would like to be cared for should he or she become
terminally ill or unable to make decisions, in which case this document appoints someone to make
medical decisions for the patient. Doctors and nurses use this statement to determine what the
patient's wishes are and make sure they are followed. There are two types of advance directives:
living wills and medical power of attorney.

When assisting patients in making advance directives, there are a few things to consider.
First, the patient's personal and cultural values and morals must be taken into account. Additionally,
several ethical principles must be considered.

The first principle is autonomy. Autonomy is the right patients have to choose what happens
to them. Health care workers must respect the patient's choice and not let their personal beliefs and
morals influence the patient. The next principle is beneficence, which means to do only good and to
remove or prevent harm. Included in that principle is the element of nonmaleficence, which means to
do no harm.

Living Will
A living will explains how a patient wishes to be cared for when the patient reaches the end
of his or her life. It can be changed anytime and is only made active once the patient can no longer
make decisions. However, in some states, it can be overturned by the family once the patient is not
competent or is unresponsive. Therefore, it is important that the patient speaks with family before
the time comes and makes sure the family understands and agrees with the patient's wishes.

Medical Power of Attorney

A medical power of attorney is a document that gives one person the right to make all
medical decisions for the patient should the patient not be able to make his or her own decisions. It
differs from the living will in that it becomes active anytime the patient can't make decisions, even if
the patient is not terminal. It also cannot be overturned by family members. However, the delegated
person doesn't have to follow the patient's wishes, so again it is very important to choose someone
who agrees with the patient's wishes.

TERMINATION OF LIFE-SUSTAINING TREATMENT & ETHICS

This lesson is going to look at the different ethical considerations associated with the
decision to terminate life-sustaining treatments. We will explore examples and the questions
surrounding the decision to terminate treatment.

Life-Sustaining Treatment
Tragedies that result in sudden death are very hard to deal with. We are forced to realize that
someone that we love is no longer with us. Death takes the person without consulting us. In other
situations, death may creep up over time and force us to make the decision to let someone go.
Deciding to let someone that you love go is one of the hardest decisions that we are sometimes faced
with in life.

18
 That decision is usually tied to a terminal illness. Other times it may occur due to a severe
injury that a person is not going to be able to fully recover from, such as a heart attack or head
trauma. There are life-sustaining treatments, which are a variety of treatments that basically prolong
the moment of death. Healthcare workers and those designated to make decisions for a person in that
situation have to work together to decide if and when these treatments should be discontinued.

Ethics of Treatment Termination

One example is Karen Ann Quinlan, a 21 year old that suddenly collapsed and went into a
coma. The doctors put Karen on a respirator and inserted a feeding tube as life-sustaining measures.
The doctors also let Karen's parents know that she had serious brain damage and was considered to
be in a vegetative state.

Personal Impact
Karen was not proactive by completing an
advanced directive, which gives directions for her
care if she cannot communicate. She also did not
designate a healthcare proxy, which is the person
who will make healthcare decisions in the event
that she is not conscious or of sound mind to make
them herself.

This would have helped to give an idea of

what Karen would want at that point. There is an
argument though that the advance directive does
not always reflect what the person may want if too
much time has lapsed since the advance directive is
written, or because people tend to feel different
about their choices when they actually have to face Advance directives can help to determine when life-
the possibility of dying. This happens frequently in sustaining treatments should be terminated
situations involving being resuscitated. This
presents a conflict for the healthcare team when one thing is in writing and the immediate family
member or person making health decisions wants to go against the previously expressed wishes.
How this pans out varies case by case.

The next ethical consideration regarding terminating the treatment is determining the point at
which sustaining Karen's life could be viewed as cruel. Some people feel as though prolonging a
person's life when they are suffering and ultimately going to die as being cruel. Others feel that
prolonging it gives a chance for a miracle to happen or cure to be found. The ethical concerns behind
this question can be magnified in some cases, like Karen's, where the life-sustaining treatments do
not help to cure or even treat the condition causing death. Karen's guardian decided to request that
the respirator be removed in order to allow Karen to die since it seemed all hope was gone.

This brought up another ethical concern, which was the possibility of the hospital and/or
doctors being accused of homicide. Her family ultimately had to request that the court not bring
charges on the hospital or doctors before they would honor the request to terminate the respirator.

The other personal, ethical aspect of terminating the treatments is the question of quality of
life. There are many people that do not want to be kept alive if they are brain dead or considered to
be a vegetable. Other people want all possible measures taken until death happens in spite of the
19
treatments. This sometimes results in a person existing without actually living for months to years at
a time. In Karen's case, the feeding tube was continued and she starting breathing on her own once
the respirator was removed. However, her quality of life could be questioned considering that she
was 21 and spent the remaining 9 years of her life in a nursing home before dying of pneumonia.

You may be wondering why the feeding tube was continued when the respirator was
removed. Was that not a part of the life-sustaining treatment? Should it not also have been removed?
Well, that addresses the ethical question of what is considered to be a basic need that should always
be provided and is not considered to be care. Things such as nutrition and water are considered by
many to be basic needs that should always be supplied until death occurs.

Socioeconomical Ethics
In addition to having to make the right ethical decision directly in relation to Karen, the
healthcare team must make the right decision in relation to other people needing the same treatment
that are not terminally ill or possibly at the end of life. This is a tricky area of ethics because it
almost requires healthcare workers and families to place the value of one person over another.

For example, this may have come into play if blood transfusions had been a part of Karen's
treatment. Once it appeared inevitable that Karen was not going to live, the ethical question comes
up as to who should receive the treatments. The argument can be made that someone that has more
life to live should receive blood transfusions over Karen who seemed to be going to die anyway.

We have to keep in mind that we do not have an unlimited supply of blood to use for
treatments. The decision to terminate the use of limited resources has to occur

in order to make sure the resources are available for those that need it and are more likely to survive.
This ethical concern relates to medications, procedures, and surgeries as well.

The resources are limited, and the use of these resources cost money. The cost is sometimes
astronomical and out of reach for people that do not have insurance. The decision to terminate the
treatments cannot be based on the ability to pay alone, but it may become a factor when it is in
conjunction with other reasons to terminate treatment.

If Karen died, she would not be around anymore, and her family would be left with a lot of
extremely high medical bills to pay for the treatments. The ethical question is whether the treatments
should be terminated since they are costly and will not save her life. The hospital continuing the
treatments could be seen as putting profit above the best interest of the patient.

DYING WITH DIGNITY: DEFINITION & OPTIONS

When a person is faced with a terminal illness, they sometimes want to control the timing
and way that they die. In this lesson, we'll examine the dying with dignity movement, including
physician-assisted suicide and euthanasia.

Dying with Dignity

Sarah has had a full and happy life, but she has a terminal illness that is attacking her central
nervous system. Her doctor has told her that she will die from this disease, but that it will be slow
and painful. By the time the disease finally takes her, Sarah will not be in control of her body
anymore. She won't be able to feed herself or wash herself or even go to the bathroom on her own.

To Sarah, the thought that she won't be able to take care of herself is worse than the thought
of dying. She doesn't want to linger in pain and lose control of her body, so she is considering her
options. Dying with dignity is a movement that promotes the ability to meet death on your own
terms. Dying with dignity involves offering options to terminally ill patients, like Sarah, other than
just waiting for the illness to kill them slowly. There are two major ways to die with dignity: suicide
and euthanasia.

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Suicide
Sarah doesn't want to live in pain and slowly lose control of her body, so she talks to her
doctor and tells him that she wants to end her life early. Assisted suicide, which is also called
physician-assisted suicide, is when a doctor gives a person the means to commit suicide. For
example, Sarah's doctor could give her a prescription for drugs that would end her life, but it's up to
her to actually take the drugs and end her life.

Many people prefer the term assisted death to the term assisted suicide because they feel that
the word 'suicide' has connotations that do not reflect the reality of a situation. They argue that
suicide is when someone who is not terminally ill kills themselves, whereas assisted death occurs
when a terminally ill patient seeks help in hastening death.

For example, if Sarah had a disease that caused her pain, but would not kill her, then by
taking drugs to end her life, Sarah would be committing suicide. That is,
she would be ending a life that otherwise would continue on. But because Sarah is terminally ill, she
will be dying anyway, so some people feel that the correct terminology is assisted death.

Euthanasia
Remember that Sarah's illness will eventually progress so that she can't take care of herself.
What if she wants to end her life then? If she can't even feed herself or go to the bathroom, it would
be impossible for her to take drugs required for her to kill herself.

Causing the death of another person to keep them from suffering is called euthanasia.
Euthanasia differs from assisted suicide because the patient commits suicide, whereas another person
commits euthanasia. For example, if Sarah isn't able to administer the drugs herself, but her doctor or
her daughter administer them for her, it is euthanasia.

There are two types of euthanasia: active and passive. Active euthanasia involves directly
causing the person's death through an action. For example, giving Sarah drugs to stop her heart
would be an example of active euthanasia. On the other hand, passive euthanasia involves
withholding treatment in a way that hastens death. Taking someone off life support or not giving a
person drugs that they need to keep them alive are examples of passive euthanasia.

Note that in most states, both assisted suicide and euthanasia are illegal. Doctors can lose
their license and go to jail for helping people die. The dying with dignity movement tries to change
the laws to make it legal for Sarah and people like her to be able to seek help from a medical
professional or a loved to help them hasten death.

DEATH AND DYING: EUTHANASIA DEBATE AND STAGES OF ACCEPTANCE

The end of one's life can be a difficult time, for both the person dying and their loved ones. In
this lesson, we'll explore some end-of-life issues that people face, including the five stages of grief
and the controversy surrounding euthanasia.

Dying
Trina has a problem. She has been diagnosed with a rare illness, which will cause her to die
slowly and painfully. She's understandably upset, and her son Lou is trying to help her cope with her
diagnosis.

Death is inevitable. Everyone dies at some point, but it can still be emotionally difficult for
the person dying and for their loved ones. Both Trina and Lou are very upset that she is dying.

21
 Let's look closer at the process of death, including the five stages of grief and the
controversial subject of euthanasia.

Stages of Grief
Trina has just found out that she is dying, and she is very upset. In fact, she is going through
a grieving process. That is, she is mourning her own death and dealing with serious emotions.

In 1969, Elisabeth Kübler-Ross proposed that there were five stages of grief. That is, when a
person is dying or dealing with the death of a loved one, they will go through five stages. You can
remember these stages with the acronym 'DABDA.'

'D' is for 'Denial.' At first, a person doesn't want to believe what they are hearing. When
Trina found out that she was diagnosed with a terminal illness, she thought, 'This can't be
happening to me.' Her son Lou, too, was in denial. He even asked the doctor to run more
tests to confirm the diagnosis.
'A' is for 'Anger.' Once a person gets past denial, and they realize that they really are
dealing with death, they feel angry. For example, Trina was angry at her doctor for
diagnosing her with the disease, even though it wasn't really his fault.
'B' is for 'Bargaining.' Moving past anger leads most people to begin thinking about 'if-
then' scenarios. Lou, for example, thinks to himself, 'If only she'd gotten things checked
out sooner, then she'd be okay.' Trina, meanwhile, is silently making deals with her god.
'If you let me live,' she prays, 'I'll be a better person. I'll volunteer every week at the
homeless shelter downtown.'
'D' is for 'Depression.' Eventually, a person recognizes that bargaining isn't going to
work. This often leads to feelings of sadness and despondency. For example, when Trina
realizes that trying to bargain for her life isn't making her better, she feels very depressed.
She stays in bed all day and cries a lot.
'A' is for 'Acceptance.' Finally, after depression, many people find acceptance. This
involves making peace with what's happening. Trina eventually realizes that she must
accept the fact that she's dying, and she feels calm. She's not happy about it, but it's no
longer keeping her up at night, either.

It's important to note that not everyone goes through every stage. For example, Lou is still
stuck in bargaining. He might never get to acceptance of Trina's death, though it would be best for
his peace of mind if he does.

Euthanasia
Trina has accepted that she's going to die, but she's facing a death that will be painful and
slow. She doesn't want to go that way; she'd rather die quickly and as painlessly as possible, so she
asks Lou and her doctor to help her commit suicide.

Euthanasia is the act of assisting someone in dying. One specific type of euthanasia is
physician-assisted suicide, which involves a doctor administering medication to help a person pass
on. For example, if Lou, who is not a doctor, helps his mother die, it is euthanasia. If her doctor
prescribes medication for her to take to kill herself, or if her doctor injects her with medication to
help her pass on, it is physician-assisted suicide.

Both euthanasia and physician-assisted suicide are illegal in some places and legal in others.
They are controversial, with people from both sides very passionate about their beliefs.

On one hand, people who believe that euthanasia should be illegal point out that it's a
slippery slope from euthanasia to murder. For example, if Lou helps Trina die, how can the police
know for sure that she wanted to die and not that he just wanted to kill her for his inheritance?
22
 Another point against physician-assisted suicide is the argument that doctors have a moral
obligation to help people heal and to do no harm, which is part of the Hippocratic Oath that doctors
take when they become doctors. People who are against euthanasia point out that physician-assisted
suicide goes against the Hippocratic Oath.

On the other hand, some people argue that euthanasia should be legal. They point out that
people like Trina should have a right to die with dignity. If a person has a disease that will lead to
their death, they should be able to choose how and when to leave the earth. For example, if Trina
doesn't want to go through a slow and painful death, some people argue that she should have the
right to decide to end her life early.

EUTHANASIA & PHYSICIAN-ASSISTED SUICIDE: A MORAL DEBATE

In this lesson, we will explore the implications of legislative decisions regarding euthanasia
and physician-assisted suicide. Further, we will evaluate the moral arguments regarding different
types of euthanasia and physician-assisted suicide.

Definitions
What are the limits to allowing people to make their own decisions about their lives? In the
1990s, Dr. Jack Kervorkian, who was often referred to as 'Dr. Death,' challenged beliefs about
euthanasia. Euthanasia is the methodical and intentional termination of life in a patient who has a
terminal or incurable disease. People choose to end their lives to avoid the pain and indignity that
often accompanies a terminal illness. Dr. Kervorkian developed assisted suicide machines that
allowed patients to painlessly transition from life to death, sparking debate about the moral and legal
implications of euthanasia and physician-assisted suicide that remain controversial today.

The subtle difference between euthanasia and physician-assisted suicide is the degree of
involvement of the doctor. With euthanasia, the doctor administers the lethal dose that ends the
patient's life. With physician-assisted suicide, the patient

takes the lethal dose of medication, which has been provided by the doctor, on their own. Let's
examine the euthanasia debate.

Legislative Decisions
Dr. Kervorkian was charged with murder in Michigan in the 1990s. There are now several
states that have 'Death with Dignity' laws that enable the terminally ill to make their own end-of-life
decisions. In 1997 Oregon was the first state to allow physicians to prescribe lethal doses of
medication for terminally ill patients. Since then, Washington and Vermont have adopted similar
laws. These states have developed a specific protocol for providing these medications. In 2009,
Michigan established legal protection for doctors who write prescriptions for lethal medication at the
request of a terminally ill patient.

In 2014, New Mexico courts established a patient's right to receive assistance in death, but
this right was challenged and overturned by the New Mexico Supreme Court in June 2016.
Washington, D.C., Washington state, California, Colorado, and Vermont have recently passed
legislation in support of a patient's right to die. Legislation that would allow patients the right to die
is currently pending in 25 other states.

Types of Euthanasia
Ethical arguments vary based on the type of euthanasia that is proposed. Euthanasia can be
divided into categories based on who is making the decision to die. It can be voluntary, non-
voluntary, or involuntary. Voluntary euthanasia is when the patient makes a request to die. Non-
voluntary euthanasia is when a person is incapable of making their own decision because of age or
disability, requiring another person to make that choice for them. Involuntary euthanasia is murder
as the person wants to live, but their life is terminated against their will.

23
 Further, euthanasia can be categorized by the degree of involvement in terminating life.
Active euthanasia is taking deliberate life-ending measures. Passive euthanasia is allowing a person
to die by removing or withholding life-saving treatment. For example, removing feeding tubes
would be passive euthanasia. Frequently, a living will dictates whether or not life-saving measures
will be applied and to what degree.

Arguments For and Against Euthanasia

In this section, we will assume that euthanasia refers to voluntary, active, assisted suicide.
People who advocate for euthanasia typically view making decisions about death as a basic human
right that should be made by the patient. End-of-life care is expensive and draining and may result in
suicide. Death with dignity laws allow the process to be regulated.

Those who oppose euthanasia frequently have ethical or religious reasons to oppose
interfering with the sanctity of life. There are worries that vulnerable populations will feel pressured
to end their lives to accommodate caregivers. Further, people fear that the quality of care for those
who choose to live will be negatively impacted.

NANCY CRUZAN & LIFE SUPPORT: ETHICAL CASE STUDY

There are many considerations to account for at the end of someone's life. Legal, ethical, and
moral issues come into play when deciding to remove a person from life support. We will look at
those concerns based on what happened with Nancy Cruzan.

Life Support
There are few things harder than seeing someone you love on life support. Life support refers
to the treatments and machines used to maintain life in a person whose vital organs are no longer
working on their own.

While life support is associated with caring for someone, particularly in late stages of
terminal illness, sudden injuries and illnesses may also be the cause.

Who Is Nancy Cruzan?

Nancy Cruzan was a 25 year old woman in 1983 when she was in a terrible car accident. She
suffered traumatic injuries and had no vital signs such as breathing or heartbeat when she was found.
The emergency responders did CPR to resuscitate her.

At the hospital she was put on ordinary care life support, which involves a feeding tube and
hydration. Within about a month, her doctors determined that she was in a persistent vegetative state
(PVS) and would not recover. This meant she had no brain function and could not respond to her
environment. This is the point when several issues were raised.

Moral and Ethical Concerns

Unfortunately, loved ones are often faced with making decisions about continuing life
support or not. This decision is sometimes made a tad bit easier when the person's wishes are known
through an advance directive. This is a document that outlines what medical interventions the person
would want and who can speak for them in the event that they cannot speak for themselves.

The document includes allowances or cessations for resuscitation and life support. Without
an advance directive, loved ones are forced to request what they believe to be the wishes of the
person who is on life support.

24
 In Nancy's case, there was no advance directive, but the family and many of her friends felt
they knew her wishes. Her parents requested to have her removed from life support because they
knew she did not want to exist in a vegetative state and 4 years had already passed since her accident
with no change in her condition.

Her doctors refused, as they were just giving her the basic of needs: food and water. They
insisted that removing these would kill her and could be seen as immoral and illegal since she would
then die of starvation and dehydration.

What a debate! The ethical problem here was whether someone can make the decision to end
another person's life by removing life support. There wasn't anything written to prove what Nancy
would want. Doctors are held to an oath to improve life, and not to take it away. The burden fell on
the family to prove what Nancy would want since Nancy was clearly unable to do so from a
vegetative state.

Legal Concerns
These ethical and moral concerns turned into legal concerns. Our Constitution gives us the
right to refuse medical treatment, but it does not outline whether the right still exists in the event that
someone is incompetent, meaning unable to make decisions for themselves. This means that courts
are left to make this decision based on their understanding of the constitution and rights outlined by
the constitutions of their individual states.

The legal issue becomes even bigger when determining if it is legal or not to allow someone
else to make that decision and determining where the differentiation exists between murder and
causing death by withholding the basic needs of life. Who can make that decision and what proof do
they need to show they are acting on the
patient's wishes?

Court Decision
Nancy Cruzan's parents went to the
Missouri court system to petition the court
to give the doctors a protective order to
allow them to take Nancy off of life support.
The state trial court granted the request
based on Nancy's housemate testifying that
Nancy told her that she would not want to
live in a vegetative state. The court decided
that the statement was enough since it was
made when Nancy was competent.

The state supreme court disagreed and reversed the decision, requiring ''clear and
convincing'' evidence of an incompetent person's wishes in such a case. More than just a housemate's
evidence was therefore required in order to grant the request for Nancy's death. In 1990, the US
Supreme court upheld this decision.

Nancy's parents had many families, friends, and co-workers to testify about Nancy's wishes
to not live in a vegetative state. The Missouri State Supreme Court withdrew, so a probate court
granted the request and life support was removed 7 years after her accident occurred. She died 11
days later.

Cruzan v. Director, Missouri Department of Health was a landmark case for the Supreme
Court. In a 5 to 4 decision, it was a very important 'right to die' case. Only a month after the last
ruling, 300,000 requests were submitted to the Society for the Right to Die for advance directive
forms.

A year later, the Patient Self-Determination Act was passed, requiring health facilities to
make patients aware of their right use advance directives.

25
SUMMARY

In the medical world, one of the biggest ethical debates is the distinction between when it's
okay to end a life and to what extent life should be prolonged. Despite the fact that medical
professionals generally have a duty to their patients' welfare, many people argue for certain forms of
euthanasia, the intentional ending of a life to relieve pain or suffering, in cases of terminal illness.

The most-ethically accepted arguments for euthanasia support doctor-assisted suicide, which
is when a medical professional oversees the end of life to ensure that it is as painless and quick as
possible. This is different than a mercy killing, euthanasia made without the knowledge of the
patient or by someone outside of the medical profession.

The other side of this is the issue of prolonging life. Medical professionals generally try to
keep patients alive, but medical technology that allows people to live on machines raises the
question of the extent to which this is moral. Most people support the use of technology to keep
someone alive who is in a vegetative state, a prolonged state of unconsciousness and lack of
response to external stimuli. However, the line is often drawn at brain death, irreversible loss of
brain function. These are all very important questions to ask. Not cheerful ones, but important.

There are many ethical considerations involved in terminating life-sustaining treatments.

These are treatments that prolong death when death is inevitable and will occur soon.

Dying with dignity is a movement that focuses on giving terminally ill patients options for
when and how to die. Assisted suicide is when a physician gives a person the means to commit
suicide, active euthanasia is when someone takes an action to end a person's life to alleviate their
suffering, and passive euthanasia involves withholding treatment to hasten death. In most states,
assisted suicide and euthanasia are illegal.

Euthanasia is deliberately ending the life of a terminally ill person through the help of a
doctor. Physician-assisted suicide is slightly different in that the doctor provides lethal medication
but does not administer it to the patient.

Euthanasia is divided into categories based on who makes the decision. These categories are
voluntary, non-voluntary, and involuntary. It is further categorized by the degree of involvement in
the process of terminating life. Euthanasia may be active or passive. Proponents of euthanasia cite
human rights, economics, and regulation as reasons for enacting laws surrounding dignity in death.
Those who oppose it cite religious or ethical issues with ending life, worries on behalf of vulnerable
populations, and concerns about care quality for those who choose to die naturally.

26
 2
1 hour
Topic 3: Nursing Roles and Responsibilities

At the end of the lesson, the students will be able to:

 Summarize the different roles that a nurse can fill in the health profession.
 Identify some ethical responsibilities of nurses.
 Describe the ethical & legal responsibilities of healthcare workers.

Overview

Ethical issues happen when choices need to be made, the answers may not be clear and the
options are not ideal. The result could be declined in the quality of patient care; problematic clinical
relationships; and moral distress, which is defined as knowing the right thing to do but not being
allowed or able to do it. Nurse managers, in particular, are susceptible to ethical issues in nursing
and moral distress because of their leadership and mentoring roles. Nurses and other medical staff
look to nurse managers for appropriate and ethical decisions.

For nurse managers, ethical decision-making stems from the American Nurses Association
Code of Ethics, which was developed as a guideline for nursing responsibilities “in a manner
consistent with quality in nursing care and the ethical obligations of the profession.” Nurse managers
help solve ethical issues in nursing through using their leadership qualities to implement the Code of
Ethics in their daily lives.

In relation to Topic 2 of Module 2, we will now determine the different nursing roles
and responsibilities in the scope of ethics.

ROLES AND FUNCTIONS OF THE NURSE

27
 What exactly does a nurse do? This lesson explores some of the different roles a nurse plays
in patient care, including caregiver, decision maker, communicator, manager of care, patient
advocate, and teacher.

Roles and Functions of the Nurse

What exactly does a nurse do? Your answer probably depends on the experiences that you
have had in the past. Most people think a nurse is someone who gives a shot at the doctor's office -
or simply is a doctor's assistant. Furthermore, images of nurses in the media also paint a different
picture of who a nurse really is.

However, a nurse has a number of roles that he or she performs, often at the same time,
depending on a patient's needs. With all of the changes in healthcare over the last few decades, that
role has expanded even more. Let's explore a few of these roles.

Caregiver
As a caregiver, a nurse provides hands-on care to patients in a variety of settings. This
includes physical needs, which can range from total care (doing everything for someone) to helping
a patient with illness prevention. The nurse maintains a patient's dignity while providing
knowledgeable, skilled care.

In addition, nurses care holistically for a patient. Holistic care emphasizes that the whole
person is greater than the sum of their parts. This means that nurses also address psychosocial,
developmental, cultural, and spiritual needs. The role of caregiver includes all of the tasks and skills
that we associate with nursing care, but also includes the other elements that make up the whole
person.

Decision Maker
Another role of the nurse, as a decision maker, is to use critical thinking skills to make
decisions, set goals, and promote outcomes for a patient. These critical thinking skills include
assessing the patient, identifying the problem, planning and implementing interventions, and
evaluating the outcomes. A nurse uses clinical judgment - his or her ability to discern what is best
for the patient - to determine the best course of action for the patient.

Communicator
As a communicator, the nurse understands that effective communication techniques can help
improve the healthcare environment. Barriers to effective communication can inhibit the healing
process. The nurse has to communicate effectively with the patient and family members as well as
other members of the

healthcare team. In addition, the nurse is responsible for written communication, or patient charting,
which is a key component to continuity of care.

Manager of Care
The nurse works with other healthcare workers as the manager of care and ensures that the
patient's care is cohesive. The nurse directs and coordinates care by both professionals and
nonprofessionals to confirm that a patient's goals are being met.

The nurse is also responsible for continuity from the moment a patient enters the hospital
setting to the time they are discharged home and beyond. This may even include overseeing home
care instructions. For nurses in the hospital setting, the nurse is responsible for prioritizing and
managing the care of multiple patients at the same time, which adds another dimension to this
process.

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Patient Advocate
Being a patient advocate may be the most important of all nursing roles. As a patient
advocate, the nurse's responsibility is to protect a patient's rights. When a person is sick, they are
unable to act as they might when they are well. The nurse acts on the patient's behalf and supports
their decisions, standing up for his or her best interests at all times. This can empower a patient while
recognizing that a patient's values supersede the health care providers'.

Teacher
As a teacher, nurses help patients learn about their health, medications, treatments, and
procedures as well as deal with challenges they may face during and after their illness. Patients often
have questions and might be confused about all that is happening to them. As a teacher, the nurse
may also need to instruct family members about how they can help a patient. In addition, discharge
instructions, or instructions about what to do once they are not in a hospital setting, are important so
that a patient can easily care for themselves at home.

Example of Roles
Now that we have discussed these roles, let's look at a patient example of how these roles are
illustrated.

Mr. Jones was playing basketball and fell on the court. He broke his right hand and will have
surgery tomorrow. The nurse comes in and gives him pain medicine, checks his hand for swelling,
and offers him something to eat. She is his caregiver. Next, she sees that his swollen hand is
dangling off the bed. She uses critical thinking skills to place a pillow under his arm to support it,
which will reduce swelling. She is a decision maker. While doing these things, she is a
communicator, as she speaks with him in an empathetic, supportive tone.

She sets up an occupational therapist to work with him at home, as he is right handed and
will need help with his computer work. She is his manager of care. Mr. Jones asks her not to wake
him up at night, as he is very tired and wants to sleep. As his patient advocate, the nurse stands up
for his wishes and communicates with the rest of the healthcare team. Finally, as his teacher, the
nurse explains to him what to expect before and after surgery, as well as the directions for his pain
medication at home.

ETHICAL RESPONSIBILITIES OF NURSES

Every profession has a code of ethics that outlines the ethical responsibilities of practicing as
a member of that profession. Codes of ethics from different professions might focus on issues
specific to practice in that field, but all share elements regarding the importance of honesty and not
taking actions that will lead to harm to others. Codes of ethics for the nursing profession tend to
focus on professional behavior and making sure that decision-making is patient driven as much as
possible.

Respect for Others

A nurse must respect the dignity and value of patients and colleagues and treat all persons
equally regardless of personal attributes or medical condition. Related to this is the responsibility to
always respect the patient's right to self-determination in her medical care.

Commitment to Patient
One of a nurse's primary ethical responsibilities is to work with the patient to provide care
that maximally enables the physical, emotional and social well-being of the patient. A nurse is also
responsible for protecting and advocating for patient safety and rights, especially in terms of
upholding the highest standards of patient privacy and confidentiality according to the law.

Honesty and Self-Integrity

29
 Nurses also have an ethical responsibility to be honest with patients and colleagues, and to
maintain self-integrity and high personal moral standards. By the same token, nurses have a personal
responsibility to maintain professional competence and strive towards personal and professional
growth so as to provide the best possible care to patients.

Professional Responsibilities
A nurse also has a number of ethical responsibilities relating to the profession of nursing and
her specialty. One key responsibility is to always strive to improve both health care environments
and conditions of employment to maximize the quality of health care delivery. Nurses also have a
responsibility to work with the public and other medical professionals to foster local school or
community, national and international efforts to improve health care systems on all levels.

ETHICAL & LEGAL RESPONSIBILITIES OF HEALTHCARE WORKERS

Healthcare workers must fulfill ethical and legal responsibilities when caring for others, and
patients can be harmed if they don't act as they should. In this lesson, we'll discuss examples of
unethical behavior and their effects.

Healthcare Ethics
Healthcare workers have a legal and ethical responsibility to protect the patients they care
for. When these responsibilities are ignored, patients suffer. Additionally, healthcare workers can be
held responsible for these behaviors. Ethical behavior or responsibility is doing the right thing for the
patient. Many healthcare professions have codes of ethics to which practitioners are expected to
adhere. For example, the nursing Code of Ethics is a lengthy document that covers ethical

expectations in detail. Some examples of unethical behaviors include fraud and neglect. Let's discuss
court cases that illustrate the negative impact of unethical practices.

Healthcare Fraud
Physicians have a legal and ethical responsibility to provide healthcare that is appropriate for
the patient. Healthcare fraud is a major issue within healthcare that negatively impacts customers.
Healthcare fraud involves filing claims for fraudulent or unnecessary procedures in order to make
more money. For example, let's say a physician filing a claim for reimbursement with an insurance
company for a diagnostic test that he or she didn't perform. That's healthcare fraud.

In 2014 a neurosurgeon named Aria Sabit was accused of billing insurance companies and
Medicare for unnecessary surgeries and implants that he fraudulently claimed to have used in those
surgeries. The surgeon was also part-owner of the company which distributed the implants used in
the procedure he claimed to be performing, so he was profiting both by performing these surgeries
and by billing for the implants he claimed to use. His actions actually impacted many people.
Patients were harmed by not getting the appropriate treatment, or by getting treatment that they
didn't actually need. His billing of insurance companies with false information caused them to suffer
financially as well, potentially affecting the premiums charged to policyholders.

Sabit made over 11 million dollars by filing false claims. He was tried by the Assistant
Attorney General for the Criminal Division of the Department of Justice. He pled guilty to
healthcare fraud in 2015. In January of 2017, Sabit was given a nearly 20-year sentence for his
healthcare fraud.

Neglect
Nursing facilities have perhaps the most notorious reputation for neglect of older adults.
Neglect is the failure of a healthcare worker to perform a duty or provide appropriate attention or
care. Neglect negatively impacts a patient's care. Nurses, nursing assistants, and doctors all have a
duty to provide care, and when this care in not provided, whether intentionally or not, it's neglect.
Neglect can cause severe patient harm.

30
 The case of R v. Patel is an example of healthcare neglect. An older man was in a nursing
home being cared for by an array of healthcare staff. One evening it was noticed that he was having
difficulty breathing. The nurse was notified and called emergency medical services. While they were
on the way, the man stopped breathing. The emergency medical technicians instructed the nurse to
attempt to resuscitate the man, but she refused because she was scared. The patient had not provided
orders or instructions not to resuscitate him in the event of an emergency, but the nurse failed to do
so. Because the man's medical wishes included resuscitation, the nurse was neglecting the man by
not resuscitating him.

She was found guilty of healthcare neglect in the Courts of Justice of England and Wales
after he died. The obvious harm to the patient in this case was his loss of life, but failing to provide
needed care can cause substantial harm short of death. Not only are healthcare workers legally
required to provide patient care, they are also ethically bound to do so.

Effects
Healthcare workers are held to a higher standard of morals and ethics than the general public.
They are expected to do what is best for the patient or consumer and make the right choices when
providing care. Unethical behaviors or illegal practices can lead to poor patient outcomes and loss of
trust.

In both the case of Aria Sabit and R v. Patel, patient health was worsened when patients did
not receive treatment they needed. Unethical behavior can have negative physical impacts on
patients. When healthcare workers do not provide necessary treatments or interventions, the patient
can't be expected to get better. For example, Sabit didn't implant hardware into his patients' backs to
improve their pain or mobility but said that he had. These actions may have caused undue harm on
the patients by prolonging their pain or disability. Additionally, when healthcare workers don't
behave as they should, a patient can die, as in the case of R v. Patel.

Unethical behavior also undermines trust. Sabit lied to his patients and insurance companies.
Not only were his patients treated improperly for their conditions, he lied about it. Trust between
patients and healthcare workers is essential. When a patient can't trust their healthcare provider,
they're less likely to accept their professional advice. For example, suppose your doctor tells you that
you need a $1,000 test to determine why your head is hurting. If you didn't trust your doctor, would
you get this test? Or if the nurse hands you a pill and says you need to take this to get better, would
you take it if you didn't trust your nurse?

SUMMARY

Let's briefly recap what we've learned about ethical and legal responsibilities of healthcare
workers. Put simply, healthcare workers are expected to adhere to ethical and professional standards
to protect the patients they care for. Neglect and healthcare fraud are only two of the possible
unethical behaviors that healthcare workers may exhibit. Neglect is the failure of a healthcare worker
to perform a duty or provide appropriate attention or care, while healthcare fraud involves filing
claims for fraudulent or unnecessary procedures in order to make more money. Caring for others is a
unique profession, and part of that caring is protecting patients from harm. Patients are harmed when
healthcare workers do not provide necessary care. Healthcare workers can also be held responsible
for not performing as they should.

31
 2 1 hour &
15 mins.
Topic 4: Ethical Decision-Making Process

At the end of the lesson, the students will be able to:

 Explain what ethical decision-making is.
 Describe the steps to follow in the ethical decision-making process.

Overview

Ethical issues happen when choices need to be made, the answers may not be clear, and the
options are not ideal. The result could be declined in the quality of patient care; problematic clinical
relationships; and moral distress, which is defined as knowing the right thing to do but not being
allowed or able to do it. Nurse managers, in particular, are susceptible to ethical issues in nursing
and moral distress because of their leadership and mentoring roles. Nurses and other medical staff
look to nurse managers for appropriate and ethical decisions.

For nurse managers, ethical decision-making stems from the American Nurses Association
Code of Ethics, which was developed as a guideline for nursing responsibilities “in a manner
consistent with quality in nursing care and the ethical obligations of the profession.” Nurse managers
help solve ethical issues in nursing through using their leadership qualities to implement the Code of
Ethics in their daily lives.

32
 In relation to Topic 3 of Module 2, we shall deepen our knowledge and skills in
making ethical decision in the best interest of the patient.

DECISION MAKING: DEFINITION & TYPES

How do you make decisions? When we talk about deciding between choices, we can break
the processes into types. This lesson will fill you in on the different ways to make decisions and give
you a few examples of each.

Making Decisions
How did you decide what to put on this morning? Or what classes to take in school? Or what
to eat for lunch? We make decisions as part of our everyday routine, from big ones, like marriage or
career, to more mundane decisions, like a muffin or bagel. In decision making, many aspects are at
play when we need to choose between a set of criteria to decide an outcome.

Often, we need to make decisions as a group. If you've ever played sports or been on a team
project at school or work, you know how important it is to make decisions using the input of each
team member. You may have noticed that not everyone was using the same skills and strategies to
choose. This is because there are different ways decisions are made. In other words, we use different
skills to make decisions. Let's take a look at some of these.

Decision making is somewhat vague, since there are a complex number of things that
influence the choice to be made. In what timeframe must a decision be made? What are the
consequences of not making a decision in that time period? How much information is available?
What form does the information take, and how accurate is it? How many people are involved in the
decision? How many people will this decision affect? How will this decision be evaluated? The
specifics can go on and on.

Humans have devised many different ways of making decisions because the situations in
which we make them are so incredibly diverse. The process you use to decide what to wear when
going to yoga and getting a coffee are totally different than what you use to decide whether or not to
accept a marriage proposal.

Decision-Making Types
So how can we categorize decision making? Scientists have noticed a few patterns.

The most common type of decision-making type is rational. This type of decision making
relies heavily on reason and logic for guidance. When you are using rational methods to make a
decision, you create a list of possible options and figure out which is best based on what you think
those solutions will create. For example, if your desired outcome is to move out of your parents'
house, you may create a list of all possible solutions, ranging from moving in with a friend, placing
an ad for a

33
roommate, or making a go of it on your own. You would then look carefully at each option, research
the pros and cons, weigh this data carefully and then make a decision.

On the other hand, sometimes decisions are made in the absence of reason and logic. When
you make decisions using your gut instinct, you're using the intuitive type of decision making. If you
decide to look for a roommate and meet someone who just feels 'off,' you're being intuitive. The
decision not to become roommates with this person isn't based on any fact, just a simple deep-rooted
feeling.

Sometimes we make decisions based more on our feelings about a situation than anything
else. This is an emotional type of decision-making process. For example, when looking for an
apartment, you may only want to look at those with hardwood floors. There is no rational reason.
You don't have pets or any logical reason for being drawn to hardwood, you simple like it. Maybe
you had hardwood floors when you were a young child, and they remind you of happy times, or
maybe you're simply strongly attracted to the look. Either way, emotional decisions are always based
on feelings.

Ever have to make a decision and tried using logic, reasoning, your intuition and feelings but
have still gotten nowhere? You may have decided to just make an educated guess. Guessing is a type
of decision making that is often resorted to when other options are unavailable or not working.
Sometimes we may flip a coin or roll the dice. Can't decide between a brick bungalow or a high rise
because both have equal pull? Go ahead and do rock, papers, scissors to figure it out.

Sometimes we need to throw the idea of one right decision out the window and just make
one. The satisficing method of decision making may result because you don't have time, energy, or
resources to use any other method. It is actually a combination of the words 'satisfy' and 'sacrifice'
because both come into play. If you need to move out of your parents' house immediately and don't
have time for lists and research, you may just end up in a friend's spare bedroom. This solution gets
you what you need (a place away from your parents' house) but gives up better possibilities at the
same time.

DECISION MAKING: LEGAL & ETHICAL PERSPECTIVES

Explore the relationship between the law and ethics. Gain an understanding of the similarities
and differences in legal and ethical perspectives and analyze why the application of decision making
in the workplace must be both legal and ethical.

Background on Decision Making

Remember the cartoon of an angel on one shoulder and a devil on the other? These cartoons
simulated trying to decide what is good and what is bad, which we all can relate to. But as we handle
more complex decisions in life, the choices of good and bad are not so clear-cut. For instance, in the
workplace doing what is 'right' means doing what is legal, or what is in the bounds of the law, and
ethical, or within the bounds of certain moral codes that aren't necessarily enforceable by law. The
decision, ideally, will be the same for either of these perspectives. However, that will not always be
the case. There will not be a clear decision supported by the angel vs. devil. There may not be one
right and one wrong choice. A legal perspective may not always equate to an ethical perspective.

Let's take a look at what each term means, and why sometimes our decisions will fall in line
with both, and sometimes they may not. Then, we'll discuss why, in the end, we must find a way to
make decisions that are both ethical and legal. The law or ethics? Actually, both!

The Legal Perspective

Handcuffs are one thought that comes to mind as we consider terms such as legal or law. The
term 'law' has a scary ring to it. Speeding tickets, tax liens, and contracts for our homes or
apartments all are part of the mysterious big 'law.' But if we push the fear aside, we realize that law
is basically just a set of rules and standards in place to maintain order. After all, what would happen

34
if we didn't have law? Chaos! So, with that in mind we gain an appreciation for looking at things
from a legal perspective.

We need to know rules and consider them so that we can make informed choices. For
instance, on a road we rarely travel, we often first look for a speed limit sign. Why? Because we
want to know how fast or slowly, we must go. In this case, we make our decision on driving based
on the law.

The Ethical Perspective

Trying to decide the direction to go is part of ethical decision making. Now let's move on to
the term 'ethics.' You probably remember your parents, teacher or even older siblings saying things
to you such as, 'That was a bad choice you made!' or 'Just do what feels right; you'll know that right
thing to do,' or even 'Go think about what you just did!' All of those statements were made under the
assumption that on some level, even as children, we have an innate understanding of what is good,
what is right, what is ethical.

Whether or not to tell a friend about a job you are applying for, that he or she might be suited
for as well, isn't a legal decision. It's an ethical one. Do you share this great opportunity with
someone in need, even if it may result in your missing out on it? Your teacher's words of 'Do the
right thing' will ring in your ears. You will think about it and maybe even discuss it with an impartial
party. In doing so, you will likely be trying to make an ethical decision.

Example of Perspectives at Work

Most workplaces now have ethical standards that they make their employees aware of.
Companies want workplaces to be productive, but also fair and considerate of employees and
customers. These internal goals are highly important to companies and as a result workers can be, at
times, terminated for not following them. Unethical conduct does not always mean, however, illegal
conduct. Likewise, doing something illegal may not fall directly under an ethical violation.

For instance, it may be unethical to drink alcohol at work in the middle of the workday, but
as an adult over the age of 21, it's certainly not illegal for you to consume. Consider also this: you
may be required to reside in New York with your child under a custody order, but it wouldn't be
unethical in the eyes of the company for you to transfer to the North Carolina office if they have no
dealing with the custody order. In the case of a conflict, what takes precedent, doing the legally
correct thing, or the ethical one? The answer is that they're of equal importance and both must be
adhered to. Violating a company's ethical standards can result in everything from a reprimand to
firing. Violating the law can result in fines, probation

and, in worse case scenarios, incarceration. For businesses and their employees, being a legal and
ethical decision maker is required.

FRAMEWORKS FOR ETHICAL DECISION MAKING

Each day we make decisions that have ethical considerations. But, how often do we apply a
consistent framework to those decisions, and does it matter if we don't? In this lesson, we'll learn
about the prevailing frameworks and what they mean.

What Are Ethics?

You've likely had discussions, even arguments, about a story in the news or someone's
actions, when someone asks: 'Was that ethical?' Some things seem so horrible that they are
obviously not ethical. Other actions may seem clearly ethical. But what do we mean when we say
that? It's more than just good or bad. It's even more than just legal or illegal. Something can be legal
but unethical. So, how do we define ethics?

35
 Probably the most universal, simple way to describe ethics is the considerations for ourselves
and others that lead us to select one course of actions over another. Basically, ethics is why we do
the things we do.

In this lesson, we are going to discuss three theories of ethics. It's not really that any of these
single approaches are more appropriate than the others; they are just different ways to try to describe
ethics. When each applies may very well depend on the situation, but it's important to be aware of
them.

Consequentialist or Teleological Ethics

Consequentialist (or teleological) ethics is focused on the outcome of a decision. A course of
action, or a decision, is ethical if it generates more good in the world than bad. The most common
theory in this family of thought is utilitarianism. The two most famous philosophers who argued that
this was the best way to define ethics were Jeremy Bentham (1748-1832) and John Stuart Mill
(1806-1873).

Let's look at an example of teleological ethics. Is building a clothing factory in a third-world

country that will make cheap clothes only for the poor residents of that country, but that may also
put off some pollution (although not illegal amounts) ethical or non-ethical? Well, the consequences
would be some mild pollution in exchange for clothing for everyone. Most people would say there is
more good than bad in that decision, so it is ethical, from a consequentialist, or teleological, ethics
perspective.

Non-Consequentialist Ethics
While a consequentialist certainly makes good points, there are some situations where you
can't easily weigh the relative goodness or badness in a decision, or you may not even know what
consequences your decision may have. This is the argument of non-consequential (or deontological)
ethics.

Non-consequential ethicists believe that you can't accurately measure the goodness or
badness of a decision, both right now and in the future. So, the better solution is to come up with a
set of ethics that you believe, based on your beliefs and society's beliefs, and follow those ethical
guidelines no matter what. In this way, it isn't the outcome that makes you ethical, it's the way in
which you behave.

Let's consider an example from a famous movie, play and book: Les Misérables. The main
character goes to prison because he stole a partial loaf of bread for his nephew. The non-
consequentialist would say 'stealing is wrong,' and thus, Jean Val Jean was wrong to steal the bread,
even if it did mean life or death for his starving nephew.

It's easy in these situations to decide if someone is being ethical, but sometimes it's hard to
deal with what that means. But the non-consequentialist would answer that the shopkeeper should
have the ethics to provide food to the hungry, so there is a way for everyone to be taken care of and
still be ethical.

Agent-Centered Theories
Along with teleological and deontological approaches, there have also been some
philosophers who favor agent-centered theories. These theories are much more individual than the
other theories, and they are much more focused on an entire life than an individual act.

While the first two types of ethical theories are applied to situations and decisions, agent-
centered theories consider ethics at a higher level. Agent-centered theories focus more on how
someone feels about other groups of people, especially marginalized groups, like women and
minorities. Essentially, they believe an ethical person would be one who doesn't believe it matters
where you come from or what physical traits you might have; the way you are treated should be the
same.

36
 One way the agent-centered theorists would suggest you apply ethics to a daily situation is to
think of life like this: imagine your personal traits have not yet been defined. You are all alone and
about to be put in a community with disabled and non-disabled people, ethnically diverse people,
men and women, people of different religions, and other kinds of unique attributes.

Now, it's your job to make the rules. You don't know who you will be; you may end up a
homosexual, male, disabled, Catholic, Asian person, or you may end up a rich, heterosexual, female
atheist. What rules would you put in place? What actions would you consider ethical, having no idea
who you will be? The answer to that may be the most ethical answer to any situation.

ETHICAL DECISION MAKING IN NURSING: MODELS & EXAMPLES

This lesson will explain ethical principles governing the nursing field and explore how
they're applied with a case example. We'll also discuss ethical decision-making processes in nursing.

Principles in Nursing
Nurses encounter ethical dilemmas constantly in our fast-paced healthcare field. Ethical
principles are thus one of the most important aspects of clinical practice. Ethical principles are a set
of standards that help nurses make informed decisions when evaluating the consequences of their
actions.

What are these principles? Nurses are first and foremost expected to respect all patients
equally without discrimination. They must also give patients autonomy, meaning patients must be
allowed to make their own decisions about treatment even if it is not in their best interest. And
another essential principle of nursing practice

is nonmaleficence, which reminds us to cause no intentional harm to patients. This includes things
like identifying both benefits and risks of medical treatment options.

Each of these main principles of respect, autonomy, and nonmaleficence should be carefully
evaluated when ethical conflicts arise to ensure that decisions do not jeopardize any of these
principles.

Participative Ethical Decision-Making Model

The participative ethical decision making (PEDM) model covers the standards we just
discussed. This model involves seven questions to be answered during an ethical dilemma. Let's take
a closer look through an example of an ethical dilemma a nurse might face.

Say there's a two year old child who has had eight ear infections in nine months. The nurse at
the pediatrician's office recommended that the parents meet with a surgeon to discuss placing ear
tubes to prevent further infections and potential hearing loss. The parents have refused to meet with
the surgeon and have returned to the pediatrician's office, and now the child has been diagnosed by
the nurse with another ear infection.

Here's how the nurse could use the steps of the PEDM model to deal with this ethical
dilemma.

Step 1: Is there a concern with no solution to which all parties can agree?

Yes, the parents are not willing to initiate surgery and the nurses ethical practice principles,
which require consideration of treatment.

Step 2: Who is involved, what is the concern, and when is a decision needed?

37
 The mother, father, and child are involved. The conflict is that parents have the right to make
decisions for their underage child, but it's important to act quickly to reduce the child's hearing loss
and they're refusing the recommended treatment.

Step 3: What professional standards are associated with the issue?

The nurse has standards requiring them to protect the child's well-being. The nurse also has
the expertise in the situation and knows that multiple ear infections are dangerous - ignoring this
would fall under the category of maleficence.

Step 4: What are the patient's principles and own values related to the situation?

The mother and father are fearful of allowing their child to have surgery because they've read
personal experiences on the Internet about children having adverse reactions to anesthetics.

Step 5: Review everyone's aims, desires, wanted outcomes, and emotions regarding the scenario.

At the office visit, the mother and father meet with the nurse to discuss the procedure of tub
placement in the ears. The parents verbalize concern about surgery for the child.

Step 6: Is there an ethical framework that are acceptable?

The family and the nurse are approaching the dilemma with open attitudes and being mindful
of outcomes and consequences.

Step 7: Is there a potential solution that all can agree to?

The mother, father and nurse discuss the history of anesthetics and the extensive measures in
pediatric health that have been taken to monitor for safety throughout surgery. The family agrees to
meet with a surgeon the following week to discuss the procedure in more detail. The family also
agrees to ask the surgeon for contact information to talk with families who would recommend the
surgeon and could talk about their own personal experiences.

ETHICAL DILEMMA CASE STUDIES

This lesson will explore the ethical decision-making process through two classic case studies.
The lesson includes a thorough examination of the Heinz and Louise dilemmas from Kohlberg's
classic dilemma research.

A History of Ethical Dilemmas

Have you ever found yourself between a rock and hard place? How about on the horns of a
dilemma? Sounds uncomfortable, right? Dilemmas are situations where there is no one obvious right
choice or situations where the choice is especially difficult because no solution is appealing. Let's
explore.

Lawrence Kohlberg was the first psychologist to do heavy research into human ethics and
how people reacted to dilemmas. Coming of age during the WWII period, Kohlberg took a special
interest in how people formed moral judgments. He eventually used his work to develop a theory of
the stages of human moral development. These are known formally as Kohlberg's Stages of Moral
Development. There are six stages leading from childlike ethical thinking processes to more
altruistic adult ones. If we make it all the way to the last one, we hope to make all our decisions
ethically and by coming from a place of altruism, or concern for the good of everyone. If that sounds
very Zen, that's because it is.

Ethical Decision-Making Process

The steps we can use to make ethical decisions are a commonly taught process. We will work
through them in two examples following this overview.

38
Stop! Now isn't the time for rash decisions.

Goals? Figure out what your objective is and what you're hoping and not hoping will come of your
choice.

Research. Consider your facts, including evaluating the reliability of your sources.

Options? Make a list of options based on the facts you have at hand and the goals you have.

Consequences? Carefully review your options. Do any of them have problems that violate your
values or ethics?

Choose! Game time: choose what best fits from the previous steps and reflects your moral values.
When in doubt, it's always a good idea to apply the Golden Rule: treat others how you want to be
treated.

Effects? Finally, what are the effects of your decision? When you look to decide something
ethically, you're keeping an eye out afterwards and are ready to assess your decision if the effects are
worse than you intended or you gain additional information.
Let's try it out.

The Heinz Dilemma Example

Classically called the Heinz dilemma, our first situation goes like this: There's a pharmacist
who creates a medicine. The medicine can save Heinz' wife from death but Doc has marked the drug
up exorbitantly because he can. Heinz pleads with the man, but he only wants to make money and
won't help Heinz out. Heinz is desperate to save his wife, and so he's debating whether he should rob
the pharmacist to secure the drug he can't afford. What should Heinz do?

In this situation, we quickly realize that Heinz has some pretty terrible options here. He can
either rob the druggist or let his wife die. On top of that, the pharmacist is a pure greedy jerk. So,
let's apply the seven steps.

Heinz needs to take a breath. What's his ultimate goal here? Let's say it's to save his wife. He
knows his facts: the pharmacist has the medication but he's not willing to part with it except at full
price because the pharmacist wants money for his work. His options he's arrived at are steal it or not
steal it. For consequences, well, if he doesn't steal it, his wife is dead. If he does and he's caught,
there's potential jail time. Even if he's not, he may feel guilty for the theft.

Now he has to choose. Let's say he steals the drug because his wife's life is more important
than maybe going to prison, or the theft itself. Great! His wife lives and he doesn't get caught. But
the guilt is eating away at him. So now Heinz decides upon re-evaluating that he should pay the
pharmacist back secretly until he hands over the full sum. Problem solved!

The Louise Dilemma Example

Another classic Kohlberg dilemma features a big sister named Louise. Little sister Judy is 12.
Judy saves up money to go to a concert after her mother promised her permission to go if she can
pay for it herself. Lo and behold, Judy earns enough money, but then mom changes her mind and
says Judy needs to spend her money on school clothes instead.

Judy decides to lie to her mother and attend the concert anyway, under the guise of being at a
friend's house. She then uses the remainder of her savings to buy a few clothes. After a week, Judy
tells her older sister Louise what she did. Louise now wonders whether she should tell their mother
or not.

Louise's situation, while not necessarily as dramatic, brings some interesting factors into
play. She can tell or not tell, but we have a mom who broke her word and a younger sister who lied
and snuck out. So none of our players are exactly behaving like angels.
39
 Let's start with Stop! Louise loves her sister, and Louise loves her mother. There's definitely
some family dynamic here. What does she owe to each? She has obligations as a sister and daughter.
What are Louise's goals? Let's say she wants a good relationship with both her sister and her mother.
She doesn't have much to research: she knows the facts. She's decided her choices are she can
choose to tell or not. The consequences are, if she tells on her sister, her sister will be mad. Maybe
she doesn't agree with her mother breaking her promise. If she doesn't tell her mother though, she's
hiding something from her.

Louise decides not to tell. However, since she doesn't like keeping a secret from their mother,
when she reaches the evaluation part, she encourages her younger sister to talk it out with their
mother and own up to her actions. That way, everyone clears the air.

SUMMARY

Decision making is something we do every day, from choosing what to wear, eat, and read to
deciding what to do with our time, energy, and lives. There are different types of decision-making
processes, things we do to figure out which outcome is best.

We've learned that what is legal and what is ethical aren't one and the same. Legal means to
be within the bounds of the law, while ethical means to be within the bounds of certain moral codes
that aren't necessarily enforceable by law.

Ethics isn't just about coming up with the right answer, though. That's why having an ethical
theory is so important. The three theories we discussed include consequentialist (or teleological)
ethics, which considers whether a course of action or a decision generates more good in the world
than bad. The argument of non-consequential (or deontological) ethics is that you can't easily weigh
the relative goodness or badness in a decision. Finally, agent-centered theories focus more on how
something feels about other groups of people and place more consideration on an entire life rather
than an individual act. Keep in mind, just as important as the ethical decision you make is the
thought process you go through when deciding if something is ethical.

Ethical decision-making is a process whereby a person makes a choice among alternative

actions and considers the ethical implications of the alternative actions in doing so. You can break
the ethical decision-making process into a series of steps. First, you need to determine whether there
is an ethical dimension to the issue or problem requiring a decision.

Then, you need to collect and evaluate relevant information in light of the organization's
values, principles and code of ethics. Alternative actions are considered, and a decision is made. The
decision is put into action and then reviewed to see if modification is necessary to create the best
ethical result.

40
 MODULE
3 Bioethics and Research

TOPIC TITLE DURATION

1 Principles of Ethics in Research 1 hr & 50 mins.

2 Ethical Issues in Evidenced Based Practice 1 hr & 20 mins.

Ethico-Moral Obligations of the Nurse in

3 Evidenced Based Practice
1 hr & 25 mins.

Instructional Objectives:
At the end of this module, you must be able to:
 Discuss comprehensibly the principles of ethics in research.
 Deepen knowledge on the importance of evidenced based practice in the health care
ethics.

3 41
 1 hour &
50 mins.
Topic 1: Principles of Ethics in Research

At the end of the lesson, the students will be able to:

 Identify the principles of ethics in research.
 Discuss the difference between Nuremberg Code, Declaration of Helsinki, and
Belmont Report.

Overview

In biomedical research, it's important that all research subjects are informed of what is going
to happen and have the opportunity to provide informed consent. We will learn exactly what this
means and how these guidelines were developed.

The Declaration of Helsinki is one of the world's most important research ethics documents
related to medical research. In this lesson, we will learn about the Declaration of Helsinki, its
purpose, and its history.

We'll also talk about the development of the Belmont Report, which was developed to
establish standards for the ethical conduct of research involving human subjects. We'll cover the
history of the report and its impact on contemporary research.

Activity 2: Nurses vs Research

Identify your role as a nurse

in terms of research.

Answers should be written in the answer sheet provided found at the end of this
module.

In relation to your activity “Nurses vs Research”, we will now discover the different
physiological changes associated with aging among older adults...

INFORMED CONSENT & BIOMEDICAL RESEARCH ETHICS

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What is Informed Consent?
Julie goes to the doctor and has some blood drawn for some medical tests. Julie doesn't know
it, but her doctor is conducting a research study. He is measuring the quantity of a specific protein in
the blood of volunteers from the local community in which Julie lives. Can he test Julie's blood for
the presence of this protein without telling her? How would you feel about this if it happened to you?
Would you be okay with participating in this research or not?

Perhaps you would want to participate in the research. After all, it won't harm you, and many
people would likely be happy to donate a small amount of blood if it might be used in research to
improve human health. However, some people might not want to participate. Do they have the right
to be informed and to say no?
These questions are ones that researchers have had to answer for many years. In the past, medical
research such as this was performed on patients without their consent. However, now we believe that
all researchers have an ethical responsibility to make sure that all participants in the research have
provided informed consent.

In order to provide informed consent, the research subject must first be informed of exactly
what procedures will be performed, what the possible risks are, and how the data will be used. He or
she must then agree, usually in writing, to participate. Just getting a form signed is not sufficient,
however. It is the responsibility of the researcher to fully explain the process and make sure that the
subject understands it BEFORE conducting any experiments.

The Nuremberg Code

How was it decided that research subjects must
provide informed consent? All of the modern laws
about research ethics can be traced back to Nuremberg,
Germany in 1947. During World War II, German
doctors engaged in medical experimentation on
prisoners in concentration camps. Of course, these
prisoners did not provide consent. Many of these
experiments were painful, and they often resulted in
death. Twenty-three doctors and scientists were
brought to trial for these crimes against humanity in
1947 in Nuremberg. During the trial, some of the
defendants asserted that they did not know that the
experiments were illegal because there was no law In 1947, the Nuremberg Code established guidelines for
determining which kinds of experiments were allowed medical research following the trial of German doctors who
were convicted of war crimes for experimentation on
and which were not. human subjects without their consent during World War II

As a result, the judges presiding over this trial added a series of ten guidelines for performing
medical research ethically to the trial verdict. These were collectively known as the Nuremberg
Code, and the first guideline in the code was that the voluntary, well-informed consent of the subject
was always required.

Although the Nuremberg Code established ethical guidelines for medical research, including
the obligation to ensure informed consent, it was not legally binding, and there were no official laws
regulating medical research, so problems still persisted. In one famous case, cancer cells were taken
from a patient named Henrietta Lacks in 1951 without her knowledge or consent. These cells were
used to start an immortalized cell line that has been used by researchers all over the world. A lot of
good things have come from using these cells, including a vaccine for polio, and perhaps Henrietta
Lacks would have agreed to donate the cells if she was given the opportunity to provide informed
consent, but she wasn't given that option. While this was clearly not as unethical as what the German
doctors did during World War II, it still did not follow the guidelines of the Nuremberg Code
because she did not have the opportunity to give informed consent.

The Declaration of Helsinki

Just a few years after the Nuremberg
Code was developed, a group of doctors and
43
other medical researchers associated with the World Medical Association met in Helsinki, Finland in
1964 to expand on the Nuremberg Code and decide on a uniform standard of ethics that should be
applied to all medical research. What came out of this meeting was a very important document
known as the Declaration of Helsinki. Just as in the Nuremberg Code, one of the primary tenets of
the Declaration of Helsinki was the duty for all researchers to obtain informed consent from subjects.

In the time since the Declaration of Helsinki was first written, it has been revised and
expanded several times. Laws governing medical research were adopted in many countries, and
these laws were largely based on the ideas in the Nuremberg Code and Declaration of Helsinki.

The Declaration of Helsinki is a formal statement developed by the World Medical

Association that provides ethical guidelines that physicians and other medical research participants
should adhere to when conducting research that uses human subjects. A human subject is any living
person that a researcher obtains data from, including data obtained through interacting with the
person and identifiable information about the person or their opinion. The Declaration of Helsinki
was first adopted in Helsinki, Finland by the 18th World Medical Association General Assembly in
June, 1964.

World War II and the Nuremberg Trials

Prior to World War II, there was no internationally accepted statement of ethical principles
governing research with human subjects, although Germany, Russia, and other nations had their own
policies. After World War II, the Nuremberg Trials were held in Nuremberg, Germany, with the sole
purpose of prosecuting Nazi war criminals. There were thirteen trials that were carried out between
1945 and 1949. From December, 1946 until August, 1947 the Doctors Trial was held, during which
23 individuals faced accusations of committing crimes against humanity. These crimes included the
horrific medical experimentation on concentration camp victims. As a result of these trials, the 1947
Nuremberg Code emerged, which is a set of ten ethical principles that govern research with human
subjects.

The Declaration of Helsinki was

heavily influenced by the Nuremberg
Code. Like the Nuremberg Code, the goal
of the Declaration of Helsinki was to
prevent human subjects from being
mistreated. The Declaration of Helsinki
provided guidance for physicians who
were conducting clinical research and
focused on researchers' roles and
responsibilities when it comes to
protecting human subjects. The
Declaration of Helsinki is seen as the first
major attempt of the medical community
to police itself. It also provided the
foundation for later research ethics
Brief summary of the ten ethical principles of the Nuremberg Code.
developments and statements.

The Declaration of Helsinki took the ten principles from the Nuremberg Code and merged
them with the Declaration of Geneva, which states that the patient's health is always the doctor's first
consideration, and the International Code of Ethics, which states that in the circumstance where the
physical and mental condition of a patient is impaired, the physician must act only in the interest of
the patient. The Declaration of Helsinki differed from the Nuremberg code in that it particularly
focused on clinical research, and it changed the consent requirements. Whereas consent was an
absolute requirement in the Nuremberg Code, the Declaration notes that consent should be obtained
if possible and allows for a legally authorized proxy to provide consent, i.e. a parent or guardian.

Since its development in 1964, the Declaration of Helsinki has undergone seven revisions,
with the most recent revision occurring at the World Medical Association General Assembly in
2013. The Declaration of Helsinki, which was 11 short paragraphs in 1964, is now 37 paragraphs
44
long as of 2013. The 2013 version of the Declaration of Helsinki is the only one that is officially
recognized by the World Medical Association; all of the prior versions were replaced by the 2013
versions and they should only be used for historical purposes.

The Belmont Report

Let's say you're designing a research study about the impact of college students' leisure
activities on their grade point average. You can design some surveys or interviews, recruit college
students to participate, and then publish your results.

There's an important step missing in your process, though: you need to get approval to make
sure your research is ethical and won't cause any harm to the students you study. Your research
might seem harmless, but there are specific protocols researchers need to follow to ensure this.

In this lesson, we'll discuss the Belmont Report, which is a federal document developed in
1974 that establishes ethical guidelines for research with human subjects. Let's talk more about the
history and significance of the Belmont Report.

Components of the Belmont Report

In 1974, the United States government passed an act called the National Research Act, which
was intended to create a systematic way to ensure that research did not harm any human subjects
involved in it. The goal was to develop guidelines so that researchers knew what was acceptable and
unacceptable conduct in the research process. The report was developed by a committee of experts
and after many discussions there were some specific guidelines produced for the ethical conduct of
research. The report revolves around three major points: respect for persons, beneficence, and
justice.

Respect for persons basically means that people involved in your experiment must be treated
with respect and as autonomous individuals. This means that people can make their own decisions
about when and how to participate in research. They can decide when to stop participating in a
research study at any time, for example. This also includes extra protections for individuals and
populations who are considered vulnerable. For example, homeless people and minors are vulnerable
populations who must have extra protections if they are to participate in research studies.

Beneficence means that people's well-being must be considered during the research process.
Researchers have an obligation to protect their subjects from harm, but this is more than kindness or
simply being nice to subjects. Researchers have an obligation to minimize any harm to research
participants while maximizing any benefits of research for participants.

Justice in research means that the costs and benefits need to be equally distributed to the
greatest extent possible. This means, for instance, that researchers cannot arbitrarily deny benefits to
one group and not another group of research participants.

So, what brought about the Belmont Report? Let's talk a little about some important
historical events that inspired its creation.

History of Research Ethics

One of the major factors that led to the creation of the Belmont Report was a now infamous
study known as the Tuskegee Syphilis experiments, where researchers in Alabama recruited 600
African American men into a study meant to observe the condition of syphilis. Participants in the
study were told that they would receive special medical treatments in exchange for their
participation. However, researchers knowingly did not provide life-saving syphilis medication to
many of the men in the study, resulting in a number of deaths. The Associated Press eventually
reported the story in the 1970s, which caused a public outcry, helping to inspire the Belmont Report.

Another important series of historical events that influenced the creation of the Belmont
Report were the Nuremberg Trials, which was a military tribunal held in the aftermath of WWII for
the prosecution of war crimes, including the Holocaust, committed by Nazi Germany. In particular,

45
Nazi physicians who experimented on women and children in concentration camps were put on trial
for their actions during these trials. Among other things, the Nuremberg Trials established the
consensus that human subjects research cannot happen without consent from those in the study.

Contemporary Research
So, how does the Belmont Report impact research today? Individuals who want to conduct
research on human subjects must submit research proposals to governing bodies that determine
whether the research is ethical and will not cause undue harm to participants. At a university, for
example, this institution is called the Internal Review Board (IRB), which meets to review the
research conducted at any university to ensure it meets the standards set forth by the Belmont
Report. As another example, the Food and Drug Administration (FDA) is responsible for ensuring
the safety of drugs developed in research.

Researchers must think carefully about any implications their research might have. For
example, how will participants be recruited? If there are benefits for the participants, will people
have an equal chance to be selected for the research? In addition, research is not allowed to involve
coercion of subjects: that means you cannot trick people or force them into participating.

SUMMARY

In 1947, the Nuremberg Code established ethical guidelines for medical research. Later, in
1964, the guidelines of the Nuremberg Code were expanded by researchers from many countries
working together to produce the Declaration of Helsinki. This document formed the basis for laws
governing medical research that were subsequently adopted in many countries. One important
principle in both the Nuremberg Code and the Declaration of Helsinki is the obligation of the
researcher to ensure that all research subjects have provided informed consent. This means that the
procedure has been fully explained, and that each subject understands the risks and understands how
their data will be used.

46
 3 1 hour &
20 mins.
Topic 2: Ethical Issues in EVP

At the end of the lesson, the students will be able to:

 Identify some ethical issues in an evidenced based practice situations.
 Discuss the advantages and disadvantages of research in the health care setting.

Overview

Science and medicine have worked very hard to uncover more and more ways for us to live
healthy lives. Many of the discoveries about how to take care of the body, repair the body, and treat
diseases have come from research. Biomedical research is the completion of experiments that seek to
understand how to make a body healthy and keep it that way. This research encompasses everything
from the vaccines we get to medications we take to surgeries performed on our bodies. Doctors
know how to treat us for certain illnesses based on outcomes from biomedical research. We have
advanced and live longer thanks to biomedical research.

In relation to Topic 1 of 3, we will shall discuss some ethical issues in research ethics.

BENEFICENCE & NONMALEFICENCE IN RESEARCH ETHICS

47
Biomedical Research
You are at home watching TV and a commercial comes on looking for individuals to
participate in an upcoming research study. They explain what they are researching and emphasize
that participants will be paid and receive all medications and procedures for free.
It sounds pretty good to you since it is addressing a condition that you have been struggling
with for years. It will just cost you some time, right? And you might be cured in the process, so why
not?

Well, your not so excited friend Trisha fills your head with all the things that can go wrong
and is on her way to convincing you that researchers do not really care about the participants. What
if they knowingly give you something dangerous? After doing some research, you decide to educate
Trisha on just how wrong she is.

The Four Principles

The first thing you explain to Trisha is that there are four ethical principles for biomedical
research.
1. Autonomy - participants give informed consent to being a part of the research.
2. Justice - researchers must be fair and treat all participants equally.
3. Beneficence - research must be something that will be helpful to the majority of people.
4. Nonmaleficence - research should not purposely cause harm.

You focus on the last two with Trisha because they address her concerns.

Beneficence
You and Trisha learn that the principle of beneficence are in place to ensure that researchers
design studies that will generally benefit people. This can include research on new medications,
surgeries, minor procedures, and nutritional supplements. The item being tested has to be intended
for the good of the majority of people.

Trisha now learns that the other aspect of beneficence is that the research studies must be
performed in a manner that it benefits those involved and minimizes any adverse effects.

For instance, researchers should use the minimum doses of medications in their studies that
receive the desired results. This decreases the amount of drugs that participants are exposed to,
especially considering that not all side effects may be understood at the time of the study.

Nonmaleficence
It does not take much research for you and Trisha to realize that nonmaleficence goes hand-
in-hand with beneficence. The principle of nonmaleficence is in place to make sure that researchers
do not create studies that are designed to intentionally hurt or harm people.

This also has two aspects to it as well. First, the research should not do anything that causes
harm such as giving toxic medications or performing harmful procedures.
The other aspect is that nothing can be removed or omitted that may cause harm, injury or danger. If
a researcher accepts patients in a study that are on life-saving dialysis, he or she cannot require them
to stop dialysis while participating in the study. In other words, nothing can be withheld from the
participants that may lead to them being hurt or losing their lives.

Basic care must be provided at all times during biomedical research. Omission of the
necessities of life cannot be a part of the research study. Anything that is considered standard care
for procedures or surgeries must be provided when the surgeries or procedures are performed.

Now that you and Trisha are aware of these principles, both of you are considering joining
the research study.

Autonomy
It is great that we are benefiting from biomedical research, but there are certain requirements
that must be fulfilled in order for it to take place. The studies usually begin in cells or tissues that
48
have been removed from the body. Eventually, the studies must take place inside of people's bodies
for us to truly know how well the body will react to whatever is being studied.

How do scientists and doctors determine who is experimented on and who isn't? The answer
is, they don't! Well, they don't decide completely on their own. Every person has the right to make
an educated decision as to whether or not they want to participate in biomedical research
experiments. This ethical right is known as autonomy. We are all individuals and able to choose
what will and will not be done to our bodies.

Education
We should bear in mind that we are talking about experiments that are going to be conducted
on our bodies. The fact that they are experiments means that scientists and doctors are not
completely sure what will happen in the body as part of the research. They have a pretty good idea
thanks to tests done in the laboratory and their understanding of how the body works. Whoever is
considering participating in a research study should be as educated on it as possible so that they
make a sound decision regarding their participation.

What information do they need to know? They should be informed of what the experiment is
testing. It is important for those conducting the research study to explain what they are researching
to anyone who is considering participating. Every single detail need not be thoroughly explained but
enough information is needed so that the person knows why they are in the study.

Research Ethics Questions

It's simply a part of human nature to want to know what to expect before we agree to do
something. If friends ask you to go on vacation with them, you are going to have some questions.
Where are we going? How long are we going? How are we getting there and back? The same is true
for biomedical research studies.

Researchers should have the answers to certain questions.

These questions include:
o What do I have to do?
o What are you going to do to my body?
o How long does the study take?
o What are some possible outcomes in my body?
o What are the possible long-term effects of being a part of the study?
o Will there be any side effects?

There is an area of ethical concern that considers whether certain other questions should also
have to be answered as a part of providing education for autonomy. What will the researcher gain
from the studies? Do they have a vested interest from an outside agency for the research to go one
way or another? Will the research benefit people as a whole, or is it about personal gain only?

Decision
Once we have sufficient information, we are generally ready to make a decision. The entire
premise behind autonomy is that everyone should decide what they do for themselves. In order to
protect our right to have this, we should simply be given the information and then allowed to make a
decision with no or very little interaction with the person or persons conducting the study.

Experimenters and those who might gain from the experiment should not discuss their
feelings or opinions with research candidates. This information can influence the decision and may
cause us to decide against what we really want to do. It is ethical to only present the facts and let us
decide from there.

It is considered unethical for researchers to attempt to persuade a potential participant's

decision by providing incentives, withholding possible negative outcomes, promising positive
outcomes, or doing anything else dishonest to get a participant on board. The person must be left to
decide on their own for it to be true autonomy.
49
SUMMARY

There are four ethical principles of biomedical research. Autonomy is allowing people to
give informed consent to be in the research. Justice is being fair and treating all participants equally.
Beneficence states that the research must be something that will be helpful to people.
Nonmaleficence requires that the research not purposely cause harm.

The two aspects of beneficence require that what is being researched and how the research is
being conducted are both beneficial. Nonmaleficence makes sure that what is being done is not
harmful and that harm is not done by omitting care or treatment.

3 1 hour &
25 mins.

Topic 3: Ethico-Moral Obligations of the Nurse in EBP

At the end of the lesson, the students will be able to:

 Identify the ethical and moral obligations of the nurse in a health care setting.
 Discuss comprehensively the significance of evidenced based practice for health
professionals.

Overview

It is not uncommon to hear the term 'evidence-based practice' in the medical field. But you
may wonder what that means. We will review what evidence-based practice is and how it can be
implemented. For many years, nursing care was guided solely by tradition. Today, nursing is guided
by evidence-based practice, which uses a scientific approach to determine the best course of action
for patients.

50
 In relation to Topic 2 of Module 3, we will discern the ethico-moral obligations of the
nurse in an evidenced based practice.

EVIDENCE-BASED PRACTICE
The nursing field is devoted to providing the best possible patient care. The nursing
profession is continuously seeking to improve nursing practice to improve patient outcomes. The
nursing field values evidence-based practice to drive this mission.

Evidence-based practice is the conscientious use of resources to make decisions about patient
care. It incorporates a problem-solving approach utilizing current research, clinical guidelines, and
other resources based on high-quality findings. Studies continue to prove that using evidence-based
practice improves patient outcomes. To put it more simply, a nurse implements her care for a patient
based on research that has shown to be effective, combined with her clinical expertise, and
considering the patient's values.

There are many different approaches to improving nursing care. These may include research
utilization, quality improvement projects, or nursing research. Research utilization was developed to
address problems with using research results in practice. Quality improvement projects are a formal
way to analyze a problem and find solutions. Nursing research is research focused on supporting
nursing practice. Evidence-based practice is not any one of these specifically, although it may
incorporate each one of these processes. Let's look at an example of evidence-based practice in
nursing.

MOVING BEYOND TRADITION

Ever wonder why Florence Nightingale is so important to nursing history? It is because she is
considered the first nurse researcher, and ultimately shaped evidence-based practice.

Florence Nightingale was a wealthy, educated woman living in London when she
volunteered to help the soldiers of the Crimean War in the mid-1850s. When she arrived at the
barracks with her team of nurses, Nightingale found very unsanitary conditions. Nightingale went to
work and changed how nursing care was delivered. She cleaned the barracks and offered proper
meals and provided hygiene to the wounded soldiers.

Nightingale also took time to record all of the nursing care given to the soldiers and the
results of that care. More soldiers lived as a result of her team's work! She had proof that the new
way of delivering nursing care was making a difference. Nightingale and her team continued to use
this evidence to deliver nursing care.

51
 WHAT IS EVIDENCED-BASED PRACTICE?
As Nightingale showed, nursing had to be more than just following traditions - and also more
than just following physicians' orders. This led to evidence-based practice (sometimes called EBP),
which is a problem-solving strategy for the delivery of safe, quality patient care. When nurses use
evidence to deliver care, it takes into account the patient's wishes, the nurse's expertise, and current
research to decide what the best course of action is for each patient.

To see what we mean by this, let's look at pain management as an illustration. Different
cultures have different ideas of how to handle pain. A male patient from a certain cultural
background might not ask for pain medication after a surgery, fearing that this might look like a sign
of weakness. The nurse caring for this patient understands that controlling the pain helps to speed his
recovery. Taking into account the patient's fears and the research on pain control after surgery, the
nurse may develop a plan to offer pain medication without waiting for the patient to ask.

WHY EVIDENCE-BASED PRACTICE?

Evidence-based practice is the science behind nursing practice. It's important because it helps
promote better patient outcomes, or results of patient care.

Before Florence Nightingale entered the picture, those soldiers were treated based on
tradition. They were kept in dark, unclean barracks, and the significance of clean spaces and
cleaning wounds was not understood. As Nightingale did then, the nurse today will look at a variety
of sources to problem-solve in the delivery of nursing care. Using EBP as a method of problem-
solving is important because this scientific approach improves quality of care.

Evidence-based practice has other benefits as well. It lowers health care costs, provides safer
care to patients, and offers benefits to nurses. Nurses, like other health care providers, are held to
higher levels of responsibility today. EBP protects and promotes the nurse's practice, as it is aligned
with safe standards of care. Nurses are better protected from consequences of poor practice,
including lawsuits, when they deliver evidence-based nursing care. Evidence-based nursing care is
nursing practice that uses the nurse's clinical expertise and current research, involves the patient in
decision-making, and follows standards of care.

SUMMARY

The goal of evidence-based practice is to implement current knowledge into nursing care
decisions in order to improve processes and patient outcomes. The public may often hear news
reports about how harm was caused in healthcare settings that could have been prevented. Evidence-
based practice aims to decrease these incidents.

Before Florence Nightingale, nurses relied on tradition to deliver nursing care. Nightingale is
considered the first nurse researcher because she pointed out the value of a scientific method of
nursing care. Now, nursing is considered a science and an art, and the delivery of nursing care
requires understanding the science that guides nursing practice. Using the science to help patients
meet their health goals is what evidence-based practice is all about. EBP is important because it
means better care, safer care, and lower health care costs. Evidence-based practice leads to better
patient outcomes and also protects the nurse's practice.

52
 MODULE
4
Guidelines and Protocol in Documentation and Health Care
Records

TOPIC TITLE DURATION

1 How to Analyze Health Care Records 1 hr & 10 mins.

2 Principles of Recording in Nursing 1 hr & 15 mins.

3 HIPAA 1 hr & 30 mins.

Instructional Objectives:
At the end of this module, you must be able to:
 Comply with the guidelines and protocols in documentation following the criteria as:
completeness, integrity, safety, accessibility and security of information.

4 53
 1 hour &
Topic 1: How to Analyze Health Care Records 10 mins.

At the end of the lesson, the students will be able to:

 Define health care records.
 Identify the different examples of health care records.
 Discuss the importance of careful handling and interpretation of health care records.

Overview

Analyzing health care records can be a challenging task! This lesson will discuss what health
care analysis is, and how to properly perform the analysis of health care records.

Activity 3:

THE ANALYSIS OF HEALTH CARE RECORDS

Sara, a nurse at Sickly Hospital, was just informed that she got a promotion after 15 years of
service. With this promotion comes a new job description, including that of Health Care Record
Analyst. Sara is ecstatic, but nervous about her new duty. What exactly is the analysis of health care
records, and how should she go about performing this new assignment?

What is Health Care Record Analysis?

54
 Health record analysis is, simply put, a comprehensive evaluation of a patient's medical
record. You can think of the medical record as a story, since it describes everything that occurred
during the care an individual patient received. The actual analysis can vary widely based on the size
of the medical facility and the reason the analysis was requested, but a health care record analysis
typically includes:

The location and organization of all medical records associated with an individual patient.
A review of clinical documentation by both nurses and physicians to ensure that: They are in
compliance with federal, state, accreditation and possibly Hospice standards; all
documentation and paperwork, including the medical facility's required forms, is complete;
and all files are properly entered into the facility's database.
Interpretation of all clinical documentation to ensure that the submitted billing codes were
justifiable and accurate concerning both the actions performed by the facility and each
specific diagnosis of the patient.
Analysis of the facts located in the individual's medical record.
It is critical that all of this is performed with a high degree of accuracy. The health care
record analysis could be a crucial step in preventing lawsuits and/or insurance reimbursement
concerns.

CLINICAL DOCUMENTATION IN THE ANALYSIS OF HEALTHCARE RECORDS

Documentation accuracy is the real meat of a medical chart analysis! This portion of the
analysis is better understood when the medical record is broken up into five main categories.

History and Physical (H&P)

The H&P section of the chart contains information that was obtained during the first
evaluation of the patient, usually by the physician. This usually includes everything from the initial
signs and symptoms experienced by the patient to the plan for addressing each condition that was
diagnosed.

The H&P section is very important because it will serve as a reference document, with
detailed information about the patient's history and initial exam. For

example, this section is often referred to whenever medications are prescribed to ensure no allergies
exist.

Progress Notes
If a patient's medical record is like a story, then the Progress Notes section is the story's main
idea.

Because the progress notes are organized in chronological order, this section is a kind of
timeline of events, from the time the patient walks into the facility until they walk out. Valuable
information is contained in the progress notes pertaining to the evaluation and care of the patient by
the treating physician and nurse, as well as the patient's response to the treatment.

Every progress report should contain the following information:

Subjective information. The physician should record in this section statements made by the
patient such as how the patient is feeling today or what the patient says about treatments, etc.
Objective information. This includes the physical exams the physician performed during that
visit and the results of the exams.
Assessment. Describes each diagnosis that the patient is suffering from.
Plan. Describe the plan of treatment for each diagnosis listed in the assessment. Each
progress note should be properly signed and dated by the creator of the report.

Physician Orders

55
 Physician orders are like a list of things that must be performed. An example of a physician
order could be to administer a certain medication, specifically listed with dosage and frequency, if a
patient's blood pressure rises above a specific amount.
In analyzing this section, the health record analyst should look for several things:
Is there documentation that supports that these orders were carried out by the appropriate
staff member?
Were the orders performed (if documentation of the performance exists) in a timely manner?
Is the physician's order relevant to the individual patient's diagnosis?

If any of these answers are no, then this section of the chart does not contain the proper
documentation and a supervisor should be notified.

Medication Record
Every single medication, both prescription and non-prescription, given to a patient by a nurse
should be recorded within the Medication Record section of a chart. This record must also be
supported by a physician's order.
The information listed here should include the following:
Name of medication
Time the medication was given to the patient
Route of administration of the medication to the patient
Dosage of medication administered

If any of this information is not properly documented, it could cause a delay in treatment or
an error.

Lab Reports
Within the Lab Reports section is a detailed summary of the results of any and all labs that
were performed on a patient. These lab reports provide the physician with diagnostic clues to the
patient's condition. Several things should be considered when analyzing the lab reports within a
chart:

Do the labs performed match the labs ordered by the physician?

Was each lab report viewed by the ordering physician?
Is the specific lab work that was ordered and performed justifiable based on the patient's
symptoms and diagnosis?
Was the lab work performed and reviewed by the ordering physician in a timely fashion?
Was the proper protocol followed and documented upon performance of the ordered lab
work?
If an abnormal finding was documented within the lab work, what did the physician do to try
to correct the condition that caused this abnormality?

SUMMARY
The process of analyzing health care records is no easy task - it's both a science and an art!
But by using a step-by-step approach, the analyst ensures that the patient's story has been told
accurately, which will benefit the patient, the facility, and the nurses and physicians providing the
treatment.

56
 4 1 hour &
15 mins.
Topic 2: Principles of Recording in Nursing

At the end of the lesson, the students will be able to:

 Discuss the importance of proper recording and documentation in the nursing
profession.
 Discern understanding of its significance for effective and efficient patient care.

Overview

Proper record keeping is an important aspect of patient care. A patient record is a permanent
document that chronicles a patient's care history. Learn why record keeping is important and the
principles of record keeping in the nursing profession.

57
 In relation to Topic 1 of Module 4, we will shall understand further the principles of
proper recording in nursing...

RECORD KEEPING
Let's say you love to cook. One day you come up with a great new way to make spaghetti
sauce. You add all the right spices in all the right amounts, and the result is delicious. But let's say
you forgot to write down the recipe. Without a record of how you made your fabulous sauce, you'll
never be able to make it again. Just like a cook needs to keep detailed records about ingredients, a
nurse needs to keep detailed records of patients.

Record keeping is the act of organizing and documenting information relevant to a patient's
treatment. Good patient records include well-documented details about patient care, and the patient's
response to that care. In this lesson, you'll learn why proper record keeping is important and
principles that must be followed to ensure proper record keeping.

IMPORTANCE
A patient record is a permanent documentation of a patient's care by a health care provider.
While it might feel as if a nurse is interrupting treatment to write down notes, patient records are
vitally important to the continuing care of a patient.

Consider this: a nurse may encounter 20 different patients in a day. It's impossible to
remember details about each of these patient encounters.

Nurses must learn the principles of good record keeping, because these records serve as a
history of client care, reveal patterns in a patient's progress, guide future care decisions, support
financial billing and may even be used as evidence if legal issues arise.

PRINCIPLES
Do you remember when we talked about the importance of writing down the recipe for your
delicious spaghetti sauce? Well, let's say you did remember to write down the ingredients. However,

58
the next time you pulled out the recipe it was so full of eraser marks, confusing abbreviations and
illegible writing that you couldn't follow it. Like a recipe, a patient's records must be complete and
written clearly to be useful.
There are general principles that nurses must follow to ensure the records do their job. Records
should be written as soon as possible after a patient encounter. This quick action makes it more
likely that important details aren't forgotten. Of course, taking notes ASAP doesn't mean they should
be rushed. Take enough time to ensure that all notes are recorded neatly. Patient records must be
clear and legible.

If you're not happy with the clarity of a note you make, remember that records should never
be altered or destroyed without proper authority. If you do something

wrong, don't erase mistakes, instead draw a line through the mistake, and then sign and date the
correction.

The records need to include notes on care that was given, any problems that arose and actions
taken to deal with the problem. You should also document if a patient refuses a treatment. For
example, a patient complains that the medication they were given on the last visit made them feel
nauseated, and they don't wish to continue that treatment. The nurse should record the medication
and the patient complaint, to alert the doctor and guide future prescriptions.

While it may feel tedious, each patient record needs to include the date, time and a signature.
These elements help develop a timeline for patient progress and could prove vital if the patient notes
are needed in a legal case. It also helps to use standard terminology and abbreviations, so there's no
confusion amongst professionals that might need to review a patient's records.

You want to avoid vague statements that are open to interpretation. For example, if you write
down that the patient seems better, you need to explain what made you come to this conclusion.
Explain any evidence you notice that supports this view, such as: the patient was talkative and
answered questions coherently.

And keep in mind that patient records are confidential. Therefore, nurses must maintain the
records as confidential to protect the patient's privacy and rights. Never leave patient records where
they may be viewed by unauthorized eyes.

SUMMARY

Let's review. Record keeping is the act of organizing and documenting information relevant
to a patient's treatment. A patient record is a permanent documentation of a patient's care by a health
care provider. These records serve as a history of client care, reveal patterns in a patient's progress,
guide future care decisions, support financial billing and may be used as evidence if legal issues
arise.

Principles of recording include the following:

Records should be written as soon as possible after a patient encounter, must be clear and
legible and should never be altered or destroyed without proper authority. If you do something
wrong, don't erase mistakes, instead draw a line through the mistake and then sign and date the
correction. The records need to include notes on care that was given, any problems that arose and
actions taken to deal with the problems. Document if a patient refuses a treatment. Include the date,
time and a signature. Use standard terminology and abbreviations and avoid vague statements that
are open to interpretation. Nurses must maintain the records as confidential.

59
 4 1 hour &
30 mins.
Topic 3: HIPAA

At the end of the lesson, the students will be able to:

 Describe the meaning and the legalities involving HIPAA.
 Discuss the difference between being HIPAA certified and HIPAA compliant.
 Explain how HIPAA protects the right of every patient in the health care setting.

Overview

This lesson discusses the United States Health Insurance Portability and Accountability Act
of 1996, better known as HIPAA. Let's take a look at the legal protections and administrative
requirements of this law. This lesson will also provide you with a brief description of HIPAA
protections and the covered entities for whom the HIPAA rules apply. We will discuss the difference
between being HIPAA certified and HIPAA compliant, as well as how HIPAA regulations affect
individuals.

60
 In relation to Topic 2 of Module 4, we shall now deepen our knowledge on the law
protecting the privacy and security of a patient's medical information.

HIPAA: DEFINITION
Have you ever been asked to sign a HIPAA Privacy Notice form when you've been treated at
your doctor's office or in a hospital setting? In general, you may know that HIPAA deals with a
patient's right to privacy, but do you have a clear understanding of the protection that it offers as you
sign those papers?

Perhaps you're considering changing jobs, but you're concerned about losing your health
insurance because you or someone in your family has a chronic illness. Do you know how HIPAA
can protect you in this situation?

HIPAA is an acronym that stands for the Health Insurance Portability and Accountability Act
of 1996. Developed by the Department of Health and Human services, the primary goals of the Act
are:
1. To provide privacy standards to protect patients' confidential health information and medical
records
2. To make it easier for people to keep their insurance when their employment situation changes
3. To help the healthcare industry reduce administrative costs

HIPAA is divided into five sections that address different aspects of health insurance reform.
The two main sections are Title I, which deals with portability, and Title II, which focuses on
administrative simplification. This chart shows the five sections (or titles) of HIPAA.

Let's take a closer look at some of the

basic protection we are afforded under HIPAA.

Title I
Title 1: Portability contains requirements that help people keep their health insurance when
they lose or change jobs so they don't have a lapse in coverage. It places limits on exclusions for pre-
existing medical conditions and prohibits discriminating against people based on their health status
and medical conditions. It also guarantees health insurance policy renewals. In the past, some people
were reluctant to change jobs for fear of losing their health care coverage. Thanks to HIPAA, folks
in that situation have legal protection.

Title II
Title II: Administrative Simplification includes the privacy rule, which sets standards for the
use and disclosure of an individual's protected health information, including our health status,
treatment, and payments for healthcare. This applies to all protected health information, including
paper copies and electronic data. The privacy rule also gives patients the right to examine and
receive a copy of their health records and to request corrections.

Some of the basic administrative requirements placed on health care entities include:
 Develop a written policy and procedures to protect healthcare information
 Designate a person to develop the privacy policy
 Designate a contact person to distribute information and investigate complaints
 Train the workforce on the policies and procedures
 Develop procedures for individuals to file complaints about compliance

61
  Help lessen any harmful effects caused by disclosure of protected information
 Maintain reasonable safeguards for protected health information
Under the Administrative Requirements, health care entities are also forbidden to retaliate
against people who file a complaint and cannot require anyone to waive their rights under the act.

Title II also establishes uniform standards for transmitting and maintaining healthcare
information. It requires all providers to use unique identifiers and encourages them to change from
paper records to electronic records to improve security and lower costs.

Health plans, healthcare clearinghouses (like billing services), and most health care providers
must comply with HIPAA. Title II's Enforcement Rule outlines compliance, investigation, and
monetary penalties for violations of HIPAA. Monetary penalties vary, depending on the type of
violation and range from $100 to $50,000 per violation.

Title III
Title III: Medical Savings Accounts provides for deductions for medical insurance. It
specifies the amount each individual may save in a pre-tax medical savings account.

Title IV
Title IV: Group Health Insurance Requirements sets the rules for group health plans,
including requirements for continuing coverage and pre-existing conditions. It clarifies the
requirements under the Consolidated Omnibus Budget Reconciliation Act (or COBRA).

Title V
Title V: Revenue Offsets has provisions regulating company-owned life insurance policies. It
also deals with taxes on people who are believed to be giving up their U.S. citizenship for tax
purposes.

WHAT IS A COVERED ENTITY UNDER HIPAA?

The Health Insurance Portability and Accountability Act of 1996 is commonly known as
HIPAA. This law protects the privacy and security of a patient's medical information. This is a pretty
important law for citizens as it sets boundaries on how, when, and if a medical practitioner can use
and release health records. So, what does this mean for a health care provider?

This law provides very strict guidelines on

security measures that should be in place to protect
both physical and electronic medical records. That
seems straightforward. Doctors have to keep medical
records secure and private. No big deal, right? Let's
take a closer look at who is held accountable for
following HIPAA.

Covered Entities
Well, the thing is, it's not just a patient's doctor who has access to medical records, so, in fact,
HIPAA applies to other people or entities in the health care field.
o Providers: These are the people or entities that actually provide health care such as
doctors, clinics, psychologists, dentists, chiropractors, nursing homes, and pharmacies.
o Health Plan: These are the entities that represent the medical insurance processors and
include health insurance companies, HMOs, company health plans, government programs
for health care - Medicare, Medicaid, as well as military and veterans' health care
programs.
o Health Care Clearinghouse: These entities process nonstandard health information they
receive from another entity. These would be entities that provide billing services,

62
 repricing companies, and claims reviewers. They are also known as Business Associates.
Let's look at them in a little more detail.

Business Associates
Business associates must have a written business associate contract detailing exactly what
they have been contracted to do. The signed contract holds these associates to the same level of
compliance with the privacy and security requirements as mandated by HIPAA as care providers.

Some examples of business associates would include:

o A CPA firm that provides accounting services
o An attorney that provides legal services
o Consultants who may perform reviews for a hospital
o An independent medical transcriptionist
o A pharmacy benefits manager who manages health plans for a pharmacist network
o Third party administrator that assists with claims processing

What this means is that anyone who may have access to a patient's records must comply with
HIPAA regulations.

HIPAA CERTIFIED VERSUS HIPAA COMPLIANT

There is a very important distinction between being HIPAA certified and HIPAA compliant.
Covered entities need to have training in HIPAA regulations including any appropriate security
measures that must be followed to ensure the privacy of medical records. HIPAA compliant means
that these security measures are actually followed and there have been no violations that resulted in
patients' information being released to non-HIPAA compliant entities.

Patients see part of that compliance when they go to their doctors' offices and are given a
brochure explaining their rights under HIPAA and are then required to sign a form that they received
this information. Patients will also have to sign a special form if they want to designate that someone
else can receive their medical records.

For example, an aging mother can sign a form allowing her son or daughter to talk to her doctor
about her care.

HIPAA PRIVACY RULE: PATIENT RIGHTS

It's a funny sounding acronym, but its meaning is quite serious. In this lesson, we'll take a
closer look at the types of rights and protections that HIPAA affords patients in a medical setting and
with health records.

Know Your Rights

Imagine this: you're working at a doctor's office and an old adversary from high school
arrives for an appointment. Curious about why they're visiting the practice, you sneak a peek at their
electronic medical records. What you find out is so juicy, you immediately text an old friend and tell
them what you discovered. Uh-oh... what you've just done in that simple text is not only gossip, but
violate the privacy rights of the patient under HIPAA.

The Health Insurance Portability and Accountability Act of 1996 provides certain protections
and rights for patients regarding their sensitive medical information. For patients, this means you
have certain rights over your health information, whether that data is written, oral or electronic. It
also provides for a variety of other protections. Let's get to know a patient's rights under HIPAA.

Patient Rights Under HIPAA

63
 From access to your medical records to determining how a provider communicates with you
about those records, your rights under HIPAA are clearly outlined and explained. Here's what you
should know about your rights.

 Right to Receive A Notice of Privacy Practices

If you've been to the doctor's office lately, you've probably received or viewed a notice of privacy
practices. Usually, you have to sign a form indicating that you've read or received it. The notice
simply apprises a patient of all of the rights which follow.

 Right to Access
Under the law, you have a right to look at, and even get a copy of, your health information. This
means you can access and inspect your own medical and billing records when you're visiting your
doctor's office. You can even get a copy of them, typically by filling out an authorization or release
through your medical facility. A cost for that request sometimes applies.

 Right to Accounting of Disclosures

As a patient, you are entitled to request a list of all disclosures made of your health record. That
means you have a right to see an accounting of everyone (or every place) who has received your
sensitive medical information, including the date, a description of the information provided and the
reason it was given out. If there is a discrepancy regarding who has received your data, checking
your disclosures might clear things up. There may be an administrative cost for this information as
well.

 Right to Amendment
What do you do if you notice incorrect or incomplete information in your medical records? With the
right to amendment, you can ask your medical provider to correct that data. Some requests may be
given verbally, but others may require a written

request for change. Most institutions may want to know why the request is being made and will
generally let a patient know when the requested changes have been made.

 Right to Confidential Communication

Confidential communication is central to ensuring a patient's rights under HIPAA are protected. For
patients, this might mean requesting that health care officials communicate with you in specific ways
or locations. You may prefer to only be contacted by telephone at home (instead of at work), for
example, or that medical information be sent only via regular postal mail. All that's required is to
communicate (get it?) your preferences to your medical provider.

 Right to Restrict Access

Don't want your medical information released to certain people or places? You have the right to
place restrictions on who can receive your treatment details and health care data. That means if you
don't want a family member to have access to your medical records, you can prevent it. You can
keep any of your providers from releasing information about a medical procedure or medication
you've taken to a friend or even an employer. Restriction requests are typically confirmed in writing,
and must include what details you want limited and who should be on the ''do not tell'' list.

 Right to Complain
To ensure your rights are being respected, you also have the right to complain about any possible
violations you feel have occurred to your privacy. Perhaps information about a pre-existing medical
condition was given to a former spouse who wants to use it against you in a court hearing. It could
be that you found out your medical records were accessed by an acquaintance working in a doctor's
office and then shared with mutual friends. You are entitled to file a complaint with the office or
department that provided your care. If not satisfied with those results, you can file a complaint with
the Department of Health and Human Services.

SUMMARY

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 Patients are afforded many rights and protections under the Health Insurance Portability and
Accountability Act of 1996. Under these guidelines, patients are entitled to certain protections
surrounding their personal medical data, whether written, electronic or verbal. Among them is the
right to receive a notice of privacy practices. This is typically provided during the check-in process
at a medical facility and requires a signature.

In that document, you learn about the rights you are guaranteed: the right to access your
medical records, your right to a list of all disclosures made of your information and your right to
amend inaccurate or incomplete information. Patients are also given the right to choose the methods
of communication used to relay your medical information and the right to restrict who can receive it.
Above all, if you're not happy with how your privacy and data is being protected, you have the right
to complain either to the facility or to the Department of Health and Human Services.

References and Further Readings:

Groves J. Randall & Edge, Raymond S. Ethics of Health Care: A Guide for Clinical Practice, 4th Edition.
Cengage Learning Asia Pte Ltd. C&E Publishing, Inc. (2019)

Timbreza, Florentino T. Bioethics and Moral Decisions, C&E Publishing, Inc. (2007)

Internet Source: www.study.com

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 Activity 1:

10 Words
Found:
1) ________________________________
2) ________________________________
3) ________________________________
4) ________________________________
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5) ________________________________
 Activity 2:

Write your answers here. . .

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 Criteria Rubrics for Activity 2, 4 & 5:
Content and Organization – 30
Composition and Grammar – 15
Creativity – 5
TOTAL: 50 points

Activity 3:

Write your answers here. . .

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 Write your answers here.

Before we move on to the next topic, I would gladly want to listen to your feedback to
this module.

Kindly rate each area with a scale of 1 – 5: 1 as the lowest and 5 as the highest.

Evaluation Rating
1. Comprehensive Content
2. Relevance of the Content
3. Clarity of the text and message
4. Alignment of the assessment activities to learning objectives

Comments/Suggestions:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Congratulations for completing the whole topic. May the learning you derived from this
activity contribute to your development as an effective and efficient nurse. Smile and enjoy learning!

NOTE:
This module covers the midterm coverage Module 2 to 5 only and shall subject for approval of the
board, program dean, and the Commission on Higher Education. Module 6 to 8 (Finals Coverage) shall be
attached further. Thank You!

Prepared by and Credits to: Gladys F. Jimlano, RN, MN-MS

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