MODULE V: BASIC PRINCIPLE IN HEALTH CARE ETHICS

It is from our general worldviews that we have developed our societal moral principles and
legal rights. These are in the continual state of evolution: As an illustration, society at one point in
history will embrace slavery and then reject it, oppress women and disregard the disabled and then
struggle to create a legitimate space for all. These societal swings may come as reactions to such
vague concepts as to “do good and avoid evil,” or the “inherent dignity of the individual.”
Professional ethic, such as those found in medicine and law, are applied ethics designed to
bring about the ethical conduct of the profession. In health care delivery, the major purpose might
be the pursuit of health, with the prevention of death and the alleviation of suffering as secondary
goals. The basic principle that have been developed to allow health professionals to determine
right and wrong in regard to value issues involving these goals are autonomy, veracity,
confidentiality, beneficence, nonmaleficence, justice, and role fidelity. The general hierarchy of
thinking in regard to biomedical ethics, as we proceed from a general worldview, to universal
principles, to rules as found in our ethical codes, and finally to decisions.
Worldview

Basic principle

Rules and code

Decisions

UNIVERSAL PRICIPLES OF HEALTH CARE ETHICS

Autonomy
The word autonomy comes from the Greek autos (self) and nomos (governance). In health
care, it has come to mean a form of personal liberty, where individual is free to choose and
implement his or her own decisions, free from deceit, duress, constraint, or coercion. Three basic
elements seem to be involved in the process: the ability to decide—for without adequate
information, and intellectual competence, autonomy seems hollow; the power to act on your
decisions—it is obvious that those in the death camps of World War II have made all the decisions
they might have wished but lack of power to implement them; and finally a respect for the
individual autonomy of others--- it is the provision of general respect for personal autonomy for
both practitioner and patients alike that ennobles and professionalizes the process. The term
self-determination is often used in synonymously with autonomy.
From the basic principle of autonomy, we have derived the rules involved in informed
consent, which generally contain the elements of disclosure, understanding, voluntariness,
competence, and permission giving. It is obvious that the patient is not free to select an appropriate
path if not given adequate information, stated in a manner that allows understanding. The
information must be provided at a time when a patient is able to sort option rationally and is in a
position to grant or refuse consent. Legal exceptions to the rules of informed consent under
therapeutic privilege have been made in cases of emergency, incompetence waiver, and when
there is implied consent. A problematic area of therapeutic privilege is that of benevolent
deception, in which the practitioner is allowed to intentionally withhold information based on the
sound medical judgment that to divulge information might potentially harm depressed and
unstable patient.
One of the great areas of struggle in health care ethics is that of autonomy versus
paternalism. Paternalism is the intentional limitation of the autonomy of one person by another, in
which the person who limits autonomy appeals exclusive to the ground of benefit to the other
person. Health care professional have special fiduciary relationship with patients based on the

1
confidence placed in us and the inequality of our position with regard to information. This
relationship places an affirmative duty on the practitioner to seek the best for patients.
Complicating the process of autonomy are the cases in which it becomes necessary limit
autonomy because the patient could not be expected to comprehend sufficiently to make an
authentic decision. For example, should a patient in severe pain be allowed to decide to refuse
treatment based on the current pain, when the treatment will be lifesaving and restore normal
function?
The patient’s right to information can be exercise only in the exercise of the patient right to
autonomy.
THE RIGHT TO INFORMATION

The patient must be informed about the whole process and must understand what this
information pertains to so that an appropriate moral decision can be arrived at.
Note: The ability to make an Informed Choice, Informed Decision and make an Informed
Consent can be exercise only by an informed person.
INFORMED CHOICE:
The patient has the right to be informed about all possibilities of alternative courses of
action taken, together with possible consequences.
INFORMED DECISION
Refers to the necessary information of, and decision on, a medical treatment/research
before it is to be carried out. The patient must be informed about the whole process and must
understand what this information pertains to so that an appropriate moral decision can be arrived
at.

INFORMED CONSENT
The patient has the right to receive all necessary information concerning diagnosis and
treatment (research) in order to be able to give consent based on his/her sense of values. This
information should be given before the treatment (research) is administered.

Veracity
Veracity bonds both the health practitioner and the patient in an association of truth. The
patient must tell the truth in order that appropriate care can be provided. The practitioner needs to
disclose the factual information so theta the patient can exercise personal autonomy. The special
fiduciary relationship that exists between patients and their health care practitioners is such the
patients have the right to expect a higher level of truthfulness from us than others with whom they
deal. If you were to buy a used car, you would hope that the dealer would tell you the truth. If asked
a direct question about a special problem and the dealer lies, he is committing fraud, but in most
jurisdictions, he is not required to volunteer the information. The practitioner, however, is bound
within the limitation imposed by her role to disclose all relevant information.
Even under the guise of benevolent deception, the idea of not telling the truth to patients is
rather suspicious. The suggestion is that individual is not strong enough to stand the truth, or more
time is needed to prepare the patient for an unpleasant fact. Unfortunately, this lack of truth telling
leads to slippery slope. Although it gives support to the one individual, it teaches all others
involved—for example, family members, friends, housekeeping staff, and hospital
volunteers—that health care practitioners lie to their patients. Rarely is lying to a patient is
justified. Modern health care is based on a complex set of agreements between the practitioner and
the patients, which work under the condition of trust, veracity, and fidelity.
Medicine’s attitude towards truth telling has always been somewhat of an ambiguous place
because of the way in which it can clash with the desire to do the best for the patient. The use of
placebos, which the practitioner knows to be medically inert but the patient feels are therapeutic, is
a good example. Fundamental to the use of placebos is that the practitioner must engage in
nondisclosure and deception for the practice to work. The defense offered is that the deception is
used only for the welfare of the patient. This is triumph of doing good (beneficence) over
autonomy, which virtually forms the definition of paternalism.
While it may be conceivable that lying to the patient might become necessary to avoid
some greater harm, lying cannot be entered into lightly as it interferes directly with the person’s
autonomy. Tolerance to lying damages the system of health care delivery. Patients believe lies

2
only because truthfulness is expected from the health care providers. An essential element of good
health care delivery will be lost once the patients begin to look for deceit.
Allied health and nursing specialist should be committed to the truth. When faced with
situations in which lying seems a rational solution, other alternatives must be sought. The harm to
patient autonomy and the potential loss of practitioner credibility makes lying to patients a practice
that in almost all cases should be avoided.

Beneficence
The common English usage of the term beneficence suggests acts of mercy and charity
although it certainly may be expanded to include any action that benefits another. Most health care
professions have statements that echo the Hippocratic Oath, which state that the physician will
“apply measures for the benefit of the sick.” The obligation to help imposes on the health care
practitioners the duty to promote the health and welfare of the patient above other considerations,
while attending and honoring the patient’s personal autonomy. In the code of ethics of the
American Nurses Association, this is clearly stated: “The nurse’s primary commitment is to the
health, well-being, and safety of the patient across life span and in all settings in which health care
needs are addresses.” Patient’s assumption that health care providers are working on their behalf is
of great importance to their morale, especially for those who are summoning all their strength to
fight illness.
Nonmaleficence
Most health care professional pledges or code of care echo the principle paraphrased front
the Hippocratic Oath statement: “I will never use treatment to injure or wrong the sick” In some
way, this seems very similar to the duty of beneficence: however, some differentiate between the
two in the following manner:
● Nonmaleficence
o One ought not to inflict evil or harm
● Beneficence
o One ought to prevent evil or harm
o One ought to remove evil or harm
o One ought to do or promote good
All statement of beneficence involved positive action toward preventing, or removing
harm, and promoting the good. In the nonmaleficence statement, the guidance is stated is staed in
the negative, to refrain from inflicting harm.
The technology of modern health care and therapeutics has made this a difficult principle
to follow, because much of what we do has unfortunate secondary or side effects. For example,
when steroids are administered to the asthmatic patient to relax the smooth muscle of the airway,
often the side effects of Cushing’s syndrome occurs. Some of the newer antibiotic given to fight
infections have serious negative side effects. Analgesic such as morphine given for pain may lead
to a suppression of respiration. In attempting to maintain the ethical position of nonmaleficence in
these cases, some practitioners have explained their action through the principle of double effect.
With this concept the secondary effects may be foreseen, but can never be the intended outcomes.
The practitioner could, when necessary, ethically prescribe or administered morphine for pain,
while understanding that the analgesic suppresses respiration so long as the intended effect is the
former and never the latter and the good intentions equal or outweigh harmful effects. Although
intuitively persuasive and defended in many duty-oriented works, the principle of double effect
has detractors who feel that unwanted effects of action that are foreseen and still allowed become
intended effects. Even if the principle of double effect id finally found not to be a useful
formulation for practice, it still asks the right question: Under what circumstances can one be said
to act morally when some of the foreseeable effects of that action are harmful?

Elements of the Principle of Double Effect

1. The course chosen must be good or at least morally neutral.
2. The good must not follow as a consequence of the secondary harmful effects.
3. The harm must never be intended but merely tolerated as casually connected with the
good intended.
4. The good must outweigh the harm

3
Confidentiality
Confidentiality is an important aspect of the trust the patients place in health care
professional. If the patient felt that information about his body or condition was the subject of
public conversation used to brighten the coffee break in the cafeteria or was subject to release to
publication, a great barrier between practitioner and patient would exist. This fear of disclosure has,
in the past, led minors with sexually transmitted diseases to suffer without care rather than to seek
aid, knowing that the system required the notification of their parents.
With sophisticated information system, personal confidentiality is under assault in all
aspect of our lives. This is especially true with medical information system in which patient
information can be brought on a CRT screen in variety of areas throughout the hospital, making
this information available to all in the system.

Justice
The maintenance of this ethical principle is seemingly simple in the abstract and complex
in application, as it deals with the concept of fairness, just deserts, and entitlement. In a just society
we require procedural justice or due process in cases of dispute between individuals. In health care
de deal with distributive justice as we struggle the distribution of goods and services, attempting in
some measure to provide a system in which individuals receive their due share:
● To each an equal share (e.g. elementary and secondary education)
● To each according to need (e.g. aid to the needy and programs such as food stamps)
● To each according to effort (e.g. unemployment benefits)
● To each according to contribution (e.g. retirement system)
● To each according to ability to pay (e.g. free market exchange)
We are currently confronted by a health care system that provides better care to rich than poor,
to the urban dweller over the rural, the elderly over the child. The problem of providing for fair and
equal distribution of health care would be difficult even if we assumed a world of unlimited
resources. Once we factor in problems of scarcity, practitioner self-determination, maldistribution
of resources and costs, it becomes an overwhelming dilemma.
Another interesting aspect is the area of compensatory justice, in which individual seek
compensation for a wrong that has been done. This has become far more important aspect of the
health care in light of the cases such as those where harm was caused by asbestos and other
materials placed in our bodies, and environment, or design flaws in medical devices.
Similar to compensatory justice is the ancient call for retributive justice of “an eye for an eye
and tooth for a tooth.” However, unlike compensatory justice, in which fines and compensation fro
injury are requested, retributive justice calls fro equal suffering. The advice given to every child by
their mother that “two wrongs never make it right” is applicable here. Retributive justice has very
little to do with any form of suitable behavior in the health care arena.

Role Fidelity
Model health care is the practice of team, as no single individual can maintain the data bank
of information needed to provide rational care. The nature of these specialties shapes the way in
which individual practitioner will respond the basic questions of biomedical ethics. An example
might be the duty of respiratory care not to tell patient’s family how critical the situation is, while
attending physician might have an obligation to relate the information. Whatever the assigned role,
the ethics of health care require that the practitioner practice faithfully within the constraints of the
role. Most often the areas of acceptable practice are contained and prescribed by the scope of
practice of the state legislation that enables that profession’s practice.

4
 Desired Lesson Learning Outcome:
Utilize ethical reasoning and decision-making in sele
and performing nursing intervention during nursing et
dilemma
Protect Patients Right and Obligation

Enabling Lesson Learning Outcome

You, as the learner, are expected to do the following:

1. categorize the basic principles found in health care ethics.

2. illustrate in writing how the principle of double-effect attempts to
resolve ethical issue of side effects and the duty of nonmaleficence
3. diagram the how principle of informed consent is derived from the
principle of basic autonomy
4. Justify a case analysis
KEY CONCEPT: Health Care Basic Principle
Enabling Lesson Learning Outcome, I: Categorize the basic principles found in health
care ethics.

Categorize what universal principles of health care are the following statements?
1. The Patient has the right to considerate and peaceful care. Briefly explain your answer.
_____________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________.
2. The Patient has the right to obtain from his physician complete current information
concerning his diagnosis, treatment, and prognosis in terms the patient can be reasonably
expected to understand. ___________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________.
3. The Patient has the right to every consideration of his privacy concerning his own medical
care program. Case discussion, consultation, examination, and treatment are confidential
and should be conducted discreetly; _____________________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________.
4. The Patient has the right to expect continuity of care. _______________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________________.
5. The Patient has the right to refuse treatment to the extent permitted by law, and to be
informed of the medical consequences of his action. _______________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________.
6. The Patient has the right to receive from his physician information necessary to give
informed consent prior to the start of any procedure and/ or treatment, except in
emergencies. ________________________,

5
 ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________.
7. I have the right to participate in decisions concerning my care. ___________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________.
8. I have the right to be cared for by those who can maintain a sense of hopefulness, however
changing this might be. ____________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________.
9. I have the right to discuss and enlarge my religious and/ or spiritual experiences, whatever
these may mean to others. ____________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________.
10. I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt
to understand my needs and will be able to gain some satisfaction in helping face my death.
________________________________,
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________.

Rubric:

Exceeds Meets Does Not Meet

3 2 1
Ideas Main Idea is clear Main Idea is stated State the main idea then
Supporting details are clear Some supporting details goes off the topic
Very specific information Some information id left out
Organization Clear introduction, body Introduction body and conclusion No organization
and conclusion Generally clear sequence of events Not readable
Logical sequencing of
events
Style Precise words Some precise words Confusing use of words
Different length of Some words are boring What is being said is not
sentences clear
Engaging
Convention Complete sentence Some error in sentences, punctuation, Many errors
Correct punctuation spelling or grammar Difficult to read
Correct spelling
Correct grammar

KEY CONCEPT: Principles of Double-effect and nonmaleficence

Enabling Lesson Learning Outcome II: Illustrate in writing how the principle of
double-effect attempts to resolve ethical issue of side effects and the duty of nonmaleficence

Read: A woman who has an ectopic pregnancy. The life of the mother can be in danger if
pregnancy continues. In the present of medical science, only the surgical removal of the fetus can
save the mother’s life. The operation, however, clearly implies the death of her fetus. Granting that
the operation is ethical, (1) explain the validity of the operation base on the principle of

6
double-effect theory going through the theory’s elements. (2) how the double-effect theory
resolves the issue nonmaleficence, specifically on the death of the fetus? Briefly and ethically
explain.
Answer here:
1) ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________.
2) ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________.
Rubric:

Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points

Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study
problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
and ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrates ethical
responsibility to considers ethics or indicates that the that the student is and professionalism
work in an professionalism as student does not aware that he/she in his/her response/s
ethical and he/she consider the fully understand have responsibility to the case study
professional case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.

KEY CONCEPT: Informed consent and autonomy

Enabling Lesson Learning Outcome III: diagram the how principle of informed consent
is derived from the principle of basic autonomy

On a schematic diagram, outline how the following principles of informed choice, informed
consent, and informed decision sprung from the principle of autonomy.

7
Rubric:

Exceeds Meets Does Not Meet

3 2 1
Ideas Main Idea is clear Main Idea is not clearly stated Idea is not clear
Organization Logical sequencing of ideas Some of the ideas are not No organization
logically in sequence
Style Precise words Some words are not precise Confusing use of words
Engaging presentation Presentation is somewhat boring Presentation is not clear

KEY CONCEPT: Case Study

Enabling Lesson Learning Outcome IV: Justify a case analysis

Read:
Mrs. B is pregnant and drinks so much alcohol and in fact a habitual alcohol drinker. Her
doctor, Dr. D, advise her to stop drinking for it will affect the fetus and repeatedly advise her about
“fetal alcohol syndrome. Mrs. B does not listen to the advice and continued her drinking spree.
Due to Mrs. B attitude the Doctor file a petition to the court asking for the issuance of an order to
incarcerate or detain Mrs. B in the hospital during the entire duration of pregnancy, forcing Mrs. B
to follow Dr. D medical advice.
Thinking ethically will you participate and support the action of Dr. D? Clearly and briefly
apply universal health care principle/s in your answer.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________.
Rubric:

Unacceptable 0 Marginal 1 Acceptable 2 Exceptional 3 Points

Able to analyze Student show no Student appear to Student Student is able to
a situation for awareness of be aware of some demonstrate analyze a complex
potential ethical potential ethical ethical problems understanding of ethical situation and
problems problems in their in case study but major ethical demonstrate an
response to the are not using problem in the case understanding of
case study appropriate study and are major and subtle
tool/principle to applying the problem/s in the
analyze the tools/principle they case study

8
 problem have learned to
analyze the
situation
Awareness of No evidence that Student appear to Student is aware of Student is aware of
Code of Ethics the student is aware of the Code the Code of Ethics the code of ethics or
and ethical aware of the Code of Ethics or or ethical principles ethical principles
principles of Ethics or ethical ethical principles and use it to when and use it routinely
principles but is not making faced with a to work in a
use of it as he/she potentially professional and
approach ethical unethical situation ethical manner
problem
Awareness of No evidence that The response to The response to the The student
their the student the case study case study indicates demonstrates ethical
responsibility to considers ethics or indicates that the that the student is and professionalism
work in an professionalism as student does not aware that he/she in his/her response/s
ethical and he/she consider the fully understand have responsibility to the case study
professional case study what it means to to work in an
manner work in an ethical ethical and
and professional professional
manner manner.

Source: Ethic of Health Care

A guide for Clinical Practice
Fourth Edition
Raymond S. Edge
J. Randall Groves