NCM108

HEALTH CARE ETHICS

MODULE 1- E
Module Coverage:
A. Ethical Theories
B. Virtue Ethics
C. Ethical Principles
D. Other Relevant Ethical Principles
E. Principles of Bioethics
F. Bio Ethics and its Application in Various Health Care Situations

THE PRINCIPLES OF BIOETHICS

BIOETHICS

A term to describe the application of ethics to biological sciences, medicine, and related fields.

A systematic study of moral conduct in life sciences and medicines.

A systematic study of human behavior specifically, in the fields of life sciences and health care, as examined in
the light of moral values and principles.

An ethics to a special focus on challenges arising from modern biotechnology.

BIOTECHNOLOGY is any technology using microorganism of biological materials for technological purposes.

SCOPE OF BIOETHICS

In its initial stages, Bioethics was concerned with ethical problems associated to medical practice but later, the
subject matter was broadened to include all biosciences. Bioethics does not deal only but solely to the doctor,
patience of relationship from a moral stand point, but it expanded to social issues related to health, animal welfare,
environmental concerns, however, biomedical ethics remains central to this paradigmatic discipline.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
The problem with bioethics has something to do with the challenges posted by the biotechnological advances and
its power over life and death.

Importance and Significance of Bioethics.

1. Provide awareness to the health team or workers of the “do’s” and “don’ts” of medical practice.

2. To enrich one’s competence by understanding that the patient is a person and a holistic individual.

- This field of study Bioethics was developed in countries that had to face many ethical challenges due to
the bio-scientific developments, but the same moral problem challenges us even in the Philippines. As
medical interventions became more powerful, ethical problems associated to medical and health practices
also grow.

- Along this line of development, it is vital for every member of the health profession to be acquainted to
ethical principles involved in the biomedical procedures. Biological sciences will continue to grow, as it
will, there is a great need for us to take a moral stand on these developments. Indeed, no end is in light
for the need of health professionals who are conversant to bioethics, for they alone will be the most
efficient and effective, at the same morally responsible health service providers.

1. THE PRINCIPLE OF STEWARSHIP AND ROLE OF A NURSE AS A STEWARD

Stewardship in Health care, in the Nursing Profession, and of Self.

The theory of stewardship incorporates concepts of environmental and theological notions of practical
reasoning. Within the nursing literature, stewardship has emerged as a topic of nurse leadership; however,
there is a need to clarify the origins and meaning of the term.

Traditional Definitions of Stewardship.

In the Book of Genesis, God appoints humanity as the steward of all creation. The Old Testament tells the story
of Joseph, who is sold by his brothers into slavery and becomes Putiphar’s steward and ultimately the Pharaoh’s.
From this parable, a steward is a selfless servant who manages assets and possessions without owning them,
foresees future trends and creates plans and interventions.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
The parable of ‘talents’ in the New Testament describes another aspect of stewardship in which a master divides
his worldly goods between his three servants. The moral portrayed in this parable is that when one is entrusted
with something of value, there is an obligation to improve on it.

The Islamic institution of Hisba is responsible for organizing public administrative functions within the dimensions
of morality, normality and technology. The head of the Al Hisba is called the Muhtasib, who was first appointed
in Medina in the 9th century. The Muhtasib in the pre-colonial Arab civilisation was responsible for the regulation
of medical practice and pharmaceuticals, which incorporated equitable provision of services to the public.

State-oriented Definitions of Stewardship.

The broad definition of state-orientated stewardship is that the function of government is responsible for the
welfare and interests of the population, especially the trust and legitimacy with which its activities are viewed by
the general public.

Six aims to improve the health care system for the 21st century. The recommendations were that health care
should be 1. safe, 2. effective, 3. patient-centered, 4. timely, 5. efficient and 6. equitable. These recommendations
have been assumed by both the health care community and the communities served and form the context around
discussions about health care. This may lead to leadership opportunities for nursing that afford ways and a
knowledge base to initiate dialogue with colleagues, including consumers and health insurers.

To achieve the six aims, nurse leaders will have to engage in developing, assessing and refining innovative and
fresh modes of care delivery. To do this, a solid foundation in health care economics, financing and statistics will
be order of the day for this aspect of stewardship.

The Potential of Stewardship.

The potential for improving and enhancing policy outcomes is the predominant positive potential of stewardship.
Another prospect of stewardship is to revive a sense of social purpose among public sectors of management,
together with assisting to restore a sense of trust and legitimacy to the role of the state. This ‘attractiveness’ of a
stewardship approach may be a realistic (and achievable) possibility to channel fresh and emerging systems of
integrated care in more socially responsible ways.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
Stewardship in Nursing.

The leadership potential of stewardship in nursing requires new models of delivery of care, and we need to
address the ever-changing nature of the work of a nurse. With evolving new roles in the nursing profession,
collaboration with nursing research colleagues will be required to develop mechanisms of evaluation and
assessment which further refine evidence that supports the essential and exclusive contributions of the
professional nurse in outcomes of care and prevention. Development and enhancement of the evidence in
research call for nursing stewards who will embark on such issues to design new financial models in order to
constantly build the business side of nursing care delivery models. Such leadership will become synergistic with
the work in the area of stewardship of the health care system.

Areas for dialogue may be within:

• patient-population centeredness

• safety for patients and health care personnel

• the needs of an ageing workforce

• increased autonomy for advanced nurse practitioners

• increased respect for the contributions made by professional nurses

• clarification of the caring work of the nurse, and

• enhancement of the collaborative practice of the multidisciplinary health care team.

Lastly, but perhaps most importantly, an opportunity for nursing stewardship lies in the regulatory and
accreditation aspects of the profession. Nurse leaders or stewards are finding themselves collaborating with
regulatory boards to improve on standards of practice, certification and accreditation, thus ensuring that
standards and regulations support the nurse of the future and new models of care delivery, and remain true to a
patient/population-centered health care system.

Another aspect is for nurse leaders or stewards to influence decision-making at the point of service. An
‘invigorating’ nurse leader or steward is urgently needed. Nurses creating health care environments that uphold
value-based nursing practice by acknowledging that who one is – one’s moral character – is essential for
leadership. Nurse leaders or stewards need to engage with how this is to be done, utilizing character, dialogue
and shared meanings and values.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
Stewardship to Self/Personal

To meet the domains of stewardship in health care and the nursing profession, it is crucial that nurse leaders
engage with the development of self. Succession planning to develop and nurture a new generation of
transformational nurse leaders may be the only way to achieve this. To meet the concept of lifelong learning,
nurse leaders or stewards will need to use of mentors and personal coaches to assist them in refining skills and
improving competencies. Healthy nurse leader stewards will thus become visible and sound role models within
their institutions to maintain the balance between self and professional fulfilment.

The future of nursing is rapidly changing. Things are somewhat chaotic at times, but the opportunities for
stewardship are many and varied. We are ideally suited to serve as nurse leaders or stewards in all aspects of
health care. By embracing the six aims of health care improvement, the leadership of nursing can be both
invigorating and transformational.

Stewardship to the Environment / Ecology

The healthcare industry, like all other industries has an ecological footprint. That footprint affects the environment,
which in turn, affects health of the individuals, families, and communities. The ecological problem is a global and
a local problem. Increased risk of water and vector borne illness due to flooding and water contamination.
Respiratory illnesses brought on or exacerbated by ongoing air pollution from fumes of vehicles and factories. The
physical, mental, and emotional strain of homes and entire communities being destroyed by natural disasters.
These are growing concerns for the healthcare force who work to improve health and well-being. Increasingly,
providers are evaluating the way the health systems functions so that the practices do not undermine the care
being delivered.

Current health practices contribute to a large portion of the country’s energy consumption and pollution emissions.
Though nurses and other healthcare providers have made efforts to develop and participate in programs that
recycle, manage waste, conserve energy and water, and promote renewable energy, there is still work to be done.

Future nurse leaders or stewards will be directly centered on working with nurse practitioners and nurse educators
to transform the practice environments in which they work. The intended outcome is to make practice
environments more positive, healthy and engaging.

The discipline of Nursing recognizes that increasing environmental health literacy and leadership among the
future nursing workforce is a proven way to improve public health outcomes. That is why the nursing discipline
provides educational opportunities both in and out of the classroom.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
The power of Nurses and other healthcare practitioners as environmental stewards are to train to advocate for
health, communicate risk, and manage complex systems. It is through these essential roles that is needed to be
ideally placed to influence public health, clinical care, emergency services to reduce and respond to the health
effects of environmental issues. Taking action, nurses should become environmental health advocates in their own
practices and communities.

2. THE PRINCIPLE OF TOTALITY AND INTEGRITY

Totality and integrity are additional ethical principles. Totality and integrity suggest that the entire patient should
be considered when planning care. This is important where serious side effects may be associated with a
treatment, despite the potential to relieve certain symptoms or alter the management course.

The roots of the principle of totality are spread through the writings of Aristotle and Thomas Aquinas. The
principle of totality presupposes that "parts exist for the whole. The good of the part is subordinated to the good
of the whole; the whole is the determining factor for the part and can dispose of its own interest. Aristotle puts it
briefly as totum quam parte, prius esse necesse. The main notions on which the principle grounds itself are "the
whole, the part, and their mutual relationships.

A simple expression of the principle of totality means, "the parts of the physical entity, as parts, are ordained to the
good of the physical whole." From the medical perspective, the principle of totality would mean that "all the parts
of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally
subordinated to the good of the whole body." The term "totality" points to the duty to preserve intact the physical
component of that integrated whole.

The Principle of Totality and the Justification of Mutilation by Thomas: Moreover, with regard to the
justification of mutilation, Thomas brings the principle of totality under the topic "injuries to the person." He raises
the following question: "Is it ever legitimate to mutilate somebody?" Thomas answers from two perspectives, viz.,
penal and medical. With regard to medical mutilation, he observes:

an organ that is endangering an individual's whole body may legitimately be removed by his own consent for the
sake of the well-being of the body as a whole, since each individual is responsible for the well-being of his body
as a whole. And the same reasoning applies where it is somebody else's responsibility to look after the person
with the infected organ. In any other case it is wrong to mutilate another.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
 Hence, one may conclude that mutilation is licit according to Thomas when it is necessary for the good of the
entire body. Concerning penal amputation, Thomas never justifies mutilation against innocent persons. Thomas
observes that individual life is greater than "any component good of that life" and hence the former should not be
subordinated to the latter. So only those who are entrusted with the good of the community can deprive the
individual of his life.

Finally, there are three basic elements that justify mutilation in the teachings of Thomas.
1) Mutilation is justified for the well-being of the whole body.
2) It is not against the role of the human person as the protector of his/her body. This is done on the basis of a
human person's limited power over his/her body for the betterment of whole body.
3) Mutilation in the form of penalty for a crime can be done by the state.

As a whole, the application of the principle of totality by a human person depends on the principle of God's
domination over man/woman. A person's right to mutilate parts of his/her body for the well-being of the whole is
the protective responsibility of the human person over his/her life. Thomas did not develop particular limitations on
human person's right to use his/her body or, more clearly, the right of the whole's domination over the part.

§ ETHICO-MORAL RESPONSIBILITIES OF A NURSE IN SURGERY

Perioperative nurses are obligated morally to respect the dignity and worth of individual patients. Perioperative
nursing care must be provided in a manner that preserves and protects patient autonomy and human rights. Nurses
have an obligation to be knowledgeable about the moral and legal rights of their patients and to protect and support
those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account both
individual rights and interdependence in decision making. By doing so, nurses can recognize situations in which
individual rights to self- determination in health care temporarily should be overridden to preserve the life of the
human community. For example, during a bioterrorism attack, victims infected with transmissible organisms (e.g.
small pox) require infection control measures to prevent transmission to others. These infection control measures
may require isolation, resulting in restricting a patient's right to freedom of movement to protect others.

Perioperative nurses preserve and protect their patients' autonomy, dignity, and human rights with specific nursing
interventions, including supporting a patient's participation in decision making, confirming informed consent, and
implementing facility advance directive policies. Perioperative nurses explain procedures and the OR environment
before initiating actions, and they respect patients' wishes in regard to advance directives and end-of-life choices.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
Perioperative nurses help patients make choices within their scope of care as applicable. They also provide
patients with honest and accurate answers to their questions, especially related to perioperative teaching, and
formulate ethical decisions with help from available resources (e.g. ethics committee, counselors, ethicists).
Patients have the right to self-determination (i.e. the ability to decide for oneself what course of action will be taken
in various circumstances).

The nurse, as a moral agent for the patient, must be ready and able to advocate for the patient's rights and needs
whenever necessary while providing care. Assuming such a stance involves acting on ethical principles and values.
Nurses must be prepared to identify advocacy issues and take action on them as needed. The nurse-patient
relationship not only allows the nurse to support the patient, but it also supports the nurse. Nurses can empower
patients by providing opportunities for them to make autonomous decisions about their health care. They can
support patient empowerment through education about appropriate administrative protocols (e.g. patients' rights,
hospital policies, procedures) that best meet individual patient's needs. When dealing with informed consent, the
nurse's role is to validate that the patient has been given the information and understands as much as is possible
about the surgical intervention. The nurse's assessment includes determining whether the patient has any
additional questions that might require another discussion with the physician. The nurse also assesses the level
of decision making the patient is able to demonstrate.

The principle of autonomy provides for patients to make decisions freely, even if those decisions are against
medical advice. The criterion that must be met is that the patient is an adult who is capable of making decisions
and has been given the information necessary to make an autonomous choice. Even if a surgeon and nurse believe
that surgery is in the best interest of the patient, the patient has the right to refuse the procedure at any time,
regardless of whether he or she signed a surgical consent form. Nurses ethically should support patients in their
choices, regardless of whether they agree with the patient's decision. Nursing assessment and care also applies
to situations in which patients identify advance directive choices or decisions related to do-not-resuscitate orders.
It is the nurse's role to ensure that surgical team members are aware of a patient's wishes in these matters. It is
important that all team members and the patient discuss and identify a plan of care before beginning the surgical
procedure.

§ STERILIZATION

A medical or surgical intervention which is performed in the patient, man or woman, incapacity for generation,
whether organic or functional, temporary, or permanent.

The technical forms of sterilization are morally indifferent, i.e., they merit the same moral judgement, except for
circumstantially greater gravity or irreversibility.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
The key to a clear view of morality of sterilization lies in knowing how to distinguish direct sterilization which is
intrinsically wrong from that is indirect or therapeutic.

Therapeutic Sterilization

This is sterilization which is inevitably required by and for the health or survival of the person. It is ruled by the
principle of totality, for the sexual organs are, like any other body organs, integrating parts must yield to the good
of the whole. Hence, within the scope of the principle we are invoking, it is licit if the following conditions are
present.

A. the sickness must be so grave, properly diagnosed and definitive that it offsets the evil of sterilization. The
gravity must be actual at least in the sense of casual;

B. the sterilization must be necessary because it is the most and only effective remedy, either the sexual organs
are diseased or because, although they are healthy, they could with their normal hormonal functioning damage
another part of the organ.
In the hypothesis of healthy sexual organs, it is essential for the correct application of the principle of totality – so
that sterilization will be therapeutic- that they really, in a causal way, have a direct or indirect effect on the disease
of other organ functions; and

C. it is also necessary that the purpose be exclusively curative, tolerating the sterilization as an indispensable
means. The insincerity of this intention is what determines the morality of action if it is carried out according to
preceding conditions.

Methods of Sterilization

1. Tubal Sterilization (Salphingectomy) consist of ligation or electrocoagulation of both the fallopian tubes. It is
highly an effective contraceptive method. It is usually irreversible, although there are techniques of recanalization.

2. Vasectomy in males refers to bilateral ligation of the vas deferens which impedes the passage of spermatocytes.

The church condemns contraception, sterilization, and abortion.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
 § PRESERVATION OF BODILY FUNCTIONAL INTEGRITY

The principle of bodily integrity sums up the right of each human being, including children, to autonomy and self-
determination over their own body. It considers an unconsented physical intrusion as a human rights violation.

While the principle has traditionally been raised in connection with practices such as torture, inhumane treatment
and forced disappearance, bodily integrity has the potential to apply to wide range of human rights violations, which
also affect children’s civil rights.

Practices which violate a child's bodily integrity include all forms of physical violence, ranging from corporal
punishment to forced medical treatment, sometimes against a child's express wishes. Non-therapeutic and
unconsented surgeries are also violations of bodily integrity, and include practices such as 'corrective' genital
surgery performed on intersex children, gender reassignment surgery, female genital mutilation, routine
circumcision of male infants and boys, and the sterilization of people with learning disabilities.

Children are especially vulnerable to such practices, as these are usually performed on people at a very young
age when they are unable to speak up for and defend themselves, or give - or refuse - consent.

§ ISSUES ON ORGAN DONATION AND ETHICAL CONSIDERATIONS IN LIVING DONATION

The demand for solid organs far exceeds the number of organs available from diseased donors. Not surprisingly,
instead of facing years on the transplantation waiting list, some patients, often with the encouragement of
transplantation teams, seek to identify relatives or others who would be willing to donate the needed organ or
partial organ directly or, in some cases, through the donor exchange program. Still donors offer a kidney or a partial
organ to patients whose stories have become known to them, perhaps though media, whereas still others make a
non-directed donation of a kidney to the transplantation system for use by any patient who needs it.

Organ donation by living donors clearly save lives, improves transplantation outcomes under some circumstances,
and reduces recipients’ waiting time. It also offers the opportunities for patients without living donors to receive
organs from deceased donors. However, it raises a series of ethical questions that have been fully addressed.

The transplantation of organs from living donors seems to violate the traditional first rule of medicine – primum non
nocere (above all, do no harm) – because it involves the removal of a healthy organ from one person for
implantation to another person. One person becomes a patient to benefit another person who is already a patient.

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
The first successful organ transplantations involved living donors. In 1954, surgeons at Peter Brent Brigham
Hospital in Boston removed a kidney from a young man and implanted it in his identical twin brother (Meriil et al,
1956).

Through the 1960s developments in transplantation technology enabled kidney transplantation to evolve into a
viable alternative to hemodialysis (Surman, et al, 2005). As developments in immunosuppressive medication
allowed the use of organs from unrelated deceased donors – at first from individuals declared dead by the use of
neurologic criteria and subsequently from individuals declared dead by the use of neurologic criteria – it also
expanded from pool of potential donors of kidneys (Abecassis et al, 2000). Transplant centers initially allowed only
genetically related family members to donate kidneys. Over the years, however, more and more patients have
received kidneys from emotionally related donors (those who do not have a genetic link to the donor but who are
nevertheless close, e.g. spouses and friends), from acquaintances, and even from altruistic strangers (those who
are not currently known by the recipient).

3. THE PRINCIPLE OF ORDINARY AND EXTRA ORDINARY MEANS

Ordinary means reasonable hope of benefit/ success; not overly bothersome; does not present an excessive risk
and are financially manageable; Proportionate to the state of the patient.

Extra ordinary means no reasonable hope of benefits/ success; overly bothersome; excessive risk and are
financially manageable; No obligation to use it/ or morally optional.

Francisco De Vitoria (1486–1546) “If a sick man can take food or nourishment with a certain hope of life, he is
required to take food as he would be required to give it to one who is sick. However, if the depression of spirits is
so severe and there is present grave consternation in the appetitive power so that only with the greatest effort
and as though through torture can the sick man take food, this is to be reckoned as an impossibility and
therefore, he is excused, at least from mortal sin”

Elements of Ordinary Means

In sum: what is reasonable?

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta
4. THE PRINCIPLE OF PERSONALIZED SEXUALITY

Personal sexuality is based on an understanding of sexuality is based on an understanding of sexuality as one of

Genuine Christian teaching on sexuality is clear enough in the scriptures. Genesis 1-3 teaches that God created
all persons as male and female and blessed their sexuality as a great and good gift. Jesus confirmed this
teaching and perfected it by affirming that men must be faithful in marriage as women (Mark 10:2-21;1Cor7:10).
Nevertheless, Jesus also taught that although sexuality is a great gift, its use in marriage is only or relative value,
which can be freely sacrificed for the sake of higher values, “for the good of the Kingdom”. Thus, for the
Christian, the celibate or single life, with its freedom from domestic cares to be of service to others, can be
personally mature and fulfilling as married life (1Cor 7:25-35).

In the Jewish-Christian tradition, which is based on the first chapters of Genesis, human sexuality is always seen
in relation to the family as the basic community into which are born and educated and on which the larger
community is built. Hence, sexuality is not only a private matter, although it involves the most intimate
relationships. It also concerns the common good of society and requires its public support and defense as basic
social institution.

The principle of personalized sexuality may be stated as follows. The gift of human sexuality must be used in
marriage in keeping its intrinsic, indivisible, specifically human teleology, it should be loving, bodily expression of
complimentary, permanent self-giving of a man and woman to each other, which is open to fruition the
perpetuation and expansion of this personal communion through the family they beget and educate.

References:
Ciabal, Laura Evelyn, 2001. Health Ethics. First Edition. Educational Publishing House.
http://www.sajcc.org.za/index.php/SAJCC/article/view/125/130
https://nursing.wisc.edu/sustainable-nursing-putting-environmental-stewardship-to-practice/
https://nursinganswers.net/lectures/nursing/professional-values
https://epublications.marquette.edu/cgi/viewcontent.cgi?article
https://archive.crin.org/en/home/what-we-do/policy/bodily-integrity.html
https://www.nap.edu/read/11643/chapter/11#264
http://www.beaumont.ie/media/OrdinaryandExtraordinaryTreatment1.pdf
http://docshare02.docshare.tips/files/3859/38592041.pdf

NCM 108 Module 1 E 1st semester 2020-2021 Dr. Gie Bautista Camarinta