BIOETHICS: Class Notes For Class Discussion use ONLY not for reference

Second Semester SY 2022-2023

Notes in BIOETHICS: For Class use ONLY

A. What is Ethics? What is Morality? What is BioEthics?

Ethics - Derived from the Greek word “ethos”, which means “way of living”, ethics is a
branch of philosophy that is concerned with human conduct, more specifically the
behaviour of individuals in society.
Morality - Morality is a system or set of ideas about right vs. wrong and good vs. evil
behavior; it is subjective rather than objective, and is part of the philosophical study of
ethics.

Ethics is a branch of philosophy that “involves systematising, defending, and

recommending concepts of right and wrong behaviour. Morality can be a body of
standards or principles derived from a code of conduct from a particular philosophy,
religion, or culture.

Bioethics - branch of applied ethics that studies the philosophical, social, and legal issues
arising in medicine and the life sciences

B. Ethical Theories
1. Deontology
2. Teleology
3. Utilitarianism
4. Natural Law Ethics
5. Virtue Ethics
C. Persons as Moral beings:
1. Person as a Rational Animal
2. Person as Free (Absolute or Determined)
3. Person as a willed-being
4. Person as a cross-point
5. Person as a moral decision-maker (Personal decision=moral decision)

Notes: To make proper ethical decisions, one must develop a “Well-formed

conscience”; this requires us to:
1) Inform ourselves of the ethical norms;
2) Reflect on this information, form a moral judgment;
3) Act according to our well-formed conscience, and
4) Accept responsibility for our actions.
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Second Semester SY 2022-2023
D. Ethical Principles

Ethical issues are commonly examined in terms of a number of ethical principles Ethical
principles are basic and obvious moral truths that guide deliberation and action. Major
ethical theories utilize many of the same principles, though either the emphasis or meaning
may be somewhat different in each. For example, respect for autonomy is a dominant
principle in deontological theory but is less important in utilitarian theory. It is vital for
nurses to understand ethical principles and be adept at applying them in a meaningful and
consistent manner.

1. Autonomy - autonomy means having the capacity to self-govern, which is the ability to
act independently, responsibly and with conviction. This concept of autonomy relies on
the agency of a moral being to exercise his/her own decisions about his/her being. From
the Latin Word Autos and Nomos or Self-rule.

In medical practice, autonomy is usually expressed as the right of competent adults to

make informed decisions about their own medical care. The principle underlies the
requirement to seek the consent or informed agreement of the patient before any
investigation or treatment takes place. The principle is perhaps seen at its most
forcible when patients exercise their autonomy by refusing life-sustaining treatment.

 Patients’ Rights
 Informed Consent
 Proxy consent/Legally Accepted representative
 Confidentiality
 Privacy
2. Confidentiality- Confidentiality is one of the core duties of medical practice. It requires
health care providers to keep a patient’s personal health information private unless
consent to release the information is provided by the patient. Respecting patient
confidentiality is an essential part of good care; this applies when the patient is a child or
young person as well as when the patient is an adult. Without the trust that confidentiality
brings, children and young people might not seek medical care and advice, or they might
not tell you all the facts needed to provide good care
3. Veracity - The principle of veracity, or truth telling, requires that healthcare providers be
honest in their interactions with patients. “Traditional ethics holds that it is simply wrong
morally to lie to people, even if it is expedient to do so, even if a better outcome will come
from the lie.
4. Fidelity- Fidelity addresses a person's responsibility to be loyal and truthful in their
relationships with others. It also includes promise keeping, fulfilling commitments, and
trustworthiness (Welfel and Kitchener 1992). Patient-Client relationship.
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Second Semester SY 2022-2023
The ethical principle of fidelity relates to the concept of faithfulness and the practice of
keeping promises. Society has granted nurses the right to practice nursing through the
processes of licensure and certification. “The authority for the practice of nursing is based
on a social contract that acknowledges professional rights and responsibilities as well as
mechanisms for public accountability” (ANA, 1995, p. 3).

The process of licensure is one that ensures no other group can practice within the domain
of nursing as defined by society and the profession. Thus, to accept licensure and become
legitimate members of the profession mandates that nurses uphold the responsibilities
inherent in the contract with society. Members are called to be faithful to the society that
grants the right to practice—to keep the promise of upholding the profession’s code of
ethics, to practice within the established scope of practice and definition of nursing, to
remain competent in practice, to abide by the policies of employing institutions, and to
keep promises to individual patients. To be a nurse is to make these promises. In fulfilling
this contract with society, nurses are responsible to faithfully and consistently adhere to
these basic principles.

5. Justice - in the context of medical ethics – is the principle that when weighing up if
something is ethical or not, we have to think about whether it's compatible with the law,
the patient's rights, and if it's fair and balanced. Kinds: distributive (determining who gets
what), procedural (determining how fairly people are treated), retributive (based on
punishment for wrong-doing) and restorative (which tries to restore relationships to
"rightness.")

Justice is the ethical principle that relates to fair, equitable, and appropriate treatment in
light of what is due or owed to persons, recognizing that giving things to some will deny
receipt to others who might otherwise have received those things. Within the context of
health care ethics, the most relevant application of the principle focuses on distribution of
goods and services. This application is called distributive justice. Unfortunately, there is a
finite supply of goods and services, and it is impossible for all people to have everything
they might want or need.

One of the primary purposes of governing systems is to formulate and enforce policies that
deal with fair and equitable distribution of scarce resources. Decisions about distributive
justice are made on a variety of levels. The government is responsible for deciding policy
about broad public health access issues, such as children’s immunization and Medicare for
the elderly. Hospitals and other organizations formulate policy on an institutional level and
deal with issues such as how decisions will be made concerning who will occupy intensive
care beds and which types of patients will be accepted in emergency rooms. Nurses and
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Second Semester SY 2022-2023
other health care providers frequently make decisions of distributive justice on an
individual basis.

For example, having assessed the needs of patients, nurses decide how best to allocate their
time (a scarce resource). There are three basic areas of health care that are relevant to
questions of distributive justice. First, what percentage of our resources is it reasonable to
spend on health care? Second, recognizing that health care resources are limited, which
aspects of health care should receive the most resources? Third, which patients should
have access to the limited health care staff, equipment, and so forth (Jameton, 1984)? In
making decisions of distributive justice, one must ask the question, “Who is entitled to
these goods or services?” Philosophers have suggested a number of different ways to
choose among people.

6. Beneficence - beneficence is understood as a principle requiring that physicians provide,

and to the best of their ability, positive benefits such as good health, prevent and remove
harmful conditions from patients.

The principle of beneficence means to do good. It requires nurses to act in ways that
benefit patients. Beneficent acts are morally and legally demanded by the professional role
(Beauchamp & Walters, 2007). The objective of beneficence provides nursing’s context and
justification. It lays the groundwork for the trust that society places in the nursing
profession, and the trust that individuals place in particular nurses or health care agencies.
Perhaps this principle seems straightforward, but it is actually very complex. As we think
about beneficence, certain questions arise: How do we define beneficence—what is good?
Should we determine what is good by subjective, or by objective, means? When people
disagree about what is good, whose opinion counts? Is beneficence an absolute obligation
and, if so, how far does our obligation extend? Does the trend toward unbridled patient
autonomy outweigh obligations of beneficence? Veatch (2002) asks whether the goal is
really to promote the total well-being of the patient or to promote only the medical well-
being of the patient. We must keep these questions in mind as we practice.

The ethical principle of beneficence has three major components: do or promote good,
prevent harm, and remove evil or harm. Beneficence requires that we do or promote good
(Beauchamp & Childress, 2008). Even with the recognition that good might be defined in a
number of ways, it seems safe to assume that the intention of nurses in general is to do
good. Questions arise when those involved in a situation cannot decide what is good. For
example, consider the case of a patient who is in the process of a lingering, painful, terminal
illness. There are those who believe that life is sacred and should be preserved at all costs.
Others believe that a natural and peaceful death is preferable to an extended life of pain
and dependence. The definition of good in any particular case will determine, at least in
part, the action that is to be taken. The principle of beneficence also requires us to prevent
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Second Semester SY 2022-2023
or remove harm (Beauchamp & Childress, 2008). In fact, some believe that doing no harm,
and preventing or removing harm, is more imperative than doing good.

All codes of nursing ethics require us to prevent or remove harm. For example, the
International Council of Nurses (ICN) Code of Ethics for Nurses (2006) says, “The nurse
takes appropriate action to safeguard individuals, families and communities when their
care is endangered by a co-worker or any other person.” Similarly, the Canadian Nurses
Association (CNA) Code of Ethics for Registered Nurses (2008) says, “Nurses question and
intervene to address unsafe, non-compassionate, unethical or incompetent practice or
conditions that interfere with their ability to provide safe, compassionate, competent and
ethical care to those to whom they are providing care, and they support those who do the
same”

7. Non-Maleficence - states that a medical practitioner has a duty to do no harm or allow

harm to be caused to a patient through neglect. Any consideration of beneficence is likely,
therefore, to involve an examination of non-maleficence.

The principle of nonmaleficence is related to beneficence. Whereas beneficence requires us

to prevent or remove harm, nonmaleficence requires us to avoid actually causing harm.
Included in this principle are deliberate harm, risk of harm, and harm that occurs during
the performance of beneficial acts. Most ethicists today tend toward the Hippocratic
tradition that says to first do no harm (the principle of nonmaleficence), placing this
principle above all others. It is obvious that we must not commit acts that cause deliberate
harm. This principle prohibits, for example, experimental research when it is fairly certain
that participants will be harmed, and the performance of unnecessary procedures for
economic gain or solely as a learning experience.

Non maleficence also means avoiding harm as a consequence of doing good. In such cases,
the harm must be weighed against the expected benefit. For example, sticking a child with a
needle for the purpose of causing pain is always bad—there is no benefit. Giving an
immunization, on the other hand, while causing similar pain, results in the benefit of
protecting the child from serious disease. The harm caused by the pain of the injection is
easily outweighed by the benefit of the vaccine.

In day-to-day practice, we encounter many situations in which the distinction is less clear,
either because the harm may appear to be equal to the benefit gained, because the outcome
of a particular therapy cannot be assured, or as a result of conflicting beliefs and values. For
example, consider analgesia for patients with painful terminal illness. Narcotic analgesia
may be the only type of medication that will relieve very severe pain. This medication,
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Second Semester SY 2022-2023
however, may result in dependence and can hasten death when given in amounts required
to relieve pain.

8. Principle of double effect - This principle aims to provide specific guidelines for
determining when it is morally permissible to perform an action in pursuit of a good end in
full knowledge that the action will also bring about bad results.

A person may licitly perform an action that he foresees will produce a good effect and a bad
effect provided that four conditions are verified at one and the same time:

1. that the action in itself from its very object be good or at least indifferent;
2. that the good effect and not the evil effect be intended;
3. that the good effect be not produced by means of the evil effect;
4. that there be a proportionately grave reason for permitting the evil effect”
In another perspective - The first principle that proposes to distinguish between a good
and an evil is the theory of double effect. Derived from Summa Theologica, the principle has
four key points:

 The act must be good, or at least morally neutral, independent of its consequences.

 The agent intends only the good effects, not the bad effect.

 The bad effect must not be a means to the good effect. If the good effect were to be the
causal result of the bad effect, the agent would intend the bad effect in pursuit of the good
effect

 The good effect must outweigh the bad effect.

The principle of double effect has use in medical ethics when dealing with abortion,
euthanasia, and other decisions where there is a conflict between a good and an evil. For
example, under this view, abortion is an evil, but saving the life of a mother is a good. Under
this view, euthanasia is an evil, but relieving pain by the use of morphine is a good. If the
person dies and the death was not intended, then is it acceptable? Major issues arise in the
application of the theory concerning how to determine a person’s intent.

9. Principle of Legitimate Cooperation - is an application of the Principle of Double Effect to

situations involving cooperation with someone else's actions. The question of the ethical
dilemma of cooperating with the wrongdoing of another (what one considers wrong) is not
just a Christian or Catholic issue.
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Second Semester SY 2022-2023
To achieve a well-formed conscience, one should always judge it unethical to cooperate
formally with an immoral act (that is, directly to intend the evil act itself), but one may
sometimes judge it to be an ethical duty to cooperate materially with an immoral act (that
is, only indirectly intend its harmful consequences) when only in this way can a greater
harm be prevented, provided:
 That the cooperation is not immediate and
 That the degree of cooperation and the danger of scandal are taken into account Types of
cooperation  Formal cooperation - occurs when a person or organization freely
participates in the actions of a principal agent. Implicit formal cooperation occurs when
even though the cooperator denies intending the object of the principal agent , the
cooperator participates in the action.
 Immediate material cooperation - occurs when the cooperator participates in
circumstances that are essential to the commission of an act, such the act could not occur
without this participation. A debate on about duress wherein an act was done at gun point.
 Mediate material cooperation - occurs when the cooperator participates in circumstances
that are not essential to the commission of the action, such that the action could occur even
without cooperation.

10. Principle of the common good and Subsidiarity – The common good is “the sum total of
social conditions which allows people, either as groups or as individuals, to reach their
fulfilment more fully and more easily.” It is about the progress of persons. A society that
wishes and intends to remain at the service of the human being at every level is a society
that has the common good – the good of all people and of the whole person as its primary
goal. We must be interested in the good of all, even of people nobody thinks about because
they have no voice and no power. The goods of the earth are there for everyone. The
common good consists not only of the material or external good of all human beings; it also
includes the comprehensive good of the human being, including even the spiritual good.
Subsidiarity principle is seen where every task of society should be assigned to the smallest
possible group that can perform it. Only if the smaller group is unable to resolve the
problem itself should a group at a higher level assume responsibility. For example, if a
family is experiencing problems, the state can intervene only if the family or the parents
are overburdened and cannot resolve them. It helps to avoid too much centralisation. Being
able to help oneself is an important component of the dignity of the human person.

The principles of “The Common Good” and “Subsidiarity” are based on the dignity and
sanctity of the human person, and the fact that we form an interdependent human
community. Social problems often result from the exclusion of people to share in the
common good: slavery; racism, or any type of oppression or bigotry. Judeo-Christian
bioethics posits a moral obligation for all to contribute to the common good, and the right for
all to share in the common good. Applied to contemporary Judeo-Christian ethics, these
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Second Semester SY 2022-2023
foundational principles require that access to healthcare be based on need—not ability to
pay or merit.

The Principle of Subsidiarity states that responsibility for human needs begins
1) with the individual;
2) the local community, and
3) gradually higher levels of authority as needed.

Competent adults are responsible for making appropriate decisions with regard to
their health, yet those who suffer illness or disability beyond their control, or
children too young to assume responsibility, need support from the community:
parents and family; the local community; employers, government.

In another perspective:
The term the "common good" has been used in various contexts to identify actions or
outcomes that have some definable benefit that extends beyond individual gain. The
common good has been addressed in professional literature pertaining to ethics, political
action, the environment, nursing, and health care. The literature examining the relationship
of the common good to nursing and other health professions mainly cites the common good
as an impetus for action; literature exploring the common good as a concept of use to
nursing and health care is very limited.
However, nursing is viewed as promoting the common good. In addition, the development
of nursing as a discrete profession reflects societal recognition that the constellation of
services provided by nurses is supportive of the common good. Although nursing literature
does not address the common good from a theological perspective, it clearly addresses
related concepts such as concern for the whole person in the community and outcomes
associated with the common good, such as distributive justice. Consistent with the Catholic
perspective of the common good, nursing also addresses the need to balance the
preservation of individual dignity and respect against societal integrity. The "added value"
of the common good to existing nursing concepts may be illustrated by examining instances
of ethical misconduct in clinical research and the evolution of the health care delivery
system.
11. Principle of Stewardship - (1) The principles of stewardship. Life comes from God,
and humans are "stewards" responsible for the care of the body. (2) The inviolability of
human life. Innocent life may never purposefully be taken in actions such as abortion,
suicide, or euthanasia.

This principle is grounded in the presupposition that God has absolute Dominion over
creation, and that, insofar as human beings are made in God’s image and likeness (Imago
Dei), we have been given a limited dominion over creation and are responsible for its care.
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Second Semester SY 2022-2023
The principle requires that the gifts of human life and its natural environment be used with
profound respect for their intrinsic ends.

Accordingly, simply because something can be done does not necessarily mean that
it should be done (the fallacy of the technological imperative). As applied to Catholic-
sponsored health care, the principle of stewardship includes but is not reducible to concern
for scarce resources; rather, it also implies a responsibility to see that the mission of
Catholic health care is carried out as a ministry with its particular commitment to human
dignity and the common good.

 Personal
 Social
 Ecological
 Biomedical

12. Principle of Totality and Integrity - These principles dictate that the well-being of
the whole person must be taken into account in deciding about any therapeutic
intervention or use of technology.

In this context "integrity" refers to each individual’s duty to "preserve a view of the whole
human person in which the values of the intellect, will, conscience, and fraternity are pre-
eminent”. ” Totality" refers to the duty to preserve intact the physical component of the
integrated bodily and spiritual nature of human life, whereby every part of the human body
"exists for the sake of the whole as the imperfect for the sake of the perfect."

Implications to:

 Surgery
 Sterilization/Mutilation
 Preservation of Bodily Functions’ Integrity
 Organ donation

13. Principle of Ordinary and Extraordinary Means -

When are we morally obliged to start or to continue a treatment? When are we morally
obliged to refuse or discontinue a treatment (even if this would lead to death)

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

Elements of Ordinary Means

1) Reasonable/proportionate hope of benefit/success
2) Common diligence
3) Proportionate – physical/social/financial
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Second Semester SY 2022-2023
4) Not unreasonably demanding

• In sum: what is reasonable!

Extraordinary means = no reasonable hope of benefit/success; overly burdensome;

excessive risk and are not financially manageable - No obligation to use it/morally
optional.

Elements of Extraordinary Means

1) “Certain impossibility” – physical or a moral

2) Great effort – excessive
3) Pain
4) Exquisite and extraordinarily expensive
5) Severe dread or revulsion

• In sum: what is inappropriate!

Development in end-of- life- care:

Gerald Kelly (Father of American Medical ethics)

• Ordinary means = “all medicines, treatments, and operations, which offer a reasonable
hope of benefit for the patient and which can be obtained and used without excessive
expense, pain, or other inconvenience”
• Extraordinary means = “all medicines, treatments, and operations, which cannot be
obtained or used without excessive expense, pain, or other inconvenience, or which, if used,
would not offer a reasonable hope of benefit” (Kelly 1957 p. 129).

Pope Pius XII (1957)

• Address to Anaesthetists

• “[…] normally one is held to use only ordinary means – according to circumstances of
persons, places, times and culture – that is to say, means that do not involve any grave
burden for oneself or another” (cited in O’Rourke and Boyle, 1999, p. 280).

• “the doctor, in fact, has no separate or independent right where the patient is concerned.
In general, he can take action only if the patient explicitly or implicitly, directly or
indirectly, gives him permission” (cited in O’Rourke and Boyle, 1999, p. 280).

Case Study:
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Second Semester SY 2022-2023

Central Question: 1) Do you think the means of treatment is ordinary or extraordinary?

Activity: Debate in groups of 3: 1) Susan 2) Health care member 3) Husband or significant

other or family or friend

As a conclusion: The principles “[…] offers patients and doctors, regardless of their
religious orientation, a reasonable and straightforward basis for assessing how much to
strive to keep alive” (Gillon 1986 p. 259). With the role of Dialogue, one could make a moral
decision “For every human problem, there is a solution that is simple, neat, and wrong.” (H.
L. Menckent).

14. Principle of Personalized Sexuality - Sexual health is now considered as one of the
four pillars of health: Physical, Mental, Spiritual and Sexual. Sexual health can be
understood as a set of principles that integrate personal values, ethics, religious beliefs,
cultural norms and unconventional sexual interests or practices. In the Christian
tradition, t takes note of a humanized sexuality, one that represents the fulfillment of
physical and sensual need but also evidenced with love and sacramental mystery. Sex is
a social necessity for the procreation of children and their education in the family so as
to expand the human community and guarantee its future beyond the death of
individual members.
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Basic Concepts in Sexuality

1.Sex is a search for sensual pleasure and satisfaction, releasing physical and psychic
tensions.

2. More profoundly and personally, sex is a search for the contemplation of the human
person through an intimate personal union of love expressed by bodily union. Ordinarily, it
is also conceived as the complementation of the male and female by one another so that
each achieves a more complete humanity.

3.More broadly, sex is a social necessity for the procreation of children and their education
in the family so as to expand the human community and guarantee its future beyond the
death of individual members.

4. Ultimately, sex is a symbolic (sacramental) mystery, somehow revealing the cosmic order.
Principle of Personalized Sexuality The gift of sexuality must be used in keeping with its
intrinsic, indivisible, specifically human teleology. It must be a loving, bodily, pleasurable
expression of the complementary, permanent self-giving of a man and a woman to each
other which is open to fruition in the perpetuation and expansion of this personal
communion through the family they responsibly beget and educate.

Implications:

Fundamentals of Marriage -Man’s cooperation in the creative power of God. Hence, man
becomes God’s co-creator. -Vehicle in the transmission of life and preservation of human
race. -Instrument in the establishment of the human family and its education. Conjugal
Love - Highest expression of union between man and woman -Originates from a supreme
origin, God, Who is Love -Not an effect of chance or product of evolution of unconscious
force. For baptized persons, represents the union of Christ and of the Church.

For moral evaluation: Application of Bioethical Principles

A. On Sexuality and Human Reproduction

 Sex outside marriage
 Homosexuality
 Artificial Family planning (Conception)
 Artificial insemination
 IVF
 Surrogate Motherhood
 What about life of kings (with concubines)
B. Death and Dying Cases
(To be discussed next)