KEY AREAS OF

ETHICAL
CONFLICTS IN
HEALTH CARE
Bioethics of Nursing Practice (CMO 14)
 This course deals with the application of ethico-moral
and legal concepts and principles to issues that affect
the practice of nursing.
 These provide the basis for appropriate decision
making given varied situations, to prepare the learner
to render effective, efficient and safe nursing care.
Furthermore, related learning experiences provide
opportunities to concretize commitment to nursing.
The critical thinking process shall be used in the unit
with the objective of developing the intellectual
capacity to conceptualize and contextualize what
students know about particular ethico-moral and legal
issues.
 Code of Ethics
 The “Code of Ethics for Nurses” BON
Resolution 220 series 2004- provides
guidance for carrying out nursing
responsibilities consistent with the ethical
obligations of the profession

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 ETHICS
• DECLARATION OF R/W- PROCESS ORIENTED,
INVOLVES CRITICAL ANALYSIS OF ACTION-
REFLECTS THE “SHOULD” OF HUMAN BEHAVIOR.

• STUDY OF MORAL CONDUCT OR PRINCIPLES OF

UNDERLYING DESIRABLE TYPES OF HUMAN
CONDUCT.

 SCIENCE OF IDEALS – GUIDES OUR JUDGEMENT

CONCERNING MORALITY OF HUMAN ACTS.
 MORALS
 REFERS TO HUMAN CONDUCT ITSELF-
APPLICATION OF ETHICS.

•FUNDAMENTAL STANDARDS OF R/W

THAT AN INDIVIDUAL LEARNS AND
INTERNALIZES
•USUALLY DURING EARLY STAGES OF
CHILDHOOD DEVT
•REFLECTS WHAT IS DONE IN A SITUATION
WHY STUDY ETHICS?
 WHY STUDY ETHICS?
ETHICS DETERMINE:
 WHYONE ACT IS BETTER THAN THE
OTHER.
 TO HAVE AN ORDERLY SOCIAL LIFE
 ETHICAL CONCERNS IN
HEALTHCARE
 CONFIDENTIALITY  RIGHT TO REFUSE
OF RECORDS TREATMENT
 RIGHT TO PRIVACY  TERMINATION OF
 RIGHT TO TREATMENT
INFORMATION  QUALITY OF
 COMPETENT SERVICE
CONSENT TO PROVIDED FOR
TREATMENT DISABLED OR
TERMINAL
PATIENTS
 ETHICS COMMITEE

 Issues of patient care that presents as

ethical dilemmas
 The institution’s ability to protect the rights
and interests of clients in general
 The development of institutional policies
and educational programs on ethical issues
 Theories of Ethics
 Utilitarianism- telos- “end”
- right action is that which has the greatest utility
and no action is in itself either good or bad
- consequentialism- action is judged as good or
bad in relation to the consequence, outcome or
end that is derived from it
- “the end justifies the means”- sometimes it is
possible to do wrong to achieve “right”
- the only right action are those that produce the
greatest happiness to all concerned
 Utilitarianism
- Concerned with the consequences or end
product of our actions. An action is right if it
brings increased happiness or benefit for those
concerned; an action is wrong if it decreases
people’s happiness or benefit
- “Primary responsibility is to support the interest
of the group”
- Mass immunization of children- voluntary or
involuntary
- Random drug testing for hospital workers
 Advantages:
- easy to use
- can justify many decisions based on the
happiness principle
 Disadvantages:
- average happiness of all or total
happiness for few
- harm can be done to the minority
- what constitutes happiness? Who
determines what is good?
- end justifies the means
 Deontology- “duty”- “duty oriented”
- rationalist view that the rightness or wrongness
of an act depends upon the nature of the act
rather than the consequences that occur as a
result of it
- human beings have the freedom,
thoughtfulness and sensibility to act in a moral
manner- knows what he/she ought to do
- Respect for person worth/dignity
- Person’s action right if it follow moral rules-fair,
honest, doing good
- A person’s action is wrong, without exception,
if it violates these rules
- Consequences (-), action still ethically right if
the original motive is consistent with moral
precepts
-Kantianism- “ One treats others always as ends
and never as a means” – respect for person-
making a person’s end your own- treating others
the same way you treat yourself
- Nurses code of ethics- importance of fulfilling
duties that are inherently owed to patients
Example:
If the client asks the nurse to promise to tell
the truth regarding her diagnosis and prognosis,
the nurse is duty bound to keep this promise.
 Advantages
- provides clear guidelines for judging the
rightness and wrongness of an act
- recognizes the dignity and autonomy of
individuals and allows all people equal
consideration
 Disadvantages
- problem with disregard for consequences
- all ethical precepts are viewed as equally
important
- exceptionless and rigid
 Case
A 13 year old girl tells the nurse caring for
her in a family practice clinic that she
suspects that she has contracted a STD.
She says that she is afraid to tell her
mother that she is sexually active. After
the interview, the girl’s mother takes the
nurse aside and inquires about the nature
of her daughter’s concern.
 Ethical problems in
Nursing Practice
 Those which include reference to
the nurse’s particular position
within the social and hierarchical
structure of the employment
setting
 Nurse’s role in ethical decision
making
 Roles of a Nurse
 Hospital Employee
 Patient Advocate
 Medical Team
Member
 Nursing
Professional
Ethical problems brought about
by the different roles of nurses
 Role conflict
 Professional loyalty
 Personal Conscience
 Obedience and Dissent
 Coercion
Practicing Nurses may come in
conflict with others.
an employee of health care
institution; occupy a position
within a bureaucratic chain of
command, accountable not only
to their patients, but also to the
administrative hierarchy within
the institution as
 Ethical Dilemmas for Nurses:
Physician’s orders vs Patient’s Rights
1. Should nurses follow physician’s orders
when:
a. They have good reasons to believe
that the orders are mistaken
b. The physician refuse to admit that he
might be mistaken
c. Following orders my jeopardize
patient’s safety or well-being
 Ethical dilemmas for Nurses:
Physician’s Orders vs Patient’s Rights
2. What should nurses do if they
have good reasons to believe that
physicians are violating their
patient’s rights to self-
determination.
Nursing Dilemmas and Patient’s
Right of Self-Determination

 Consent for Surgery

 DNR orders
 Truth telling
 “One moral problem for any
ethical theory is what an
individual’s moral obligations are
when the person feels an act is
wrong, but that act has been
ordered by someone else”

Robert Veach
As hospital employees, nurses
are obliged to abide by the
institution’s policies and rules,
many of which have been
established by others with
limited input from nurses at the
staff level.
 Whatif a nurse finds
herself in basic
disagreement with a
hospital policy because in a
given situation it may
deprive the patient of his
human rights or dignity?
What is a nurse to do when she has
reason to believe that a patient’s
rights are being violated due to
any number of factors such as
inadequate staffing, lack of
informed consent, negligence or
incompetence?
 This is a case of a Siamese twins
with anomalies ; born in a hospital in
Illinois. After the birth of the twins the
physician allegedly gave orders not
to feed them, in accordance with the
wishes of the parents. A staff nurse
not only questioned the order but told
the physician that a number of other
nurses on the unit were also
concerned.
 Does the moral
obligation to protect
patient’s rights override
any duty she may have
to her employer?
 When faced with a situation of
moral conflicts will the nurse
weigh alternative solutions in
terms of the consequences to
herself rather than in terms of
justice to the individual patient?
•Because of the nurse’s
subordinate position within the
organizational system she will
tend to resolve situations of
moral conflict by doing what is
expedient rather than that might
be in the best interest of the
individual patient.
 Such behavior maybe
destructive to nurse’s
individual morality in that it
results in loss of personal
integrity and accountability and
has permitted nurses to
absolve themselves of guilt by
placing blame and
responsibility to others.
 Unlikephysicians, nurses do not have
the same degree of freedom to act on
their own ethical judgments, due to
constraints in their practice
environment that are related to their
status as employees.
 Another major factor which
may constrain ethical action on
the part of the nurse is the
authority of the physician. In
most health care institutions
the medical profession is
dominant. This means that the
majority of the work done by
other occupations that is
related to care of patient is
subject in the order of the
physician.
 Many of the major
decisions made on behalf
of the patient are not
made by the nurse. The
nurse is expected to
follow physicians orders
as they relate to patient’s
medical diagnosis and
treatment plan.
 Occasionally situations do arise
where the nurse has reason to
suspect that a certain order may
be erroneous and could cause
harm to the patient. Under such
circumstances the nurses legally
as well as morally obligated to
question the order. According to
law, a nurse can be held negligent
when she knowingly implements
orders with the knowledge that
theirs implementation will cause
harm to the patient.
 The fact that she is following a
doctor’s order is not in itself a
defense.
 What are the nurse’s rights
when she refuses to carry out
an order that she believes is
morally indefensible? What is
she to do when confronted with
the problem of being expected
to engage practices that violate
her own conscience?
 Nurse’s Code of Ethics
stipulates that obligation to
the patient takes precedence
over the nurse’s duties to
colleagues and employer
 Some solutions to lessen or
avoid Conflicts
 Ifnurses wish to exercise their
professional and moral
responsibilities towards patients and
to be included in ethical decision
making they need to understand
more fully the process of ethical
reasoning and role of ethics in
everyday practice
 Solutions
 Nurses also need to have a clearer
understanding of their own and of what it
means to be truly professional which
includes the giving of oneself to the
service and well-being of others
 Solutions
 We will need nurses who are not only
knowledgeable, articulate and committed but
who will have the courage to stand up for their
moral convictions and the rights of those who
are vulnerable.
 Nurses who will not hesitate to proclaim and
make known their values to others and who will
fearlessly and openly raise questions about any
wrongdoing or injustices that may come to their
attention
 Solutions
 We will need nurse educators who, in their
teachings will move beyond value clarification
toward a consideration of what their values
ought to be; educator who will not hesitate to
convey to students that the so called traditional
values are more than meaningless outdated
platitudes; that a non-judgmental, ethically
neutral stance may actually be an indifference to
what is morally right or wrong; that tolerance
may be a virtue of those who have no
convictions of their own.
 Solutions
 We will need nursing administrators who will
preserve and defend their commitment to quality
patient’s care in the face of diminishing
resources.
 Who will use their influence in developing a
service climate that will allow nurses to act as
responsible moral agents.
 Administrators who will exercise their power and
authority without arrogance or prejudice but with
humility and justice.
 To practice as a human and
humane professional in the
present system is not without
risk or difficulty. Nonetheless to
do otherwise is to betray the
dignity of the profession and the
trust of those who would seek
to come under our care.
RESPECT FOR PERSON

MOST FUNDAMENTAL HUMAN RIGHT

FOUNDATION OF ALL ETHICAL

PRINCIPLES

RESPECTING THE WORTH AND VALUE OF

A PERSON
 PRINCIPLE OF RESPECT

“The human person

ought to be
respected always.”

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 Every human being has an inner worth and inherent
dignity. These he possesses not because of what he has
or what he does but because of what he is: a human
person

 As a human person, he must be respected regardless of

the nature of his health problem, social status,
competence, past actions

 Certain actions may never be done because performing

them would constitute a violation against the person’s
dignity
 Newborn, healthy adult, senile elderly
 Comatose patient, crazy individual
 Illiterate slum dweller, university president,
uneducated housemaid, convicted killer

Are they all persons? Do they have equal

human dignity? How is respect for this
dignity manifest?
 Ethical Principles
 Autonomy
O
 Beneficence
U  Nonmaleficence
T  Veracity
L  Confidentiality
I  Justice

N  Fidelity

E
 AUTONOMY
- Recognizing patients as persons who are
entitled to such basic human rights such
as the right to know, privacy and right to
receive treatment

- ability of a person to make their own

decisions without interference
 Principle of Autonomy
Autonomy- self- governing
- freedom to make choices about issues
that affect one’s life
- Respect for persons; unique and
valuable members of the society
- Free to choose and implement one’s own
decision, free from lies, restraint or
coercion

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 This principle assumes rational thinking on
the part of the individual and may be
challenged when the rights of others are
infringed upon by the individual
Consider this:
What if the patient wants to do something
that will cause harm to him/herself? Under
what circumstances can the healthcare
team intervene?
 PATERNALISM
 Deliberate restriction of people’s autonomy
by health care professionals based on the
idea that they know what’s best for the
clients- can be justifiable at times
 Doinggood should take precedence over
autonomy
 PRINCIPLE OF AUTONOMY
Who gives proxy consent?
1. Power of attorney
2. Closest of kin
Adult- married- spouse, children of major
age
Below 18- parents, grandparents
No spouse- siblings, uncles/aunts
  Advance Directives
 Definition: an advance declaration by a
person of treatment preferences if he or
she is unable to communicate his or her
wishes.
 Living Will
 Durable power of attorney for health
 Health care proxy

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 PRINCIPLE OF AUTONOMY
The doctor can decide:
1. Doctor can act as loco-parentis
2. If it is a matter of life and death
3. Court
E.g. Jehovah’s witness 12 years old
 Autonomy
 Elsa goes to the doctor because she has a
vaginal discharge. She however refuses to
talk about her personal life
 Mia , 16, is afraid of injections and
hospitals. She has acute appendicitis and
needs surgery but she refuses

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 Autonomy
 Carlo, 30 year old Jehovah’s witness is
admitted with massive GI bleeding. The
attending staff tells him blood transfusion
will save his life. He refuses because his
religion does not allow it
 Ernie enjoys listening to music. He plays
his music loud even if his dorm mates are
studying

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 PRINCIPLE OF
INFORMED CONSENT
It is a patient’s right to exercise freedom to
make decisions for his/her health.
Appropriate and necessary information are
required so that medical protocols and
management may be done for his interest.
 PRINCIPLE OF FREE AND
INFORMED CONSENT
To protect the basic need of every human
person for health care and the person’s
primary responsibility for his or her own
health,
(1) no physical or psychological therapy maybe
administered without the free and informed
consent of the patient, or,
(2) if the patient is incompetent, the person’s
legitimate guardian acting for the patient’s
benefit and, as far as possible, in accordance
with the patient’s known and reasonable wishes.
 Elements of Informed Consent
1.Disclosure
2. Understanding
3. Voluntariness
4. Competence
5. Consent
 Informed Consent
 Mikee’s parents chose her career and the
school she is to study in
 Yoly, a 21 year old daughter, is asked to
donate her kidney to her dying mother
 Leah, a 6year old girl, is asked if she
wants her painful tooth pulled out

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 Nazi Experiments (WWII)
 Experiments on twin children in concentration camps were
created to show the similarities and differences in the genetics
and eugenics of twins, as well as to see if the human body
can be unnaturally manipulated.
 Dr. Josef Mengele, who performed experiments on over 1,500
sets of imprisoned twins, of which fewer than 200 individuals
survived the studies.
 The twins were arranged by age and sex and kept in barracks
in between the test, which ranged from the injection of
different chemicals into the eyes of the twins to see if it would
change their colors to literally sewing the twins together in
hopes of creating conjoined twins.

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 Hypothermia Experiments
 In1942 the Luftwaffe conducted
experiments to learn how to treat
hypothermia. One study forced subjects to
endure a tank of ice water for up to three
hours

 Another study placed prisoners naked in

the open for several hours with
temperatures below freezing. The
experimenters assessed
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 Infected Wounds
 July 1942-Sept 1943- experiments to investigate the
effectiveness of sulfonamide, a synthetic antimicrobial
agent, were conducted at Ravensbrück.

 Wounds inflicted on the subjects were infected with

bacteria such as Streptococcus, gas gangrene, and
tetanus. Circulation of blood was interrupted by tying off
blood vessels at both ends of the wound to create a
condition similar to that of a battlefield wound. Infection
was aggravated by forcing wood shavings and ground
glass into the wounds. The infection was treated with
sulfonamide and other drugs to determine their
effectiveness.
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 Tuskegee Syphilis Study
 The Tuskegee Study of Untreated Syphilis
in the Negro Male was a clinical study,
conducted between 1932 and 1972 in
Tuskegee, Alabama, in which 399 (plus
201 control group without syphilis) poor —
and mostly illiterate — African American
sharecroppers were denied treatment for
Syphilis.

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 By the end of the study, only 74 of the test
subjects were still alive. Twenty-eight of
the men had died directly of syphilis, 100
were dead of related complications, 40 of
their wives had been infected, and 19 of
their children had been born with
congenital syphilis.

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 Nuremberg Code
 Nuremberg Code (1947)- foundation of all research
ethics codes
 10 principles
 Voluntary consent, results need to be of good to the
society, animal experiments 1st, avoid unnecessary
physical and mental suffering/ injury, should not be
done if it will cause death/disability
 risk vs benefits, proper preparations and adequate
facilities , only on qualified patients, free to end
participation, researcher must be prepared to
terminate experiment at any time
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 Basic Ethical Principles
 Respect for Persons
- Respect for autonomy and protection of persons with
diminished autonomy

 Beneficence and Non-maleficence

- Maximize benefits and minimize harm

 Justice
- Equitable distribution of both burdens and benefits of
research

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 Medical Research
 Declaration of Helskinski (1964, 1975, 1983,
1989, 1996, 2000, 2008)
- Developed by WMA- guidance to research not
present in Nuremberg Code; for doctors doing
research on their patients
 Belmont Report (1976)
(Medical and Behavioral Research)
- Practice vs Research

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 Principle of Confidentiality
- Requires the non-disclosure of private or
secret information with which one is entrusted
- ICN (2000)- “ the nurse holds in confidence
personal information and uses judgment in
sharing this information”
- An important component of autonomy-
maintains dignity and respect for the person

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 PRINCIPLE OF
CONFIDENTIALITY
The following are subjects of Confidentiality and
should not be revealed to anyone except for
graver cause:
1. Private Secrets
2. Contractual Secrets
3. Professional Secrets
Graver Cause:
1. Personal decision
2. Reportable cause
3. Legal case
 Breaches of Confidentiality
 Computerization of Medical Records
 Access to hospital patient charts
 Patients discussed by colleagues

Mandatory Disclosure
 Communicable disease
 Child abuse and neglect
 Vulnerable adults
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 CASE
A 30 year old married man consults a physician
complaining about his difficulty in
urinating. He attributes this to what he had taken five
days ago when he attended a convention. After
examinations of his blood and urine, he was told that he
has Gonorrhea. He was afraid the his wife might
discover it. So he told the Doctor not to tell anyone,
including his wife for fear the she might leave him. He
loves his wife and family. The wife however, after a
week, asks the doctor as to the condition of her
husband because she was a bit worried why her
husband does not want to make love with her. If you are
the doctor, should you confide to the wife about her
husband’s condition knowing that you know the
obligation attached to the Principle of Confidentiality?
Confidentiality
 BENEFICENCE
 Duty to actively do good for patients
 Primary goal of healthcare is to do good for
patients under their care

Consider this:
- Deciding what interventions should be provided
for patients who are dying when some of those
interventions may cause pain
- Who decides what is good? Patient, family,
nurse, physician? How do you define good?
 Beneficence
This principle may create a duty when the
law doesn’t- Doing something out of duty
at times
 Often conflicts with the principle of
autonomy
 Beneficent act: A nurse prevents a patient
from acting on suicidal impulses
 Good Samaritan Act

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 Beneficence
 Mon, a so-so swimmer, sees Marco
drowning

 Jay brings her lunch to school everyday.

One day, she saw a thin boy watching her
eat. The boy extends his hands asking for
food

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 Non-Maleficence
 Duty to prevent or Avoid Harm Whether
Intentional or Unintentional
 Does not mean avoidance of harm altogether…
avoidance of harm unless the action promises a
greater good
Consider this:
- Is it harmful to accept an assignment to “float” to
an unfamiliar area that requires administration of
unfamiliar medications?
- Is it acceptable to refuse an assignment?
 Non-maleficence
 Different issues on euthanasia,
withholding and withdrawing treatment and
the use of artificial nutrition and hydration

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 Non-maleficence
 Tony has AIDS. He is bedridden and
emaciated. He asks the doctor to give him
medicine to end his life
 Perla has a lump in the breast. When she
consults at a public hospital, the doctor
asks 8 medical students to feel the lump

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 Nino, a 52 year old male is in coma in the ICU
with a massive inoperable intracranial bleed. His
attending physician orders IV fluid, medications,
intubation and respirator support. He talks to the
family to inform them of the poor prognosis and
probability the patient is going to die in 1 week.
The wife insists that all aggressive measures be
done. She has 7 children but no means of
support. What should the doctor do?

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 A. Do as the wife insists

B. If treatment is useless and impose

excessive
burden, recommend stopping the tx

C. Transfer the patient to another MD

D. Transfer patient
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 Principle of Proportionality
 Do all available means have to be used all
the time ?
 How long should these means be used?
 Is treatment effective?
 Will it impose unacceptable burden?

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  Euthanasia & assisted suicide
 Orthothanasia – letting the incurably diseased
person “die his own death’ while making no extra
efforts to prolong his life.
 Passive Euthanasia – refraining of any medical
treatment aimed at retarding death
 Active Euthanasia – terminating a person’s life in
a painless way, at his request & with the intention
to prevent person from suffering
 Dysthanasia- prolonging a person’s suffering

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 Withholding treatment is an act of
omission while withdrawing treatment is an
act of commission.

 Treatment is not only in terms of

medications but also utilization of
equipment, intubation, ventilators and
feeding tubes

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 PRINCIPLE OF BENEFICENCE
AND NON-MALEFICENCE
(Patient Benefit and Avoidance of Harm)

Prologue of Hippocratic Oath

“I will use treatment to help the sick according to my
ability and judgment, but will never use it to injure or
wrong them.”
 JUSTICE

 The duty to treat all patients fairly

 Equal treatment of equal cases and equal

distribution of benefits- no discrimination on
the basis of sex, race, religion, age and
socioeconomic status

 Involves allocation of scarce and expensive

health care resources

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 Justice
Triage- medical screening of patients to
determine their priority of treatment

Finite resources-limited fund, medical

supplies, healthcare services
The needs of everyone, even if its due,
cannot all be served

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 VERACITY
 Duty to tell the truth

 Fundamental to the development and

continuance of trust among human beings-
truth telling, integrity and honesty

Consider this:
 Is lying to a patient ever justified? If a
patient finds out that you have lied to
them, will they have reason to trust you?
 FIDELITY
 Obligation of an individual to be faithful to
commitments to him/herself and also to
others
 Main support for the concept of
accountability
 Keeping information confidential and
maintaining privacy and trust
Consider this:
To whom to do we owe fidelity? Who has
the right to access patient medical
records? When should we “ blow the
whistle” on unsafe staffing patterns?
 Case
 The parents of 9 year old Kevin who is
suffering from a metastatic bone cancer
request that the child not be told of the
illness. Should the attending doctor
comply?

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 Dr. E. Kubler Ross, the question:

“ Should we tell the child?”

 Should not be an issue, rather we should

ask:

“ How do I share this with the patient?”

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 A. The physician should comply
B. Parents should have full decision control
C. The physician knows what is the best for
the child
D. Parents should be allowed considerable
time to accept seriousness of child’s
condition and to be honest to their
children

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Determinants of the Morality
of Human Act
 The ACT itself
 The INTENTION
 CIRCUMSTANCES
 No amount of good intention
or difficult circumstance can
make a wrong action correct.
Basic Axioms of Morality
 Majority opinion is not the norm of
morality
 Widespread custom or the conventional
wisdom is not the norm of morality
 A good end does not justify an evil
means
 If an act is evil by its nature, nothing can
make it good
 We cannot allow our emotions to warp
our moral judgment
 Principle of Double Effect
 Act itself must be morally good or
at least indifferent.
 The motive behind the act must be
to achieve the good effect never the
evil effect, even though it is
foreseen and permitted
 The good effect of the act must
precede the evil effect or at least
simultaneous with it.
 The good effect must be sufficiently
desirable to outweigh the evil effect.
 CASE
Ara M, a 34 year old woman is pregnant,
AOG=24 weeks. During her pregnancy and at her
usual check-up while complaining of some
burning pain in her stomach, her OB-Gyn sent her
for an Ultrasound procedure. The Ultrasound
revealed a tumor that is cancerous. Surgical
operation was indicated. Ara M was told that if
this operation pushes through, she is going to
lose her baby. It is actually her first. Ara M is
confused and does not know if the procedure is
morally acceptable. How do you educate Ara M
on this matter?

Double effect
THANK YOU

HAVE A NICE DAY!