Ethics at A Glance: January 2005
Ethics at A Glance: January 2005
Ethics at A Glance: January 2005
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ETHICS AT A GLANCE
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Table of Contents
The study of ethics falls into three main areas of focus: metaethics, normative
ethics and applied ethics. Metaethics is concerned with the very nature of right
and wrong, where and how ethical judgments originate, and what they mean in
relation to human nature and conduct. For example, questions posed in
metaethics include how to define the nature of a good act and whether or not
morality exists independently of human beings.
2
Moral Objectivism and Ethical Relativism
A central question in ethics is whether there are one or many valid ethical
viewpoints. Attempts to answer this question reveal two fundamentally different
assumptions from which moral reflection begins.
Moral objectivism holds that at least some moral principles and rules are
objectively knowable on the basis of observation and human reasoning. The
term universalism suggests that basic right and wrong is the same for everyone,
while also allowing for some variation in individual circumstances and context.
On the other hand, ethical absolutism is “the view that there exists an eternal
and unchanging moral law that transcends the physical world and is the same for
all people at all times and places” (Holmes, 1993). In this view, moral rightness
and wrongness exist independent of human beings and unrelated to human
emotions and thought. There is an absolute source of truth that transcends
human rationality and choice.
Critics of this view point to human diversity and the difficulty of deriving a single,
“true” morality that everyone would hold in common at all times and in all
circumstances. The fact that beliefs and behaviors have changed over time in
relation to individual preference and social approval suggests that an absolutist
approach may ultimately conflict with observed human nature and behavior.
3
Wikipedia. Moral Relativism. http://en.wikipedia.org/wiki/Moral_relativism
4
Deontological and Teleological
Assumptions in Normative Ethics
In contrast, teleology (from the Greek telos, meaning goal or end) describes an
ethical perspective that contends the rightness or wrongness of actions is based
solely on the goodness or badness of their consequences. In a strict teleological
interpretation, actions are morally neutral when considered apart from their
consequences. Ethical egoism and utilitarianism are examples of teleological
theories.
5
Principlism and the Moral Principles
The term principle can be defined in several ways. A principle may refer to a
basic truth, law or assumption. For example, a principle may take the form of a
law or rule that describes a natural phenomenon. With respect to ethics, the
term principle can refer to a generalization that can be used in moral reasoning
or a specific rule of good conduct.
6
Principle of Respect for Persons
In its simplest form, respect for persons maintains that human beings have
intrinsic and unconditional moral worth and should always be treated as if there is
nothing of greater value than they are. This principle rests on the unique
capability of human beings to behave as rational agents, that is, self-aware and
capable of objective thought and the ability to reason. The ability to reason is
believed to give humanity an intrinsic dignity that must be respected above all
other considerations.
This inherent value attributed to human beings means that each person is an end
in him or herself and should not be treated solely as a means to some other end.
It also implies that all persons have equal worth and should be treated equitably
and in ways that we ourselves would want to be treated. Principles of truth
telling, loyalty, privacy, and confidentiality are all rooted in this basic requirement
of unconditional respect and value.
Finally, as rational agents, we are free and capable of making our own decisions
and choosing actions based on our own goals and reasoning. In other words, we
are self-determining or autonomous. The principle of respect for persons affirms
the primary importance of allowing individuals to exercise their moral right of self-
determination. To violate their ability to be self-determining is to treat them as
less than persons. In doing so we deprive them of their essential dignity.
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/respect_persons.asp
7
http://www.ascensionhealth.org/ethics/public/issues/autonomy.asp
8
Nonmaleficence
The principle of nonmaleficence states that we should act in ways that do not
inflict evil or cause harm to others. In particular, we should not cause avoidable
or intentional harm. This includes avoiding even the risk of harm. It is important
to point out that this principle can be violated with or without intention. That is,
you don’t have to intend harm to violate this principle. In fact, you don’t even
have to cause harm. If you have knowingly or unknowingly subjected a patient or
colleague to unnecessary risk, you have violated this principle (Munson, 2004).
Beauchamp and Childress (2001) point out the difficulty in defining the nature of
harm. There are many types of harm ranging from physical and emotional injury
to deprivation of property or violations of rights. In health care, the primary focus
on harm relates to a narrower definition including pain, disability, or death.
However, harm can be very much in the eye of the beholder, and a broader
definition of harm is often required in ethical considerations.
Likewise, more than one level of harm may come into play in a situation. For
example, a surgeon will inflict a level of pain and suffering on a patient in order to
avoid their death. The surgeon has imposed one harm in order to avoid a
greater harm. However, in all cases, we are prohibited from acting in ways that
are likely to cause undue risk or needless harm.
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/beneficence.asp
9
Beneficence
The principle of beneficence is often simply stated as an obligation to act in
ways that promote good. Beauchamp and Childress (2001) explain this to
include both the prevention and removal of harm as well as doing good. That is,
we should act in ways that prevent harm, remove harm, and promote good.
As with harm, the definition of good is difficult. As noted by Munson (2004), the
sheer number of ways one might promote the welfare of another defies a
complete description. In the health care context, welfare is generally seen in
terms of health and physical well-being, although other welfare concerns can be
raised.
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/beneficence.asp
10
Veracity
Veracity is the principle of truth telling, and it is grounded in respect for persons
and the concept of autonomy. In order for a person to make fully rational
choices, he or she must have the information relevant to his or her decision.
Moreover, this information must be as clear and understandable as possible.
Truth telling is violated in at least two ways. The first is by the act of lying, or the
deliberate exchange of erroneous information. However, the principle of veracity
is also violated by omission, the deliberate withholding of all or portions of the
truth. Finally, the principle of veracity can also be violated by the deliberate
cloaking of information in jargon or language that fails to convey information in a
way that can be understood by the recipient or that intentionally misleads the
recipient.
In the health care context, there are two broad applications of this principle. The
first relates to patient care and such issues as informed consent. Patients and
families rely upon physicians and other caregivers for the information they need
to make informed choices about their care. They also expect to be told the truth
about their care, including any errors or untoward events. Alternatively, some
patients or patients’ families do not want to be told the truth, placing the
physician, nurse or other health care professional in a situation in which his or
her duty to obtain informed consent is compromised by the wishes of the patient
or family.
The second application relates more generally to professional ethics and the
basic expectation that we are honest in our professional interactions. This
particular application of veracity is apparent in a broad range of issues including
professional relationships, documentation standards, billing practices, risk
management, peer review, community relations, and regulatory reporting, and
compliance.
11
Fidelity
The principle of fidelity broadly requires that we act in ways that are loyal. This
includes keeping our promises, doing what is expected of us, performing our
duties and being trustworthy. Role fidelity entails the specific loyalties
associated with a particular professional designation, and Purtillo (2005) lists five
expectations associated with what patients might reasonably expect in terms of
fidelity in the health care context:
Fidelity is perhaps the most common source of ethical conflict. In any particular
situation health care professionals may find themselves at odds between what
they believe is right, what the patient wants, what other members of the health
care team expect, what organizational policy dictates and/or what the profession
or the law requires.
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Principles of Justice
A general principle of justice requires that we act in ways that treat people
equitably and fairly. Actions that discriminate against individuals or a class of
people arbitrarily or without a justifiable basis would violate this basic principle.
Of special concern in the health care context is the notion of distributive justice.
This conception of justice refers to an equitable balance of benefits and burdens
with particular attention to situations involving the allocation of resources.
Munson (2004) offers four specific principles of distributive justice that can be
considered in situations involving the distribution of material goods and
resources, especially those that are scarce. The principle of equality requires
that all benefits and burdens be distributed equally. The advantage to this
conception of justice is that everyone is entitled to an equal share of resources;
however the principle becomes problematic when not everyone is perceived as
equally deserving of an equal share.
The last two principles address more directly our sense of fairness. The
principle of contribution maintains that persons should benefit in proportion to
their individual contribution. Those who contribute proportionately more to the
production of goods should receive proportionately more goods in return.
Similarly, the principle of effort recognizes the degree of effort made by an
individual as the determining factor in the proportion of goods to be received.
Obvious difficulties with these principles lie in defining the exact nature and
impact of a contribution and accounting for the inherent differences in the
outcomes of individual efforts regardless of the amount of effort expended.
Two very specific categories of justice, included under the broad umbrella of
distributive justice, are also relevant to the health care context and health care
leadership. Procedural justice requires processes that are impartial and fair.
This form of justice underlies the requirement of due process when conducting
disciplinary action against an employee or the manner in which a patient
complaint is investigated. Procedural justice might also relate to how resources
are allocated in situations where other relevant criteria such as need or effort are
substantively equal.
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negligence are obvious examples of compensatory justice, along with damages
awarded for discriminatory personnel practices or fines levied for violations of
legal or regulatory requirements.
Ascension Health
http://www.ascensionhealth.org/ethics/public/key_principles/distributive_justice.a
sp
Beyond Intractability
http://www.beyondintractability.org/m/distributive_justice.jsp
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Virtue Ethics
Virtue-based ethics does not rely directly on ethical principles in its formulation.
In virtue ethics, the focus is on the role of character as the source of moral
action. Human character is shaped over time by a combination of natural
inclinations and the influence of such factors as family, culture, education, and
self-reflection. This means that some people will be more likely to choose
virtuous behavior than will others.
Virtue ethics traces its roots to the ancient Greeks whose original exploration of
morality did not focus on right and wrong, but rather the concepts of human
excellence and human thriving (Taylor, 2002). Generally, a moral act is one that
satisfies two requirements. First, the act must promote the good. Devettere
(2000) defines good in terms of seeking the good life, a life that allows us to
achieve a level of personal happiness and that also serves the communal best
interest. The second requirement for a moral act is that the action must be taken
with the intent to do good. In other words, it is not enough to do the right thing.
Virtuous behavior requires more than just meeting an obligation or performing a
duty. The person of virtuous character is one who displays the proper motive as
well.
Virtues are character traits that predispose a person with good or virtuous
intentions to do the right thing when faced with a moral choice. Writers vary on
what they include on a list of moral virtues. Devettere (2000) emphasizes the
central virtues of temperance, courage, love, justice, and dignity. Other lists
might commonly include respect, honesty, sympathy, charity, kindness, loyalty,
and fairness. Munson (2004) also categorizes a set of practical virtues including
intelligence, patience, prudence, shrewdness, and proficiency. These virtues,
while not moral in and of themselves, can enhance virtuous behavior. For
example, intelligence and prudence can add depth and clarity to ethical
deliberation. Finally, Christian ethics proposes the theological virtues of faith,
hope and charity (Catholic Encyclopedia).
In the health care context, there is an expectation that caregivers and other
professionals act with integrity and virtue. As such, this theory appeals to our
intuitive belief that we can discern the difference between right and wrong action
based on our own moral character and good intentions as professionals. On the
other hand, a weakness of virtue ethics lies in the absence of guidance in
specific situations. Because virtuous character develops over time and in
response to both self-reflection and positive external influences, we may not
always be able to rely on our own incomplete base of experience and insight in
making a particular decision. To complicate matters further, not everyone may
agree on the basis of the good life to be sought through moral choices.
15
Catholic Encyclopedia. Virtue. http://www.newadvent.org/cathen/15472a.htm
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Catholic Moral Tradition
The Catholic moral tradition has rich and varied roots; however, all intellectual
viewpoints emphasize an abiding commitment to the promotion and defense of
human dignity from conception to death. Each human life is considered sacred
and deserving of a right to life. Such a right includes proper origination and
development of a life with access to an adequate level of care. Also emphasized
are the need to accept social responsibility in caring for the poor and the
promotion of the common good. In this perspective, the common good is defined
in terms of protecting fundamental rights in order that all individuals are enabled
to realize their common purposes and goals (National Conference of Catholic
Bishops 1995).
One of the founding voices of the Catholic moral tradition is that of Thomas
Aquinas, a Dominican saint who lived in the thirteenth century. He is associated
with a particular interpretation of natural law, a philosophical tradition dating
back to early pre-Socratic philosophers. In general, natural law proposes
fundamental laws that have been laid down by nature itself and are discoverable
through experience, observation, induction and insight into commonly shared
aspects of human nature and behavior. Aquinas viewed human beings as
intelligent, rational creatures, created in the image of God, whose human reason
is answerable to the basic principle of doing good and avoiding evil (Catholic
Encyclopedia). Good is simply that which is proper to human nature and
consistent with the objective goal of human happiness. Through the application
of our human reason, in combination with our natural inclination to recognize and
seek the good, we are able to reflect upon and discover laws, in the form of
general tendencies, that satisfy basic human needs and fulfill the divinely
intended nature of human beings (Meaney, personal communication).
Aquinas proposes four basic goals of human nature: to prolong life, procreate,
form community, and seek truth (Ashley & O-Rourke, 1997). For example, our
natural inclination to preserve our lives creates obligations to care for ourselves
and avoid actions that put us in danger of losing our lives. This respect for our
own dignity and life is rationally extended to the dignity and lives of others.
Likewise, the inclination to create and care for offspring generates support for the
institution of marriage and prohibits actions that would interfere with the
procreative process.
17
Catholic natural law is, in essence, a teleological theory based on God’s plan for
man within the universe. However, it is not strictly consequentialist in that
consequences are not seen as the sole determinant of a moral act. Instead, a
moral act is determined by the act itself, the motive or intentions of the actor, and
the circumstances surrounding the act. While rooted in natural law, the Catholic
moral tradition has evolved various approaches to the process of moral
reasoning.
Proportionalism is an approach that evolved in the 20th century with the intent of
formulating a dynamic, evolutionary and more pluralistic worldview in light of the
complexity of contemporary society. It relies on intuitive positive values such as
love and loyalty that can be weighed through the reasoning process in any
particular situation to achieve a proportionately favorable outcome. A primary
strength of this approach is its acknowledgement of the very complex issues
presented by rapidly evolving technologies and pluralistic social orders. Critics of
this approach claim that consequences are weighed too heavily allowing for
inherently evil acts to be too easily justified in some situations (Ashley &
O’Rourke, 1997).
A strength of the Catholic moral tradition in health care ethics lies in the specific
guidance given with respect to medical decision-making on a number of complex
issues including abortion, assisted reproduction, end-of-life care, euthanasia and
emerging genetic technologies. The primary weakness lies in its applicability as
an ethical justification for people who do not share the assumptions of natural law
in general or specific theological assumptions embedded within Catholic
theology.
18
The Ethical and Religious Directives for Catholic Health Services.
http://www.usccb.org/bishops/directives.shtml
19
Kantian Ethics
Kant further believed that since we cannot control the outcome of our actions, the
morality of an act cannot depend on the outcome or consequences, but must be
judged based on the motive or intent of the actor. A moral action is one that is
performed solely for the purpose of meeting a moral obligation, and the action
itself can only be judged moral in light of the intention behind it. The actual
outcome is not considered morally relevant.
A second formulation of the imperative, often used in health care, requires that
we never treat another person solely as a means to our end. For example,
involving people in a risky medical experiment without their knowledge deprives
them of their ability to make a rational choice about participation and uses them
as a means to some other end. The fact that the knowledge gained from the
research might benefit thousands of other people is not relevant in this
perspective.
The primary strengths of Kantian ethics in the health care context are that it
prohibits us from using oneself or others solely as means to another end and
requires us to be consistent in our moral action. For example, we should not
experiment on people solely for the benefit of others; and, if it were wrong to
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involve one set of subjects in dangerous research without their consent, then it
would be wrong to involve any subject in dangerous research without their
consent. Some of the weaknesses of a strict Kantian perspective are the
absence of any guidelines for dealing with the inevitable conflicts between duties
and the lack of recognition that emotion and intuition can play a constructive role
in ethical decisions. For example, an absolute duty to tell a patient the truth
might cause a patient harm in certain circumstances; therefore the duty to always
tell the truth conflicts with the duty to avoid needless harm or injury.
Furthermore, human emotion and intuition can be helpful in detecting the
potential for harm, and it is probably not realistic or even desirable to completely
eliminate these natural abilities from our moral actions.
21
Utilitarianism
In any given situation, we are likely to have to consider a range of goods and
preferences to determine what will constitute the greatest overall balance of
good. This consideration uses a type of moral cost/benefit analysis in which a
moral act should produce the greatest benefit (happiness) at the least cost
(unhappiness). A moral act may, at times, result in some unhappiness; however,
the overall consequences must be balanced toward the good.
There are two main applications of utilitarian thought. Act utilitarianism focuses
on the consequences of particular actions in particular circumstances. That is,
an act is right to the extent that it produces the highest utility in that individual
circumstance. This allows you to consider every situation as completely unique.
On the other hand, it also allows for inconsistency in action and requires that you
basically start every analysis from scratch.
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and exceptions likely to be generated, as well as the possibility that the rules
would conflict in some circumstances.
23
Rawlsian Ethics
Contemporary philosopher John Rawls provides one example of an ethical
theory that places the concept of justice at its center. Rawls’ primary concern is
that we be able to design and evaluate social institutions and practices on the
basis of principles of justice. The basis of such principles is found in a concept
that Rawls termed the original position. Imagine a group of people
representing the range of human diversity and then place them behind a veil of
ignorance so that they no longer know who they are on the other side. Rawls
contends that from this original position people would agree to establish a social
order based on the moral standards of an egalitarian form of justice. That is,
they would promote rules and institutions that would ensure their own well-being
once the veil is lifted.
In its strictest sense, egalitarianism requires that all persons receive an equal
distribution of certain political, social, and economic goods and rights; however,
Rawls does not advocate a strict egalitarianism. He maintains that inequalities
are inevitable but can be justified and minimized with at least two principles
discoverable in the original position. The first is the liberty principle, which
advocates that each person should have an equal right to as many basic liberties
as possible and still allow a similar system of liberty for all (Munson 2004). That
is, each individual should possess as much liberty to live and seek opportunity as
is possible, short of infringing on the liberty interests of others.
The second principle that Rawls identifies is termed the difference principle and
requires that social and economic inequalities be arranged so that they benefit
those who are least advantaged. In other words, differences in wealth and social
position are acceptable as long as they can be shown to benefit everyone and, in
particular, those who have the fewest advantages. This principle also requires
that systems allow for all people to have access to goods and positions under
conditions of fair equality of opportunity based on both need and merit (Munson
2004).
Rawls believes that people in the original position would agree on a set of duties
that one owes to both oneself and others. He termed these natural duties and
includes among them the duties of justice, avoiding harm to others, promise
keeping, and helping others in need. Such duties also suggest and support
principles such as respect for persons, nonmaleficence, fidelity, beneficence, and
a form of procedural justice.
Rawls’ theory is obviously applicable to ethical issues in the larger health care
system involving health policy and allocation of resources. Rawls would
approach these issues from the particular perspective of individual liberties and
rights. In addition, the concept of natural duties can also be applied to questions
of autonomy and caregiver obligations. A strength of Rawls’ theory is its dual
emphasis on moral obligation and the need to mitigate the practical
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consequences of social systems. A primary criticism includes a question of
whether the original position is, in fact, biased by Rawls’ own privileged view of
the current system.
25
Feminist Ethics
Feminist ethics does not rely on moral principles per se, arguing that the
commonly cited principles are too abstract to be useful in the context of human
relationships. Instead, actions are generally viewed in relation to their effect on
the quality of relationships among people with an emphasis on considerations of
justice and the concept of caring.
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A general strength of feminist ethics is an emphasis on the importance of
considering the context of an individual situation in medical decision-making.
Similarly, the emphasis on relationships allows for the realities of emotion and
intuition to be factors in our deliberations. On the other hand, as pointed out by
Munson (2004), the wide range of feminist views prevents feminist theory from
presenting one unified and coherent theory. Additionally, there does not appear
to be a method for resolving moral conflicts.
FeministEthics.ca. http://www.feministethics.ca/
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Ethic of Care
Carol Gilligan (1993), and other writers, contend there are two different patterns
of moral reasoning, with women generally exhibiting a relationally based ethic
(predominantly concerned with care) and men preferring a rule-based ethic
(more concerned with justice and rights). Gilligan labeled the first pattern of
reasoning, with its focus on feelings and relationships, the ethic of care. The
second pattern of reasoning, with its focus on developing universal rules in order
to ensure fairness, was labeled the justice perspective. It is important to point
out that both men and women are capable of reasoning in either perspective and
may lean toward one in some situations and the other in other situations.
Nel Noddings (1984) is often cited for her model of caring that is developed to be
applicable to both men and women. Noddings suggests that, in reality, we are
not guided by ethical principles but by the ideal of caring itself. The ethic of care
demands that we maintain conditions under which caring can flourish. Noddings
further notes specific standards or ideals within a caring relationship including
caring itself, compassion, concern, and sensitivity to context.
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and emotion may also lead to a rejection of otherwise justifiable obligations and
rights.
29
Rights and Rights-Based Ethics
As with many ethical perspectives, rights-based approaches also have their roots
with ancient philosophers concerned with the concept of justice, as well as
natural law philosophers who recognized a potential for certain rights inherent in
human nature. Natural rights are generally held to be a gift of nature or God
that cannot be taken away. Modern notions of natural rights are most closely
associated with the seventeenth century British philosopher John Locke (Almond,
1993) and his contention that human beings are entitled to life, liberty and
property. In contemporary theory, these and other moral claims have come to
be referred to as universal human rights and form the basis for establishing
and/or evaluating ethical standards within the social order.
Beauchamp and Childress go on to point out that, while some rights may be
argued to be absolute, most are better considered as prima facie rights. In
other words, most rights should be observed in the absence of competing claims:
however, all rights are likely to be subject to compelling, competing claims at
some point. For example, the fundamental right to life is often deferred in
situations involving self-defense or killing during war.
Another useful distinction is that of positive and negative rights. A positive right
is “a right to receive a particular good or service from others” (Beauchamp &
Childress, 2001). Therefore, a positive right assumes that someone (individual
or agency) is obligated to do something for you. A negative right is “a right to
be free from some action by others”, so a negative right obligates others to
refrain from action. An important implication here is that a right places an
obligation on another individual or social entity, as well as consideration of
whether the associated duties are then interpreted to be absolute.
While the concept of rights is appealing as a basis for moral argument and
justification in modern democratic societies, it is also open to a number of
concerns (Almond, 1993). First, there is no general agreement on what or who
can be the subject of a right. A similar lack of agreement exists on what kinds of
things there can be a right to. Finally there are questions about whether rights
can ever be inalienable or absolute.
30
Catholic Encyclopedia. Right. http://www.newadvent.org/cathen/13055c.htm
31
Communitarian Ethics
This leads to a second premise that emphasizes the common good as an ideal.
Such a premise downplays the values of individuality, autonomy, and personal
rights, so prevalent in other ethical theories, in favor of a focus on the virtues and
actions that support the interests of society as a whole. While this does include
respect for human life and dignity, allowing for all persons to achieve a
meaningful potential, the common good also calls for concern for long-term
sustainability, intergenerational justice, an emphasis on active and informed
citizenship, and a balance between individual and communal interests. At times,
the common good may require all citizens to consider the needs of the broader
community above the needs of any one individual, group, or organization.
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Strengths of the communitarian perspective include the emphasis on strong
connections between people, encouragement of collaboration, diminished
emphasis on self-serving individualism, and sacrifice for the greater good as a
measure of character. On the negative side, many would question how realistic it
is to achieve a common set of global, or even local, values. We might also be
concerned with the potential for erosion of individual rights and no systematic
method for resolving ethical conflicts (Johnson, 2005).
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REFERENCES:
Almond, B. (1993). Rights. In Peter Singer (Ed.) A companion to ethics. Oxford: Blackwell.
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Devettere, R. (2000). Practical decision making in health care ethics: Cases and concepts (2nd
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Jagger, A. M. (2001). Feminist ethics. In Hugh LaFollette (Ed.) The Blackwell guide to ethical
theory. Oxford: Blackwell.
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Thousand Oaks: Sage.
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CA: Wadsworth.
National Conference of Catholic Bishops (2001). Ethical and Religious Directives for Catholic
Health Care Services. Available online at http://www.usccb.org/bishops/directives.shtml
Noddings, N. (1984). Caring: A feminist approach to ethics and moral education. Berkeley:
University of California Press.
Purtillo, R. (2005). Ethical dimensions in the health professions (4th ed). Philadelphia: W.B.
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Tam, H. (1998). Communitarianism: A new agenda for politics and citizenship. New York: New
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