Lesson 5 Bioethical

Principles
BIOETHICAL
PRINCIPLES
BIOETHICAL PRINCIPLES
Respect for Human Life
Dignity of Man - potentiality
AUTONOMY
NONMALEFICENCE
BENEFICENCE
Distributive JUSTICE
VERACITY
CONFIDENTIALITY
ACCOUNTABILITY
Introduction
It is difficult to hold rules or principles that are absolute. This is due
to the many variables that exist in the context of clinical cases as
well as the fact that in health care there are several principles
that seem to be applicable in many situations. Even though they

rules and
are not considered absolute, these

principles serve as powerful

action guides.
Basic Bioethical Principles

AUTONOMY
NONMALEFICENCE
BENEFICENCE
Distributive JUSTICE
VERACITY
CONFIDENTIALITY
ACCOUNTABILITY
1.The Principle of Respect for
Autonomy

▪ Human beings deserve personal liberty in

order to make informed judgments and decisions about their
lives
▪ In health care decisions, our respect for the autonomy of the
patient would mean that the patient has the capacity to act
intentionally, with understanding,
and without controlling influences
that would mitigate against a free and voluntary act.
Greek autos (self) and monos (governance)

Personal liberty of action in which the individual

determines his/her own course of action in
accordance with a plan chosen by him/herself;
Self-determination.
Implies independence and self-reliance, freedom of
choice, and ability to make decisions.
Informed Consent
The patient has the capacity to act
intentionally, with understanding,
and without controlling influences
that would mitigate against a free
and voluntary act.

This principle is the basis for the

practice of- "informed consent" in the
physician/patient transaction
regarding health care.
Practice of "informed consent"
This right and responsibility is exercised
by freely and voluntarily consenting
or refusing consent to recommended
medical procedures. The ability to give
informed consent depends on:
1) adequate disclosure of information;
2) patient freedom of choice;
3) patient comprehension of
information;
4) patient capacity for decision-making.
INFORMED CONSENT
Required for any procedure or surgery unless in
life-threatening emergency (MD can invoke
“implied consent” in emergencies)
Observe 3 conditions:
▪1. Must be given voluntarily, freely w/o threat
or pressure and must be witnessed by another
adult. (Voluntariness).
▪2. Must be given by an individual w/ the
capacity & competence to understand
(Competency).
▪3. Must be given enough information* to be the
ultimate decision maker (Completeness)
*information includes – risks, benefits, side-
effects, costs and alternatives.
Guidelines to Informed Consent
Two Criteria Must Be Satisfied:
1.The person(s) giving consent 2.The consent is given by one
must fully comprehend who has legal capacity
▪ The procedure to be ▪ Competent adult
performed ▪ Legal guardian/representative
▪ The risks involved for the incompetent adult
▪ Expected or desired ▪ Emancipated, married minor
outcomes ▪ Parent or legal guardian of a
▪ Any complications or child
untoward side effects ▪ Minor for diagnosis &
▪ Alternative therapies, treatment of specific
including no therapies at all. conditions
▪ Court order
Guido, GW 1988. Legal issues in
nursing
Practice of "informed consent"
Three necessary conditions are satisfied:
1) that the individual’s decision is voluntary;
2) that this decision is made with an appropriate
understanding of the circumstances; and
3) that the patient’s choice is deliberate insofar as the
patient has carefully considered all of the expected
benefits, burdens, risks and reasonable alternatives.

Legally, adequate disclosure includes information

concerning the following: 1) diagnosis; 2) nature and
purpose of treatment; 3) risks of treatment; and 4)
treatment alternatives.
RN’s role
▪ Consent is obtained by the physician.
▪ RN’s role is to witness patient’s signature in the
express consent form.
▪ RN has to make sure patient is informed – if not, seek
remedy.
▪ Even if RN has role to teach & inform, be careful NOT
to give new information or contradict the physician.
Autonomy
▪ If brought to the hospital in an unconscious state or with no
decision-making capacity consent can be presumed ,
provided that the procedures performed are necessary and cannot
be postponed until the person has regained consciousness or
decision-making capacity.
▪ If a surgeon sees the critical need of more extensive surgery in the
course of an operation. In these circumstances, there may be no
time to contact the spouse, parents or surrogate of the unconscious
patient.
▪ For incompetent or incapacitated individuals, this right and duty of
the patient to give consent is to be exercised on his or her behalf
by a surrogate. This is known as vicarious consent ,
which is regulated by individual state and federal laws, following
various standards of surrogate decision-making, including
substituted judgment and best interests.
For example,

Jehovah's Witnesses have a belief that it is wrong to

accept a blood transfusion.
In a life-threatening situation where a blood
transfusion is required to save the life of the patient,
the patient must be so informed.
The consequences of refusing a blood transfusion must
be made clear.
When properly and compassionately informed, the
particular patient is then free to choose whether to
accept or whether to refuse, even to the point of
accepting his death.
Against medical advice (AMA),
▪Against medical advice, sometimes known
as discharge against medical advice, is a
term used in health care institutions when a
patient leaves a hospital against the advice
of their doctor.
Advance Directives – Living Will
▪Health care advance directives are legal
documents that communicate a person's
wishes about health care decisions in the
event the person becomes incapable.
▪Only used if you are in danger of dying and
need certain emergency or special
measures to keep you alive
▪ Broadly, an advance directive is any legal document
that addresses your wishes about your future
medical care. Doctors refer to your advance
directives if you’re ever incapacitated and unable to
communicate. This could happen if you:
▪ Were in a coma
▪ Had a stroke
▪ Suffered from dementia
▪ Were under anesthesia
▪ Had an illness that left you too sick to communicate
Advance Care Planning
Decisions
▪ Sometimes decisions must be made about the use
of emergency treatments to keep you alive.
▪ Doctors can use several artificial or mechanical
ways to try to do this. Decisions that might come
up at this time relate to:
▪ CPR (cardiopulmonary resuscitation)
▪ Ventilator use
▪ Artificial nutrition (tube feeding) and artificial
hydration (IV, or intravenous, fluids)
▪No Code
▪DNR
▪No Chemical Code
▪Etc…
Patient autonomy in the area of human
experimentation.

It was generally agreed that patients must give informed

consent to any experimental procedures performed on
them. But how much information should they be given? The
problem was particularly acute in the case of randomly
controlled trials, which require that patients agree to
courses of treatment that may consist entirely of placebos.

When experiments were carried out using human subjects

in developing countries, the difficulties and the potential for
unethical practices become greater still. In 2000 the World
Medical Association, responding to reports of abuses,
revised its Declaration of Helsinki, which sets out the
ethical principles that should govern medical research
involving human subjects.
2. The Principle of Non-maleficence

"first, do no harm," or the Latin, primum non

nocere
Do no harm; prevent harm. This principle rejects
knowingly doing harm.
Not to intentionally create a needless harm or injury to
the patient, either through acts of commission or
omission.
It is negligence if one imposes a careless or
unreasonable risk of harm upon another. Providing a
proper standard of care that avoids or minimizes the
risk of harm is supported not only by our commonly
held moral convictions, but by the laws of society as
well.
Non-maleficence
In the course of caring for patients, there are
some situations in which some type of harm
seems inevitable, and we are usually
morally bound to choose the lesser of the
two evils, although the lesser of evils may
be determined by the circumstances.
For example, most would be willing to
experience some pain if the procedure in
question would prolong life.
 Principle of Double Effect
Natural Law Ethics

There is another category of cases that is also confusing since a single

action may have two effects, one that is considered a good effect,
the other a bad effect.
A typical example might be the question as to how to best treat a
pregnant woman newly diagnosed with cancer of the uterus. The
usual treatment, removal of the uterus is considered a life saving
treatment. However, this procedure would result in the death of the
fetus. What action is morally allowable, or, what is our duty? It is
argued in this case that the woman has the right to self-defense, and
the action of the hysterectomy is aimed at preserving her life. The
unintended consequence (though undesired) is the death of the
fetus.
There are four conditions that
usually apply to the Principle of
Double Effect (review of Natural Law Theory):

▪ the action itself must NOT be intrinsically wrong, it

must be a good or neutral act.
▪ only the good effect must be intended, not the bad
effect, even though it is foreseen.
▪ the bad effect must not be the means of the good
effect, (the end should not justify the means)
▪ the good effect must outweigh the evil that is
permitted.
*Application of Principle of Double Effect applies in
serious cases.
3. The Principle of Beneficence
Do good; promote goodness! This standard
rejects knowingly doing evil.
The ordinary meaning of this principle is the
duty of health care providers to be of a benefit
to the patient, as well as to take positive steps
to prevent and to remove harm from the
patient.
One clear example exists in health care where the
principle of beneficence is given priority over the
principle of respect for patient autonomy.

This example comes from Emergency Medicine. When

the patient is incapacitated by the grave nature of
accident or illness, we presume that the reasonable
person would want to be treated aggressively, and
we rush to provide beneficent intervention.
Justified Paternalism
When the physician acts from a benevolent spirit in
providing beneficent treatment that in the physician's
opinion is in the best interests of the patient, without
consulting the patient, or by overriding the patient's
wishes, it is considered to be "paternalistic“.

A clear cut case is seen in the treatment of suicidal

patients who are a clear and present danger to
themselves. Here, the duty of beneficence requires
that the physician intervene on behalf of saving the
patient's life or placing the patient in a protective
environment, in the belief that the patient is
compromised and cannot act in his own best interest
at the moment.
Discuss: Autonomy versus Paternalism
4. Principle of Distributive Justice
A form of fairness, or as Aristotle once said, "giving to each that which
is his due." This implies the fair distribution of goods in society and
requires that we look at the role of entitlement. The fact that some
goods and services are in short supply, there is not enough to go
around, thus some fair means of allocating scarce resources must be
determined.
In fact, our society uses a variety of factors as a criteria for
distributive justice, including the following:
▪ to each person an equal share
▪ to each person according to need
▪ to each person according to effort
▪ to each person according to contribution
▪ to each person according to merit
▪ to each person according to free-market exchanges
Rules of distributive justice
▪ We expect (and can demand) to be treated justly in
our dealings with other people and with institutions.
The following rules reflect this basic sentiment.

▪ They are best understood in terms of John Rawls’

position.

▪ From a bioethical perspective, they have clear

relevance to questions about, for example, access to
health insurance, the distribution of organs, and who
should shoulder the burden of health care costs.
Rules of distributive justice
Equality
▪ According to the principle of equality, all benefits and burdens
are to be distributed equally.

Need
▪ The principle of need is an extension of the egalitarian principle
of equal distribution.

▪ If goods are parceled out according to individual need, those

who have greater needs will receive a greater share. However,
the outcome will be one of equality.

▪ Since the basic needs of everyone will be met, everyone will end
up at the same level. The treatment of individuals will be equal,
in this respect, even though the proportion of goods they receive
will not be.
Rules of distributive justice
Contribution
▪ According to the principle of contribution, people
should get back that proportion of social goods that is
the result of their productive labor.

Effort
▪ According to the principle of effort, the degree of
effort made by the individual should determine the
proportion of goods received by the individual.
Is closely linked to the concepts of human dignity, the
common good, and human rights.

In the context of health care, distributive justice

requires that everyone receive equitable access to the
basic health care necessary for living a fully human
life insofar as there is a basic human right to health
care.
Implies that society has a duty to the individual in
serious need and that all individuals have duties to
others in serious need.
In decisions regarding the allocation of resources, such
as rationing decisions, the duty of society is not
diminished because of the person’s status or nature of
illness. Everyone is entitled to equal access to basic care
necessary for living in a human way.
Triage must presume an essential equality of persons. In
other words, allocation decisions should not be based
upon judgments of the quality of persons.
Benefits and burdens should also be distributed in a just
manner.
In the broadest terms, there are four major healthcare models:
the Beveridge model, the Bismarck model, national health
insurance, and the out-of-pocket model. While each model is
distinct in and of itself, most countries don't adhere strictly to a
single model; rather, most create their own hybrids that involve
features of several.

Healthcare Models
 The Beveridge model

Developed in 1948, by Sir William Beveridge in the United Kingdom,

the Beveridge model is often centralized through the establishment of a
national health service. Or, in the case of the UK, the National Health
Service.
Essentially, the government acts as the single-payer, removing all
competition in the market to keep costs low and standardize benefits.
As the single-payer, the national health service controls what "in-
network" providers can do and what they can charge.

Funded by taxes, there are no out-of-pocket fees for patients or any

cost-sharing. Everyone who is a tax-paying citizen is guaranteed the
same access to care, and nobody will ever receive a medical bill.
▪ One criticism of the Beveridge model is its potential risk of
overutilization. Without restrictions, free access could
potentially allow patients to demand healthcare services that
are unnecessary or wasteful. The result would be rising costs
and higher taxes.
▪ However, that's why many of these systems have regulations in
place to manage usage and proactive prevention campaigns.
▪ There is also criticism around funding during a state of national
emergency. Whether it's a war or a health crisis, a
government's ability to provide healthcare could be at risk as
spending increases or public revenue decreases. It remains to
be seen if this will be the case as a result of the COVID-19
pandemic.
▪ Used by the United Kingdom, Spain, New Zealand, Cuba,
Hong Kong, and the Veterans Health Administration in the U.S.
 The Bismarck model

▪ Within the Bismarck model, employers and employees are

responsible for funding their health insurance system
through "sickness funds" created by payroll deductions.
Private insurance plans also cover every employed
person, regardless of pre-existing conditions, and the
plans aren't profit-based.
▪ Providers and hospitals are generally private, though
insurers are public. In some instances, there is a single
insurer (France, Korea). Other countries, like Germany
and the Czech Republic, have multiple competing
insurers. However, the government controls pricing, much
like under the Beveridge model.
▪ Unlike the Beveridge model, the Bismarck model
doesn't provide universal health coverage. It requires
employment for health insurance, so it allocates its
resources to those who contribute financially.
▪ The primary criticism of the Bismarck model is how to
provide care for those who are unable to work or
can't afford contributions, including aging populations
and the imbalance between retirees and employees.
▪ Used by Germany, Belgium, Japan, Switzerland, the
Netherlands, France, and some employer-based
healthcare plans in the U.S.
The National Health Insurance Model

▪ The national health insurance model blends different

aspects of both the Beveridge model and the Bismarck
model. First, like the Beveridge model, the government
acts as the single-payer for medical procedures.
However, like the Bismarck model, providers are private.
▪ The national health insurance model is driven by private
providers, but the payments come from a government-
run insurance program that every citizen pays into.
Essentially, the national health insurance model is
universal insurance that doesn't make a profit or deny
claims.
▪ Since there's no need for marketing, no financial
motive to deny claims, and no concern for profit,
it's cheaper and much simpler to navigate. This
balance between private and public gives hospitals
and providers more freedom without the frustrating
complexity of insurance plans and policies.
▪ The primary criticism of the national health
insurance model is the potential for long waiting
lists and delays in treatment, which are considered
a serious health policy issue.
▪ Used by Canada, Taiwan, and South Korea, and
similar to Medicare in the U.S.
 The Out-of-pocket Model

▪ The out-of-pocket model is the most common model in less-

developed areas and countries where there aren't enough
financial resources to create a medical system like the three
models above.
▪ In this model, patients must pay for their procedures out of
pocket. The reality is that the wealthy get professional medical
care and the poor don't, unless they can somehow come up
with enough money to pay for it. Healthcare is still driven by
income.
▪ Used by rural areas in India, China, Africa, South America, and
uninsured or underinsured populations in the U.S.
Title: Bioethics & Justice
Video Resource
▪ https://www.youtube.com/watch?v=9vxRs_poQwU
▪ 13.3 min.
▪ This talk focuses on bioethics and justice: ethical issues in
the allocation of scare health care resources from donated
organs to expensive interventions, and ethical issues at the
intersection of environmental and human health.
▪Assignment Series – Reflection Journal
Entry # 5

▪Choose 2 Bioethical Issues presented and

give your personal POINT-OF-VIEW &
REFLECTION.
Ethical Implication
▪ Healthcare will continue to be a topic of debate
and concern due to the aftermath of the COVID-19
pandemic. After the dust settles, there needs to be
a meaningful conversation on necessary reforms
that involves providers, systems, payers, and the
government. That conversation should include a
thorough examination of the strengths and
weaknesses of these global models so they can
inform new healthcare policies and ultimately build
a model that can work for everyone.

https://www.verawholehealth.com/blog/global-healthcare-4-
major-national-models-and-how-they-work
Commentary / Opinion

Reflect on the government’s

scheme of distributing the COVID
19 vaccine.
5. Principle of Veracity
Veracity – duty to tell the truth
Inattention to truth or violations of honesty by medical
personnel is serious business. There is a lot at stake as
well for nurses, researchers and other health
professionals.
Not telling the truth in the MD/RN-patient relationship
requires special attention because patients today, more
than ever, experience serious harm if they are lied to.
Not only is patient autonomy undermined but patients
who are not told the truth about an intervention
experience a loss of that all important trust which is
required for healing. Honesty matters to patients. They
need it because they are ill, vulnerable, and burdened
with pressing questions which require truthful answers.
▪ Fidelity – duty to keep promises
Benevolent Deception
Lying in a clinical context is wrong for many reasons but
less than full disclosure may be morally justifiable
(Benevolent Deception). If a patient is depressed and
irrational and suicidal, then caution is required lest full
disclosure contribute to grave harm. If a patient is
overly pessimistic, disclosure of negative possibilities
may actually contribute to actualizing these very
possibilities.
Determining the appropriateness of less than full
disclosure is one thing, but trying to justify a blatant lie
is another thing entirely.
Lying and deception in the clinical context is just as bad
as continued aggressive interventions to the end. Both
qualify as torture.
Now that so many medical interventions are
available it is obviously wrong not to disclose
the truth to a patient when the motive is to
justify continued intervention or in order to
cover up for one's own failures for your benefit,
not the benefit of the patient.
Doctors and nurses, however, can do as much
harm by cold and crude truth-telling as they can
by cold and cruel withholding of the truth.
To tell the truth in the clinical context requires
compassion, intelligence, sensitivity, and a
commitment to staying with the patient after
the truth has been revealed.
6. Principle of Confidentiality

Confidentiality – duty to respect

privileged information
Commonly applied to conversations
between doctors and patients. This
concept is commonly known as
patient-physician privilege.
Legal protections prevent physicians
from revealing their discussions with
patients, even under oath in court.
 US
▪ Mandated in America by HIPAA laws, the Privacy
Rule, and various state laws. However, numerous
exceptions to the rules have been carved out over
the years.
▪ For example, many states require physicians to
report gunshot wounds to the police and impaired
drivers to the Department of Motor Vehicles.
Confidentiality is also challenged in cases
involving the diagnosis of a sexually transmitted
disease in a patient who refuses to reveal the
diagnosis to a spouse, and in the termination of a
pregnancy in an underage patient, without the
knowledge of the patient's parents. Many states
in the U.S. have laws governing parental
notification in underage abortion
https://www.youtube.com/watch?v=QZMpoUpBwW8

Cathy Parkes RN, covers Nursing Fundamentals - Telephone

Orders, HIPAA and Delegation.

Telephone Orders, HIPAA and

Delegation
Stewardship / Accountability
▪ Obligation to take care of the world.
▪ Obligation to take care of the body, mind and freedom
Title: Bioethics Across Borders
Video resource:
▪ https://www.youtube.com/watch?v=Z3uZFe3hTw0
▪ This talk focuses on bioethics across borders, examining a
cluster of quirky and complex issues that arise due to the
interdependent nature of our globalized world, ranging from
medical tourism to the issue of global food supply on a
rapidly-developing planet.

▪Assignment Series – Reflection Journal

Entry # 6

▪Choose 2 Bioethical Issues presented and

give your personal POINT-OF-VIEW &
REFLECTION.
 Principle of Accountability
▪ Responsibility is an ethical concept that refers to the fact that
individuals and groups have morally based obligations and
duties to others and to larger ethical and moral codes,
standards and traditions.

▪ Accountability is accepting responsibility for one's own

actions. Nurses are accountable for their nursing care and other
actions. They must accept all of the professional and personal
consequences that can occur as the result of their actions.

▪ In the professional context, accountability is about answering to

clients, colleagues and other relevant professionals. The
demand to give an account of one’s judgments, acts and omissions
arises from the nature of the professional-client and the
professional-professional relationships.
▪ According to Aristotle, moral responsibility was viewed as originating
with the moral agent as decision-maker, and grew out of an ability to
reason, an awareness of action and consequences, and a willingness
to act free from external compulsion.

▪ Accountability is the readiness or preparedness to give an explanation

or justification to stakeholders for one’s judgments, intentions and
actions.

▪ “It is a readiness to have one’s actions judged by others

and, where appropriate, accept responsibility for errors,
misjudgments and negligence and recognition for
competence, conscientiousness, excellence and
wisdom.”
▪ While responsibility is defined as a bundle of obligations associated
with a role, accountability could be defined as “blaming or crediting
someone for an action”—normally associated with a recognized
responsibility.
Although definitions of accountability vary, Marcia M. Rachel,
writing for American Nurse Today, states that accountability in
nursing must include five concepts:
https://www.myamericannurse.com/accountability-a-concept-worth-
revisiting/

1. Obligation: a duty that usually comes with consequences.

2. Willingness: accepted by choice or without reluctance.
3. Intent: the purpose that accompanies the plan.
4. Ownership: having power or control over something.
5. Commitment: a feeling of being emotionally compelled.

Creating an environment of accountability requires three

elements:

✓ Clarity: set clear and specific expectations, goals and metrics.

✓ Commitment: after making a request, ask for a commitment or
discuss alternative options.
✓ Consequences: develop action plans for failure to commitments.
.
PERSONAL ACCOUNTABILITY
The ANA considers accountability in nursing a personal
matter for nurses, regardless of organizational culture.
Personal accountability includes factors such as the
following:

• Commitment to doing your best.

• Learning best practices and advocating for patients.
• Taking responsibility for your mistakes and learning
from constructive feedback.
• Actively supporting your teammates and helping them
remember to honor their commitments.
• Serving as a positive role model
 Totality
It demands respect for self and respect
for others.
An individual may not dispose of his
organs or destroy their capacity to
function, except to the extent that this
is necessary for the general well-being
of the whole body.
Destroying an organ or interfering with
its capacity to function prevents the
organ from achieving its natural
purpose.
Principle of totality
▪ The principle of totality has implications for a great
number of medical procedures.

▪ Strictly speaking, even cosmetic surgery is morally right

only when it is required to maintain or ensure the normal
functioning of the rest of the body.

▪ More important, procedures that are typically employed

for contraceptive purposes— vasectomies and tubal
ligations—are ruled out since such procedures involve
“mutilation” and the destruction of the capacity of the
organs of reproduction to function properly.
WHEN PRINCIPLES COLLIDE
Honesty may conflict with confidentiality; for
example, a supervisor might not be able to reveal
pending dismissals to workers in her department.

Autonomy might be in opposition to

paternalism, as when adult children face the
problem of nursing home placement unwanted by
their parents.

Beneficence collides with nonmaleficence when

individuals defend themselves from unjust
aggressors.
Solutions to such conflicting
norms are shaped according to
the principle(s) valued most
highly by the decision maker(s)
in the actual situation...
Addendum
 ▪ The principle in ethics that a
law can be
broken to achieve a greater
good reasonable.
▪ Summa Theologica, Part II-II (Secunda
TRIVIA Secundae) Translated by Fathers of the
English Dominican Province
PRINCIPLE ▪ “This is the result of a long-standing habit of
criticism of authority and over-emphasis of
of EPIKIA the principle of epikeia.”
▪ “Greeks insisted on the virtue of epikeia,
whereby it is reasoned that the law is too
general to cover every particular case and
that therefore there are valid exceptions
which epikeia discovers.”
▪ Seemingly epikeia pronounces
judgment on the law, when it deems
that the law should not be observed
in some particular case.”
 An eye for an eye, and a tooth for a tooth."
This phrase, goes back to ancient
Mesopotamian culture that prospered
TRIVIA long before the Bible was written or the
civilizations of the Greeks or Romans
flowered.
"An eye for an eye ..." is a paraphrase of
Hammurabi's Code, a collection of 282
laws inscribed on an upright stone pillar.
The code was found by French
Hammurabi's archaeologists in 1901 while excavating
the ancient city of Susa, which is in
Code modern-day Iran.
An Eye for an Eye Hammurabi is the best known and most
celebrated of all Mesopotamian kings. He
ruled the Babylonian Empire from 1792-50
B.C.E. Hammurabi states that he wants "to
make justice visible in the land, to destroy
the wicked person and the evil-doer, that
the strong might not injure the weak."
END.

Prepare for an end-of-lesson quiz.