Bioethics in Nursing Practice
ETHICAL ASPECTS OF NURSING
PRINCIPLE OF AUTONOMY
Morals



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
Ethics

Based on norms of conduct about right or wrong
Society’s moral codes guide what people ought to do
Professional codes such as the code of ethics for
nurses, communicate the goals and ideals of the
profession
Science of ideals – what a person should do because it
is the right thing to do
Morality

Application of Ethics
Code of Ethics

The “Code of Ethics for Nurses” BON Resolution 220
series 2004
o
Provides guidance for carrying out nursing
responsibilities consistent with the ethical
obligations of the profession
o
If you violate any provisions in terms of the
Code of Ethics, sanctions could be suspension
or revocation of license
o
Always be on the safe side = respect of the
person
Professional Code of Ethics

Nurses have a contract with society to behave in
accordance with rules dictated by society and the
nursing profession

Nurse Practice Acts vs Code of Ethics

Delineates nursing’s moral ideals, provides guidelines
for ethically principled behavior and holds nurses
morally accountable for their actions
Ethical Principles

Autonomy

Beneficence

Non-maleficence

Veracity

Confidentiality

Justice

Fidelity
RESPECT FOR PERSON

Most fundamental human right

Foundation of all ethical principles

Respecting the worth and value of a person

Imago Dei (Created in the Image of God)

“The human person ought to be respected always.”



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
* What we do in the hospital has legal and ethical implications
* Everybody must be treated equally
* We can be taught ethics but morality is always up to us
University of Santo Tomas – College of Nursing / JSV

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
* Lies, restraints, coercion = wrong decision
* No matter what, we must let patients decide for himself
* Autonomy is NOT absolute.
Factors that affect decision:
o
Emotions
o
Time
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?
Examples:

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
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
o
Not everything legal is ethical and vice versa

Doing good should take precedence over autonomy
PRINCIPLE OF AUTONOMY
Competent for Decision Making

18 y/o and above

Emancipated minor – self- supported, financially
independent
o
Female – 18
o
Male – 24 and below – parental consent

Mentally coherent
o
90 y/o – depends if mentally competent or
not
o
Illiterate – CAN give consent

Thumb mark and initials are NOT
used as a signatures

For + initials – not allowed
o
Signed by closest relative,
patient gives the consent
Consent – immediate family
o
Adult – Patient, spouse if married, children of
major age
o
Below 18 – Parents, siblings, grandparents
Who gives proxy consent?
1. Durable Power of Attorney
o
Designating somebody else to make a
decision for me
o
Authorization
Bioethics in Nursing Practice
2.
Closest of kin
o
Adult – married - spouse, children of major
age
o
Below 18 - parents, grandparents
o
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.

Instructions for the future

Living Will
o
Document that tells you what I want in the
future in case I cannot make a decision
anymore
o
Both oral and written are acceptable in the
court of law – needs to be proved

Durable Power of Attorney
o
Designates somebody else to make the
decision for me in case in the future I cannot
make a decision anymore
o
Authorization letter
o
Specific and with proof
Health Care Proxy

The doctor can decide:
1. Doctor can act as loco-parentis
o
Substitute parent
o
The doctor knows what’s best for you
2. If it is a matter of life and death
3. Court
o
Both oral and written are acceptable in court
o
If you want something to be respected, have
it written
o
E.g. Jehovah’s witness 12 years old
There are people who die because of their religious beliefs

They’d rather die than go to hell

Respect their values
Examples:

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
 Respect autonomy
 There are people who die because of their
religious beliefs

Ernie enjoys listening to music. He plays his music loud
even if his dorm mates are studying
 If it causes harm to others, stop the autonomy
PRINCIPLE OF FREE AND 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.
Assent



Approval of the person of anybody below 18 y/o
Aged 7 - 17 y/o
Example: circumcision
To protect the basic need of every human person for health care
and the person’s primary responsibility for his or her own health
University of Santo Tomas – College of Nursing / JSV
1.
2.
No physical or psychological therapy may be
administered without the free and informed consent of
the patient, or
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.
Examples:

Mikee’s parents chose her career and the school she is
to study in
 Depends on Mikee’s age

Yoly, a 21 year old daughter, is asked to donate her
kidney to her dying mother
 Not a violation if voluntarily given

Leah, a 6year old girl, is asked if she wants her painful
tooth pulled out
 No need to ask for assent
Elements of Informed Consent

Disclosure
o
Procedure
o
Reason
o
Risks vs Benefits
o
Prognosis
o
Cost
o
Alternatives

Understanding
o
Do not use medical jargons

Voluntariness
o
Patient if mentally competent

Competence

Consent
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.
Hypothermia Experiments

In 1942 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 different ways of rewarming
survivors.
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
Bioethics in Nursing Practice
and ground glass into the wounds. The infection was
treated with sulfonamide and other drugs to determine
their effectiveness.
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.

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.
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

Placebo

Practice - NOT acceptable

Research - Acceptable as long as with consent
BASIC ETHICAL PRINCIPLES

Respect for Persons
o
Respect for autonomy and protection of
persons with diminished autonomy

Beneficence and Non-maleficence
o
Maximize benefits and minimize harm

Justice
o
Equitable distribution of both burdens and
benefits of research
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
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
University of Santo Tomas – College of Nursing / JSV

Do not the tell the diagnosis to those who are not
directly involved – nurse aides and janitors
o
If directly involved – needs to know dx
o
If not directly involved – use standard
precaution

No need to mention the dx
The following are subjects of Confidentiality and should not be
revealed to anyone except for graver cause:
1. Private Secrets
2. Contractual Secrets
o
Secret comes first before the promise to keep
the secret
3. Professional Secrets
o
Understanding at the very start that you will
not say anything before the secret comes out
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 is physically abused
o
Report even if it is just a suspicion, report to
SOCIAL SERVICES
o
Evidence of Child Abuse and Neglect

Bruises in different stages of healing –
“clumsy”
o
Black and blue – fresh
o
Yellowish - healing

Bruises under the clothing

Frequent hospitalization

Child is guarded – withdraws from
touch

Quiet when parents are around but
talkative when only healthcare
providers are around

Failure to thrive

Child is sexually abused
o
Familiar with vulgar/ sex language
o
Inspect perianal area

Abusers do not usually penetrate the
vagina because it is easily detected
by police/ hospital

They usually penetrate the rectal
area

Vulnerable adults
o
Elderly
o
Mental incapacity
Example:
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 that 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?
Bioethics in Nursing Practice
PRINCIPLE OF BENEFICENCE AND NON-MALEFICENCE
* If stated in a positive manner, BENEFICENCE
* If stated in a negative manner, NON-MALEFICENCE

Avoid, prevent, not
Healthcare Worker duties in Patient Care:
1. Duty to do or promote good
2. Duty to remove or prevent evil or harm.
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 when some of those interventions may cause
pain

Burn clients receiving mafenide acetate
o
Give analgesics prior to wound care
o
Stinging sensation when applied
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
Examples:

Mon, a so-so swimmer, sees Marco drowning

Jay brings her lunch to school every day. One day, she
saw a thin boy watching her eat. The boy extends his
hands asking for food
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

Different issues on euthanasia, withholding and
withdrawing treatment and the use of artificial nutrition
and hydration
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?



Go but choose patients that you could handle
Only do something within your capability
General Rule: If what you did is what a prudent nurse
have done in the same situation, you are covered –
Nursing Jurisprudence
Examples:

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
University of Santo Tomas – College of Nursing / JSV

Ben has a urethral secretion, which reveals gonorrhea.
Clara, the clinic nurse on duty, is a good friend of Fe,
Ben’s wife. Fe asks Clara for the result of the test
Case:
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?
A.
B.
C.
D.
Do as the wife insists
If treatment is useless and impose excessive burden,
recommend stopping the tx
Transfer the patient to another MD
Transfer patient to the Service ward
PRINCIPLE OF PROPORTIONALITY

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

Do all available means have to be used all the time?
How long these means should be used?
Is treatment effective?
Will it impose unacceptable burden?
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


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
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
Triage

Medical screening of patients to determine their priority
of treatment

Colors
o
Red
o
Yellow
o
Green
o
Black
Finite Resources

Limited fund, medical supplies, healthcare services
The needs of everyone, even if it’s due, cannot all be served
Bioethics in Nursing Practice
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?


Have continuing education – Professional Development
Patient’s record – about the patient but owned by the
hospital
o
Doctor’s permission
o
Medical records’ permission
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?
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?”
A.
B.
C.
D.
The physician should comply
Parents should have full decision control
The physician knows what is the best for the child
Parents should be allowed considerable time to
accept seriousness of child’s condition and to be
honest to their children
ETHICAL PRINCIPLES AND NURSING CARE
•
Respect for human life in all stages
•
Safe, competent and compassionate care
•
Cooperation with fellow-workers
•
Responsible management of resources
University of Santo Tomas – College of Nursing / JSV