LUNA GOCO COLLEGES

SCHOOL OF NURSING
NCM 108-BIOETHICS

LESSON 2- BIOETHICS AND ETHICAL DECISION MAKING

ETHICAL PRINCIPLES
A. Autonomy

- Autonomy is the freedom and ability to act in a self-determined manner. It

represents the right of a rational person to express personal decisions
independent of outside interference and to have these decisions honored. The
principle of autonomy sometimes is described as respect for autonomy
(Beauchamp & Childress, 2013).
- In the domain of health care, respecting a patient’s autonomy includes
obtaining informed consent for treatment; facilitating and supporting patients’
choices regarding treatment options; allowing patients to refuse treatments;
disclosing comprehensive and truthful information, diagnoses, and treatment
options to patients; and maintaining privacy and confidentiality.
- Respecting patients’ autonomy is important, but it also is important for
nurses to receive respect for their professional autonomy.

B. Informed Consent

- Informed consent in regard to a patient’s treatment is a legal, and ethical, issue

of autonomy. At the heart of informed consent is respecting a person’s
autonomy to make personal choices based on the appropriate appraisal of
information about the actual or potential circumstances of a situation

Elements of Informed Consent

- I. Threshold elements (preconditions)

- 1. Competence (to understand and decide)
- 2. Voluntariness (in deciding)

- II. Information elements

- 3. Disclosure (of material information)
- 4. Recommendation (of a plan)
- 5. Understanding (of 3 and 4)
-
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- III. Consent elements
- 6. Decision (in favor of a plan)
- 7. Authorization (of the chosen plan)
Dempski (2009) presented three basic elements that are necessary for informed
consent to occur:
1. Receipt of information: This includes receiving a description of the
procedure, information about the risks and benefits of having or not having
the treatment, reasonable alternatives to the treatment, probabilities about
outcomes, and “the credentials of the person who will perform the treatment”
(Dempski, 2009, p. 78).

2. Consent for the treatment must be voluntary: A person should not be under
any influence or be coerced to provide consent. This means patients should
not be asked to sign a consent form when they are under the influence of
mind-altering medications, such as narcotics.

3. Persons must be competent:

Persons must be able to
communicate consent and to LEGAL PERSPECTIVE
understand the information Nurses should not obtain informed
provided to them. If a person’s
condition warrants transferring consent for a provider who will
decision-making authority to a
perform a patient’s invasive
surrogate, informed consent
obligations must be met with the procedure.
surrogate. However, nurses may be
legally liable if they know or should
Advanced-practice nurses are legally and
ethically obligated to obtain informed have known informed consent was
consent before performing risky or
invasive treatments or procedures within not obtained and if nurses do not
their scope of practice. In everyday appropriately notify providers or
situations all nurses are required to explain
nursing treatments and procedures to supervisors about this deficiency.
patients before performing them. If a
patient understands the treatment or
procedure and allows the nurse to begin the
nursing care, consent has been implied. Nursing procedures do not need to meet all

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NCM 108-BIOETHICS
of the requirements of informed consent if procedures are not risky or invasive
(Dempski, 2009).

LEGAL PERSPECTIVE
Assault and battery are two legal terms describing offenses against a person. Both are relevant
to the ethical requirement of informed consent. Assault is the threat of harm; for example,
someone commits assault if he or she acts or talks in a way that causes another person to feel
apprehension about his or her physical safety. Battery consists of one person offensively
touching another person.

C. Intentional Nondisclosure

-In the past, medical and nursing patient-care errors were something to be
swept under the rug, and care was taken to avoid patient discovery of these
errors. However, when healthcare leaders realized that huge numbers of
patients, as many as 98,000 per year, were dying from medical errors, the
Institute of Medicine (IOM) began a project to analyze medical errors and try
to reduce them. One outcome of the project is the book To Err Is Human:
Building a Safer Health Care System (IOM, 2000). The IOM project
committee determined that to err really is human, and good people working
within unsafe systems make the most errors.

-It is now expected that errors involving serious, preventable adverse events
be reported to patients and other organizational reporting systems on a
mandatory basis (IOM, 2000). Reporting near misses (i.e., errors that cause
no harm to patients) are more controversial (Lo, 2009). Some professionals
tend to avoid telling patients about near-miss errors since no harm was done
to the patient, but ethicists recommend disclosure of these events.

-Intentionally not disclosing information to a patient or surrogate is legal

in situations of emergency or when patients waive their right to be informed.

Respecting a patient’s right not to be informed is especially important in
culturally sensitive care.

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NCM 108-BIOETHICS
-Other more legally and ethically controversial circumstances of intentionally
not disclosing relevant information to a patient involve three
healthcare circumstances (Beauchamp & Childress, 2013). The first
circumstance falls under therapeutic privilege. The second relates to
therapeutically using placebos. The third involves withholding information
from research subjects to protect the integrity of the research.

D. Nonmaleficence

- Nonmaleficence is the principle used to communicate the obligation to do no

harm. Emphasizing the importance of this principle is as old as organized
medical practice. Healthcare professionals have historically been encouraged
to do good (beneficence), but if for some reason they cannot do good, they are
required to at least do no harm.

- Nonmaleficence is the maxim or norm that “one ought not to inflict evil or
harm” whereas beneficence includes the following three norms: “one ought
to prevent evil or harm, one ought to remove evil or harm, one ought to do or
promote good”

ISSUES AND CONCEPTS ASSOCIATED WITH THE PRINCIPLE OF NONMALEFICENCE

1. Upholding standards of due care means abiding by the standards that are specific to one’s
profession; the acceptable and expected care a reasonable person in a profession would
render.
2. Negligence is “the absence of due care” and imposing a risk of harm; imposing an
unintended careless risk of harm or imposing an intentional reckless risk of harm.
3. Making distinctions of and rules governing nontreatment and end-of-life decisions
a. Withholding and withdrawing life sustaining treatment
b. Extraordinary (or heroic) and ordinary treatment
c. Sustenance technologies and medical treatments
d. Intended effects and merely foreseen effects (rule of double effect)

e. Killing and letting die

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NCM 108-BIOETHICS
E. Beneficence

The principle of beneficence consists of performing deeds of “mercy,

kindness, friendship, charity and the like”. Beneficence means people take
actions to benefit and promote the welfare of other people.

Rules of Beneficence
1. Protect and defend the rights of others.
2. Prevent harm from occurring to others.
3. Remove conditions that will cause harm to others.
4. Help persons with disabilities.
5. Rescue persons in danger.

F. JUSTICE
Justice, as a principle in healthcare ethics, refers to fairness, treating people
equally and without prejudice, and the equitable distribution of benefits and
burdens, including assuring fairness in biomedical research.
Distributive justice refers to the fair allocation of resources, whereas social justice
represents the position that benefits and burdens should be distributed fairly
among members of a society, or ideally that all people in a society should have
the same rights, benefits, and opportunities. The mission to define and attain
some measure of social justice is an ongoing and difficult activity for the world
community.

PROFESSIONAL–PATIENT RELATIONSHIPS
The quality of patient care rendered by healthcare professionals and patients’
satisfaction with health care often depend on harmonious relationships between
professionals and patients and among the members of professions themselves. If
healthcare professionals view life as a web of interrelationships, all their
relationships potentially can affect the well-being of patients.
- Unavoidable Trust
When patients enter the healthcare system, they usually are entering a foreign
and frightening environment. Intimate conversations and activities, such as
being touched and probed, that normally do not occur between strangers are
commonplace between healthcare professionals and patients. Patients
frequently are stripped of their clothes, subjected to sitting alone in cold and
barren rooms, and made to wait anxiously for frightening news regarding the
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continuation of their very being. When patients need help from healthcare
professionals, they frequently feel a sense of vulnerability and uncertainty.
The tension patients feel when accessing health care is heightened by the need
is called unavoidable trust.

-Patient Advocacy

Nurses acting from a point of patient advocacy try to identify unmet patient
needs and then follow up to address the needs appropriately Advocacy, as
opposed to advice, involves the nurse’s moving from the patient to the
healthcare system rather than moving from the nurse’s values to the patient.

Introduction to Critical Thinking

and Ethical Decision Making
In health care and nursing practice, moral matters are so prevalent that nurses
often do not even realize they are faced with minute-to-minute opportunities
to make ethical decisions. It is vitally important that nurses have the analytical
thinking ability and skills to respond to many of the everyday decisions that
must be made. Listening attentively to other people, including patients, and
not developing hasty conclusions are essential skills for nurses to conduct
reasoned, ethical analyses.

Personal values, professional values and competencies, ethical principles, and

ethical theories and approaches are variables to consider when a moral
decision is made.

Pondering the questions, “What is the right thing to do?” and “What ought I
do in this circumstance?” are ever-present normative considerations in
nursing.

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NCM 108-BIOETHICS
CRITICAL THINKING

The concept of critical thinking is used quite liberally today in nursing. Many
nurses probably have a general idea about the meaning of the concept, but
they may not be able to clearly articulate answers to questions about its
meaning.

Examples of such questions include the following: Specifically,

- What is critical thinking?

- Are critical thinking and problem-solving interchangeable concepts?
- If not, what distinguishes them? Can critical thinking skills be learned, or does
critical thinking either occur naturally?
- If the skill can be learned, how does one become a critical thinker?
- Is there a difference between doing critical thinking and reasoning?

Critical thinkers have certain characteristics:

• They ask clear, pertinent questions and identify key problems.
• They analyze and interpret relevant information by using abstract thinking.
• They are able to generate reasonable conclusions and solutions that are
tested according to sensible criteria and standards.
• They remain open minded and consider alternative thought systems.
• They solve complex problems by effectively communicating with other people.

REFLECTION: So, are you a critical thinker???

MORAL IMAGINATION

The foundation underlying the concept of moral imagination, an artistic or aesthetic

approach to ethics, is based on the philosophy of John Dewey. Imagination, as
Dewey proposed it, is “the capacity to concretely perceive
what is before us in light of what could be”.

Dewey (1934) stated imagination “is a way of seeing and feeling things as they
compose an integral whole”. Moral imagination is moral decision making through
reflection involving “empathetic projection” and “creatively tapping a situation’s

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possibilities”. It involves moral awareness and decision making that goes beyond the
mere application of standardized ethical meanings, decision-
making models, and bioethical principles to real-life situations.

An important role for nurses is to provide leadership and help create healthy
communities through individual-, family-, and population-based assessments;
program planning; program implementation; and program evaluation. When
assuming this key leadership role, nurses continually make choices and decisions
that may affect the well-being of both individuals and populations.

REFLECTIVE PRACTICE

Reflection-on-action involves looking back on one’s actions, whereas reflection-in-

action involves stopping to think about what one is choosing and doing before and
during one’s actions.

THE FOUR TOPICS APPROACH TO ETHICAL DECISION MAKING

Jonsen and colleagues’ (2010) Four Topics Method for ethical analysis is a practical
approach for nurses and other healthcare professionals. The nurse or team begins
with relevant facts about a particular case and moves toward a resolution through a
structured analysis.

Four Topics Method for Analysis of Clinical Ethics Cases

Medical Indications
The Principles of Beneficence and Nonmaleficence

1. What is the patient’s medical problem? Is the problem acute? Chronic? Critical?
Reversible? Emergent? Terminal?
2. What are the goals of treatment?
3. In what circumstances are medical treatments not indicated?
4. What are the probabilities of success of various treatment options?
5. In sum, how can this patient be benefited by medical and nursing care, and how
can harm be avoided?

B. Patient Preferences
The Principle of Respect for Autonomy

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1. Has the patient been informed of benefits and risks, understood this information,
and given consent?
2. Is the patient mentally capable and legally competent, and is there evidence of
incapacity?
3. If mentally capable, what preferences about treatment is the patient stating?
4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for the incapacitated patient?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

C. Quality of Life
The Principles of Beneficence and Nonmaleficence and Respect for Autonomy

1. What are the prospects, with or without treatment, for a return to normal life, and
what physical, mental, and social deficits might the patient experience even if
treatment succeeds?
2. On what grounds can anyone judge that some quality of life would be undesirable
for a patient who cannot make or express such a judgment?
3. Are there biases that might prejudice the provider’s evaluation of the patient’s
quality of life?
4. What ethical issues arise concerning improving or enhancing a patient’s quality
of life?
5. Do quality-of-life assessments raise any questions regarding changes in treatment
plans, such as forgoing life-sustaining treatment?
6. What are plans and rationale to forgo life-sustaining treatment?
7. What is the legal and ethical status of suicide?

D. Contextual Features
The Principles of Justice and Fairness
1. Are there professional, interprofessional, or business interests that might create
conflicts of interest in the clinical treatment of patients?
2. Are there parties other than clinicians and patients, such as family members, who
have an interest in clinical decisions?
3. What are the limits imposed on patient confidentiality by the legitimate interests
of third parties?
4. Are there financial factors that create conflicts of interest in clinical decisions?
5. Are there problems of allocation of scarce health resources that might affect
clinical decisions?
6. Are there religious issues that might influence clinical decisions?
7. What are the legal issues that might affect clinical decisions?

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8. Are there considerations of clinical research and education that might affect
clinical decisions?
9. Are there issues of public health and safety that affect clinical decisions?
10. Are there conflicts of interest within institutions and organizations (e.g.,
hospitals) that may affect clinical decisions and patient welfare?

THE HEALTHCARE TEAM

When patients and families are experiencing distress and suffering, it often is during
times when decisions need to be made about risky procedures or end-of-life care.
Family members may want medical treatment for their loved one, while physicians
and nurses may be explaining to the family that to continue treatment most likely
would be nonbeneficial or futile for the patient.

In caring for particular patients and interacting with their families, nurses sometimes
find themselves caught in the middle of conflicts. Though nurses frequently make
ethical decisions independently, they also act as an integral part of the larger team
of decision makers. Many problematic bioethical decisions will not be made
unilaterally—not by physicians, nurses, or any other single person.

By participating in reflective dialogues with other professionals and healthcare

personnel, nurses are often part of a larger team approach to ethical analysis. When
a team is formally assembled and is composed of preselected members that come
together regularly to discuss ethical issues within an organization, the team is called
an ethics committee.

An organization’s ethics committee usually consists of physicians, nurses, an on-

staff chaplain, a social worker, a representative of the organization’s administrative
staff, possibly a legal representative, local community representatives, and others
drafted by the team. Also, the involved patient, the patient’s family, or a surrogate
decision maker may meet with one or more committee members.

Goals of an Ethics Committee

• Provide support by providing guidance to patients, families, and decision makers.
• Review cases, as requested, when there are conflicts in basic values.
• Provide assistance in clarifying situations that are ethical, legal, or religious in
nature that extend beyond the scope of daily practice.
• Help clarify issues, discuss alternatives, and suggest compromises.
• Promote the rights of patients.
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• Assist the patient and family, as appropriate, in coming to consensus with the
options that best meet the patient’s care needs.
• Promote fair policies and procedures that maximize the likelihood of achieving
good, patient-centered outcomes.
• Enhance the ethical tenor of both healthcare organizations and professionals.

####### FIN######

EXERCISE:

Research Note: Tuskegee Syphilis Study

During the late 1920s in the United States, syphilis rates were extremely high
in some areas. The private Rosenwald Foundation teamed with the United
States Public Health Service (USPHS) to begin efforts to control the disease
using the drug NEOSALVARSAN, an arsenic compound. Macon County,
Alabama, particularly the town of Tuskegee, was targeted because of its high
rate of syphilis, as identified through a survey. However, the Great Depression
derailed the plans, and the private foundation withdrew from the work. The
USPHS repeated the Rosenwald survey in Macon County and identified a
syphilis rate of 22% among African American men in the county and a 62%
rate of congenital syphilis cases. The natural history (progression) of syphilis
had not been studied yet in the United States, and the surgeon general
suggested that 399 African American men with syphilis in Tuskegee should
be observed, rather than treated, and compared with a group of 200 African
American men who were uninfected. The men were not told about the
particular details of their disease. They underwent painful, nontherapeutic
spinal taps to provide data about the natural history of syphilis and were told
these procedures were treatments for “bad blood.” The men were given free
meals, medical treatment for diseases other than their syphilis, and free
burials. Even after penicillin was discovered in the 1940s, the men were not
offered treatment. In fact, the USPHS researchers arranged to keep the
uninformed study participants out of World War II because the men would be
tested for syphilis, treated with penicillin, and lost from the study. The
unethical research continued for 40 years, from 1932 to 1972. During the 40
years of research, an astonishing number of articles about the study was
published in medical journals and no attempt was made to hide the
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surreptitious terms of the research. No one intervened to stop the travesty.
Finally, a medical reporter learned of the study and the ethical issues were
exposed. ###

After reading this chapter and researching more information on the Internet about
the Tuskegee research, answer the following questions:

1. What were the main social issues with ethical implications involved in this study?
2. Which bioethical principles were violated by the Tuskegee study? Explain.
3. How do various ethical approaches or ethical concerns or dilemma relate to the
Tuskegee study?

Submit your output via email with file name:

BIOETHICS_LESSON2_BIOETHICS_YRSEC_FULLNAME (ei.
BIOETHICS_LESSONONEOUTPUT_BSN2A_MACALINAO, KEZIAH)
to kimgmcclearlgc@gmail.com.

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