Bioethics Premid
Bioethics Premid
Bioethics Premid
Is the study of typically controversial ethics brought about by advances in biology and medicine.
It is also moral discernment as it relates to medical policy, practice, and research.
It also includes the study of the more commonplace questions of values ("the ethics of the ordinary")
which arise in primary care and other branches of medicine.
ETHICS
Defined as the philosophical science that deals with the morality of human conduct.
INTELLECT
Acts as the thinking faculty of the human person
WILL
It does or implements what it has chosen.
PROFESSIONAL ETHICS
assesses the moral dimension of human activity in the classic occupations of law, medicine, ministry and
by extension higher education, engineering, journalism, management and other occupations that aspire
to professional status.
is concerned with the standards and moral conduct that govern the profession and its members.
ETHICAL THEORIES
Deontology
The term “deontology” is a modern combination of Classical Greek terms, and means the study or science (logos)
of duty, or more precisely, of what one ought to do (deon). In contemporary moral philosophy, “deontology” is
used most commonly to refer to moral conceptions that endorse several theses regarding the nature of duty (the
right), the nature of value (the good), and the relationship between the primary ethical concepts of the right and
the good.
An ethical theory that uses RULES to distinguish what is right from wrong.
Teleology
The term “teleological” comes from the Greek word telos for goal or aim. The idea of teleological ethics in recent
usage has been understood, most fundamentally, as standing in contrast with “deontological” approaches to
ethics. Focuses on the result of the act.
Utilitarianism
A prominent, compelling, and controversial theory about the fundamental basis of morality, utilitarianism holds
that human conduct should promote the interests or welfare of those affected.
The ethical theory determines right from wrong by focusing on outcomes
Theorists
Plato - Plato is one of the founding fathers of philosophy and has had a massive impact on the history of
western thought.
Aristotle - Aristotle, a Greek philosopher, and protégé of Plato is considered the Father of the Scientific
Method, the creator of formal logic, and one of the greatest thinkers in the history of the Western world.
Friedrich Nietzsche - Friedrich Nietzsche has emerged as perhaps the most influential thinker of the recent
past. To a significant degree, this is due to the fact that he took time seriously in terms of both cosmology
and ethics.
Immanuel Kant- Immanuel K Kant, like Plato and Aristotle, counts as one of the most influential
philosophers of all time.
Jeremy Bentham - Jeremy Bentham is known today chiefly as the father of utilitarianism.
John Stuart Mill - John Stuart Mill (1806–73) changed the way in which the modern world views and legal
systems address the issues of individual liberty of thought, expression, lifestyle, and action. His ideas
remain both influential and controversial to this day.
1. The object of the act must not be intrinsically contradictory to one's fundamental commitment to God and
neighbor (including oneself), that is, it must be a good action judged by its moral object (in other words, the action
must not be intrinsically evil);
2. The direct intention of the agent must be to achieve the beneficial effects and to avoid the foreseen harmful
effects as far as possible, that is, one must only indirectly intend the harm;
3. The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other
means of achieving those effects are available;
4. The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects (the proportionate
judgment);
5. The beneficial effects must follow from the action at least as immediately as do the harmful effects.
4. Cooperation
Along with the principles of double effect and toleration, the principles of cooperation were developed in
the Catholic moral tradition as a way of helping individuals discern how to properly avoid, limit, or
distance themselves from evil (especially intrinsic evil) in order to avoid a worse evil or to achieve an
important good.
In more recent years, the principles of cooperation have been applied to organizations or "corporate
persons" (the implication being that organizations, like individual persons, are moral agents). Like the
principle of double effect and some other moral principles, the principles of cooperation are actually a
constellation of moral criteria:
Formal Cooperation.
Formal cooperation occurs when a person or organization freely participates in the action(s) of a principal
agent, or shares in the agent’s intention, either for its own sake or as a means to some other goal.
Implicit formal cooperation occurs when, even though the cooperator denies intending the object of the
principal agent, the cooperating person or organization participates in the action directly and in such a
way that it could not be done without this participation.
Formal cooperation in intrinsically evil actions, either explicitly or implicitly, is morally illicit.
Immediate Material Cooperation.
Immediate material cooperation occurs when the cooperator participates in circumstances that are
essential to the commission of an act, such that the act could not occur without this participation.
Immediate material cooperation in intrinsically evil actions is morally illicit. There has been in the tradition
a debate about the permissibility of immediate cooperation in immoral acts under "duress." When
individuals are forced under duress (e.g., at gunpoint) to cooperate in the intrinsically evil action of
another, they act with diminished freedom.
1. Autonomy – one should respect the right of individuals to make their own decisions
2. Paternalism – telling people what is best; an approach to personal relationship, in which the desire tohelp,
advise, and protect may neglect individual choice and personal identity.
1. Respect for AUTONOMY and PATERNALISM
Autonomy
o Comes from the Greek word “autos” meaning self and “nomos” meaning governance.
o It involves self-determination and freedom to choose and implement one’s decision, free from deceit,
duress, constraint or coercion.
Any notion of moral decision-making assumes that rational agents are involved in making informed and
voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in
common parlance, imply that 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.
Case 1
In a prima facie sense, we ought always to respect the autonomy of the patient. Such respect is not simply a matter
of attitude, but a way of acting so as to recognize and even promote the autonomous actions of the patient. The
autonomous person may freely choose values, loyalties or systems of religious belief that limit other freedoms of
that person. For example, Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion.
Therefore, in a life-threatening situation where a blood transfusion is required to save the life of the patient, the
patient must be informed. The consequences of refusing a blood transfusion must be made clear to the patient at
risk of dying from blood loss. A desire to "benefit" the patient, the physician may strongly want to provide a blood
transfusion, believing it to be a clear "medical benefit." When properly and compassionately informed, the
particular patient is then free to choose whether to accept the blood transfusion in keeping with a strong desire to
live, or whether to refuse the blood transfusion in giving a greater priority to his or her religious convictions about
the wrongness of blood transfusions, even to the point of accepting death as a predictable outcome. This
communication process must be compassionate and respectful of the patient’s unique values, even if they differ
from the standard goals of biomedicine.
Paternalism
· Paternalism occurs when the nurse does not respect the patient’s right to autonomy by acting as if he or she
knows what’s best for the patient, rather than the patient (Silva & Ludwick, 1999).
· Paternalism disempowers the patient. A nurse is being paternalistic by acting as an authority to regulate
needs by making decisions on behalf of a patient.
Examples of Acting Paternalistic
The physician decides that the patient needs to have a spiritual leader for a nearby church visit him as he
is. The patient refused to have a visit earlier as he doesn’t have religious faith. The physician’s actions are
dying paternalistic as he assumes that he can make decisions for the patient better than the patient can
himself
2. The Principle of NONMALEFICENCE
The principle of nonmaleficence requires of us that we not intentionally create harm or injury to the
patient, either through acts of commission or omission. In common language, we consider it negligent 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).
This principle affirms the need for medical competence. It is clear that medical mistakes may occur;
however, this principle articulates a fundamental commitment on the part of health care professionals to
protect their patients from harm.
Case 2
In the course of caring for patients, there are 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. However, in other cases, such as the case of a patient dying of painful intestinal carcinoma, the patient
might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego
life-sustaining technology such as dialysis or a respirator. The reason for such a choice is based on the belief of the
patient that prolonged living with a painful and debilitating condition is worse than death, greater harm. It is also
important to note in this case that this determination was made by the patient, who alone is the authority on the
interpretation of the "greater" or "lesser" harm for the self.
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 by stemming the bleeding, mending the broken or
suturing the wounded.
4. The Principle of JUSTICE
Justice in health care is usually defined as 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.
It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the
application of Medicare, which is available to all persons over the age of 65 years. This category of
persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need
or other noteworthy factors about the persons in this category.
In fact, our society uses a variety of factors as criteria for distributive justice, including the following:
a. To each person an equal share
b. To each person according to need
c. To each person according to effort
d. To each person according to contribution
e. To each person according to merit
f. To each person according to free-market exchanges
John Rawls (1999) and others claim that many of the inequalities we experience are a result of a "natural lottery"
or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the
playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial
issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another
way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health
care for all citizens, regardless of ability to pay. Medicaid is also a program that is designed to help fund health care
for those at the poverty level. Yet, in times of recession, thousands of families below the poverty level have been
purged from the Medicaid rolls as a cost-saving maneuver. The principle of justice is a strong motivation toward
the reform of our healthcare system so that the needs of the entire population are taken into account. The
demands of the principle of justice must apply at the bedside of individual patients but also systemically in the laws
and policies of society that govern the access of a population to health care. Much work remains to be done in this
arena.
APPLICATION OF BIOETHICAL PRINCIPLES TO THE CARE OF THE SICK
a. AUTONOMY and INFORMED CONSENT
AUTONOMY
Autonomy refers to the patients’ rights to make self-governing decisions or self-determine a course of action. In
healthcare, this applies to the patient’s right to make decisions about their own lives and health without
interference from the nurse, physician, or another team member. The nurse must respect the patient’s right to
independent decision making. This involves resisting the urge to interject one’s own feelings, values, or beliefs
onto the patient. Infringement upon this right is unethical.
Autonomy was brought to the public’s eye when the Patient Self Determination Act was passed by Congress in
1990. This Act states that competent individuals are allowed to make their own decisions pertaining to the end of
life care. It also outlined patients’ right to appoint a durable power of attorney, which designates another
individual the authority to make end-of-life decisions when the individual is no longer able to do so themselves
(American Nurses Association, 2011).
Examples of Applying Autonomy
The hospital maintains a supply of brochures in the lobby that provides information on appointing a
durable power of attorney.
The nursing staff of a dialysis clinic has been treating a patient with end-stage renal disease for several
years. One day, the patient informs them that this will be his last visit, as he no longer wants to receive
dialysis after being turned down for a kidney transplant. The nurses realize that the patient is competent
to make such decisions. Although some of the nurses are emotionally distressed about his choice, they
understand that the patient has the right to decline treatment and respect his decision.
The staff of a genetic clinic practices a form of nondirective counseling, which is commonly used in the
field of genetics. The clinician or counselor provides information to a couple that predicts the chances that
they will have a child with a genetic defect. While providing this information, they keep the conversation
based on facts, offering data on probability rates as requested, but do not attempt to direct the patients’
decision-making in any way. The right of the patients to make self-governing decisions is respected.
INFORMED CONSENT
Informed consent involves the patient’s right to autonomy and self-determination. Accurate information
must be provided to enable patients to make an informed decision about their treatment (Daly, 2009).
There are variations in how it is obtained from the individual; it may be generally implied or expressed.
Expressed consent can be obtained in either verbal or written methods (Lin & Chen, 2007). Performing a
procedure without consent can be construed as battery or assault. Clinicians and nurses that feel that
they know what’s best and force their beliefs upon a patient are acting in a paternalistic manner. There
are three elements of informed consent.
3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment
and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and
to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other
appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify
patients of any policy that might affect patient choice within the institution.
4. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable
power of attorney for health care) concerning treatment or designating a surrogate decision maker with the
expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital
policy. Health care institutions must advise patients of their rights under state law and hospital policy to make
informed medical choices, ask if the patient has an advance directive, and include that information in patient
records. The patient has the right to timely information about hospital policy that may limit its ability to fully
implement a legally valid advance directive.
5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and
treatment should be conducted so as to protect each patient's privacy.
6. The patient has the right to expect that all communications and records pertaining to his/her care will be
treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when
reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the
confidentiality of this information when it releases it to any other parties entitled to review information in these
records.
7. The patient has the right to review the records pertaining to his/her medical care and to have the information
explained or interpreted as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable
responses to the request of a patient for appropriate and medically indicated care and services.
The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case.
When medically appropriate and legally permissible, or when a patient has so requested, a patient may be
transferred to another facility.
The institution to which the patient is to be transferred must first have accepted the patient for transfer.
The patient must also have the benefit of complete information and explanation concerning the need for,
risks, benefits, and alternatives to such a transfer.
9. The patient has the right to ask and be informed of the existence of business relationships among the hospital,
educational institutions, other health care providers, or payers that may influence the patient's treatment and
care.
10. The patient has the right to consent to or decline to participate in proposed research studies or human
experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies
fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to
the most effective care that the hospital can otherwise provide.
11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by
physicians and other caregivers of available and realistic patient care options when hospital care is no longer
appropriate.
12. The patient has the right to be informed of hospital policies and practices that relate to patient care,
treatment, and responsibilities.
The patient has the right to be informed of available resources for resolving disputes, grievances, and
conflicts, such as ethics committees, patient representatives, or other mechanisms available in the
institution.
The patient has the right to be informed of the hospital's charges for services and available payment
methods.
The collaborative nature of health care requires that patients, or their families/surrogates, participate in
their care.
The effectiveness of care and patient satisfaction with the course of treatment depend, in part, on the
patient fulfilling certain responsibilities.
Patients are responsible for providing information about past illnesses, hospitalizations, medications, and
other matters related to health status.
To participate effectively in decision making, patients must be encouraged to take responsibility for
requesting additional information or clarification about their health status or treatment when they do not
fully understand information and instructions.
Patients are also responsible for ensuring that the health care institution has a copy of their written
advance directive if they have one.
Patients are responsible for informing their physicians and other caregivers if they anticipate problems in
following prescribed treatment.
Patients should also be aware of the hospital's obligation to be reasonably efficient and equitable in
providing care to other patients and the community.
The hospital's rules and regulations are designed to help the hospital meet this obligation.
Patients and their families are responsible for making reasonable accommodations to the needs of the
hospital, other patients, medical staff, and hospital employees.
Patients are responsible for providing necessary information for insurance claims and for working with the
hospital to make payment arrangements, when necessary. A person's health depends on much more than
health care services.Patients are responsible for recognizing the impact of their life-style on their personal
health.
Hospitals have many functions to perform, including the enhancement of health status, health promotion, and
the prevention and treatment of injury and disease; the immediate and ongoing care and rehabilitation of
patients; the education of health professionals, patients, and the community; and research. All these activities
must be conducted with an overriding concern for the values and dignity of patients.
1. Autonomy: In medicine, autonomy refers to the right of the patient to retain control over his or her body. A
health care professional can suggest or advise, but any actions that attempt to persuade or coerce the patient into
making a choice are violations of this principle. In the end, the patient must be allowed to make his or her own
decisions – whether or not the medical provider believes these choices are in that patient’s best interests –
independently and according to his or her personal values and beliefs.
2. Beneficence: This principle states that health care providers must do all they can to benefit the patient in each
situation. All procedures and treatments recommended must be with the intention to do the most good for the
patient. To ensure beneficence, medical practitioners must develop and maintain a high level of skill and
knowledge, make sure that they are trained in the most current and best medical practices, and must consider
their patients’ individual circumstances; what is good for one patient will not necessarily benefit another.
3. Non-Maleficence: Non-maleficence is probably the best known of the four principles. In short, it means, “to do
no harm.” This principle is intended to be the end goal for all of a practitioner’s decisions and means that medical
providers must consider whether other people or society could be harmed by a decision made, even if it is made
for the benefit of an individual patient.
4. Justice: The principle of justice states that there should be an element of fairness in all medical decisions:
fairness in decisions that burden and benefit, as well as equal distribution of scarce resources and new treatments,
and for medical practitioners to uphold applicable laws and legislation when making choices.
Communication
The exchange of thoughts, messages, or information—is of vital importance to the nursing process.
A nurse uses communication skills—speech, signals, writing, and behavior—during a patient assessment,
as well as the planning, implementing, and evaluating of nursing care.
A nurse communicates with patients, families, groups, and members of the health care team. They are
competent in oral and written forms of communication, as well as in techniques of therapeutic
communication.
Teaching
One of the most important roles of a nurse is to assist patients and their families with receiving
information necessary for maintaining a patient’s optimal health.
A nurse provides patients and families with information that is based on their assessed learning needs,
their abilities, their learning preference, and their readiness to learn.
Fundamental to the provision of patient education is a nurse’s belief that patients have the right to make
informed decisions about their care. Nurses provide information that is accurate, complete, and relevant
to client needs.
A nurse often clarifies information provided by other members of the health care team.
Critical Thinking
Nurses are constantly involved with making accurate and appropriate clinical decisions. We believe nurses
must be able to think critically and make decisions when patients present problems for which there may
not be clear textbook solutions.
A nurse must question, wonder, and be able to explore various perspectives and possibilities in order to
best help patients. Critical thinking involves an active, organized cognitive process designed to allow a
nurse to explore and challenge assumptions.
Nurses that engage in critical thinking reflect on past experiences, think independently, take risks based
on knowledge, persevere in the face of difficult problems, are curious, creative, and ethical.
Psychomotor Skills
We believe that fundamental to nursing is the “laying on of hands” to provide comfort, and the use of
specific skills to accomplish client assessment and to provide and evaluate nursing care.
Nursing skills are utilized in a manner that maximizes client comfort and dignity, optimizes the client’s
ability to respond positively, provides the highest level of accuracy of the information, and provides for
the most favorable patient outcomes.
Psychomotor skills are best learned through practice after achieving an understanding of the basic
principles of skills as part of a nurse’s education.
Applied Therapeutics
A nurse applies medically-ordered therapeutic modalities, like pharmacological and nutritional
interventions, etc.
A nurse’s application of these modalities is based on a knowledge base regarding their therapeutic uses,
as well as skills in patient assessment and evaluation.
The competent application of nutritional knowledge also involves its use in health and wellness, as well as
when therapeutic diets are prescribed.
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