HEALTH CARE ETHICS

prelims
INTRODUCTION /DEONTOLOGY

 ETHICS - Philosophical and practical science that deals with the study of the morality of human
acts or human conduct.
 ETHICS AS SCIENCE - Comprises data on the morality of human acts that are put together and
arranged in order
 Ethics - Ethics is the enterprise of disciplines reflection on the moral intuitions and moral choices
that people make”
 Ethics is the concept of interpreting morality.
 How should we behave?
 What choices should we make about how we live our lives?
 What do we consider acceptable in our society?

I. MORAL FACT – BEING GOOD IS MORAL

II. MORAL TRUTH – HELPING PEOPLE IS MORAL
 How are millennials so different to other generations?
 What is the best decision you ever made?
 What is the best advise you ever received from your parents?

https://www.youtube.com/watch?v=xfO1veFs6Ho

MORALITY

 Addresses the question of what is Right and what is Wrong.

 We are all born with a certain mind of direction and this is our gift.

WHAT FACTORS AFFECT HOW WE FIND ANSWERS?

 Family, Religion Traditions, customs, beliefs, practices, nurturance, quality of living- rearing
experiences, society, and environment we live in

AN ACT IS RIGHT IF IT CONFORMS TO AN OVERRIDING MORAL DUTY

For example – do not tell lies, do not kill.

 Christian ethics – The Ten Commandments

 But Christian ethics are not important for some people in the world so moral duties vary
between cultures and societies

WE USUALLY THINK OF THE ‘BIG’ ISSUES

Like: definition of life, what is a person, quality of life, prolonging life, ending life, human rights.

But day to day ethical issues can involve:

 -Respecting people
 -Treating people with dignity
 -Treating people fairly
 -Supporting patient’s choices

BIOETHICS - Bioethics is the investigation of ethical issues that arise in life sciences by applying moral
philosophy principles.

Bioethics covers: Medicine, Healthcare Genetics , Biology Research and Pharmacology

 The study of bioethics affects how healthcare evolves and is delivered. Healthcare, medicine and
research are regulated by law.
 Often the outcome of medical advancement can be unknown.
 It is essential to recognize that law and bioethics are not always a reflection of each other.
 Simply because something is illegal does not always mean it is morally wrong.
 Consider the arguments for euthanasia.
 Likewise, because something is legal does not mean that it is morally right.
 Consider the opposition arguments to abortion and cosmetic surgery

WHAT IS AN ETHICAL ISSUE?

 When you have to judge what is right or wrong

 Choosing between options
 Deciding whether to do something or do nothing
 Should I or shouldn’t I?
 Weighing up the potential impact of your decisions or actions
 A dilemma – making a difficult choice

HEALTH CARE ETHICS

 Health care ethics at its simplest, is a set of moral principles, beliefs and values that guide us in
making choices about medical care.
 Health ethics is the branch of ethics that deals with ethical issues in health, health care,
medicine and science.
 It involves discussions about treatment choices and care options that individuals, families, and
health care providers must face.
 It requires a critical reflection upon the relationships between health care professionals and
those they serve, as well as the programmes, systems, and structures developed to improve the
health of a population.

ETHICAL ISSUES IN HEALTH CARE

1.Improving Access to Care

2.Protecting Patient Privacy and Confidentiality

3.Building and Maintaining a Strong Healthcare Workforce

4. Care Quality vs. Efficiency

HEALTH CARE ETHICS

 Health ethics involves deliberating about the allocation of resources, and reflecting on the
complex moral choices arising from ongoing health care restructuring and advancing
technology.
 It also entails a critical, political, and ethical analysis of the definition and the determinants of
health.

WHY ARE ETHICS PART OF PROFESSIONAL PRACTICE?

 Professional codes of conduct exist as a result of the ethical and legal duties and
responsibilities expected of practitioners.
 Through ethically reasoned argument we establish what is considered right and a positive
obligation, or what is considered wrong and prohibited.
 Provides a moral standard that patients and staff can expect from us.

1. DEONTOLOGY
Greek:

Deon- “duty”

logos- “science”

Duty or principle based theory

 Our care for patients should be based on sound judgement

 -some of this judgement is about having a strong sense of what is right or wrong
 -having a strong sense of what we should be doing and shouldn’t be doing
- as nurses having a strong sense of what our priorities ought to be

DEONTOLOGY

 Duty-based ethics- the right course of action is that which is consistent with one’s moral duties.
 According to Immanuel Kant, the theory’s most well known proponent, one of these duties is to
never use another person as a means to one’s own ends.
 Before making a decision, one should think about whether it would be reasonable for everyone
to act in the proposed way.
 According to deontology then, an action itself has features that are distinct from the action’s
consequences, and that make the action right.
 Holds that certain things are right or wrong regardless of the consequences.

Example: Telling the truth may cause happiness or upset but is considered the right thing to do

 In Deontological ethics an action is considered morally good because of some characteristic of

the action itself, not because the product of the action is good.

IMMANUEL KANT - First great philosopher to define deontological principles.

The founder of critical philosophy whose ethics were much influenced by Christianity
2. TELEOLOGY
Greek:
Telos- “end”
logos- “science”
Teleology is the study of the ends or purposes that things serve
• Aristotle believed that the best way to understand why things are the way they are is to
understand what purpose they were designed to serve

Teleology
 Key questions which teleological ethical systems ask include:
 What will be the consequences of this action?
 What will be the consequences of inaction?
 How do I weigh the harm against the benefits of this action?
Also known as Consequentialism- a Normative Moral Theory
TELEOLOGY- Theory in morality that derives duty or moral obligation from what is good or
desirable as an end to be achieved. It is opposed to deontological ethics which holds that the
basic standards for an action’s being morally right are in dependent of the good or evil
generated.
Actions are right or wrong according to the balance of their good and bad consequences

WHAT IS HAPPINESS? - Pleasure! This called the HEDONISTIC THEORY OF VALUE OF THE GOOD- What
makes people happy is to experience Pleasure.

- To a UTILITARIAN THIS DOES NOT not always aim to promote the Idea. The Moral task
is to promote as much pleasure as possible as such taking every person into account
sometimes, we need to Sacrifice our own pleasure!
- PETER SINGER ( Famous Utilitarian). Do the most good you can for the most people.

If the action creates the most good possible, It is morally right according to the consequentialism. The
consequentialist determines the Right action in terms of what causes good to people, one must
provide the definition of “Good”

Great Consequentialist of the UTILITARIAN

MOVEMENT- JEREMY BENTHAM And JOHN STUART MILL

  Teleological moral systems are characterized primarily by a focus on the consequences which
any action might have for that reason, they are often referred to as consequentialist moral
systems.
 In order to make correct moral choices, we have to have some understanding of what will
result from our choices.
 When we make choices which result in the correct consequences, then we are acting morally.
 When we make choices which result in the incorrect consequences, then we are acting
immorally.

CONSEQUENTIALISM - Does not supply us with very good guidance , It is very difficult , if
not impossible to predict the consequences of actions.

- If we constantly measure our actions, it undermines important practices and norms.

 First and foremost a standard for what makes actions right not a procedure to apply to every
action.
 Calculating the positive and negative consequences

UTILITARIANISM - Utilitarian type theories hold that the end consists in an experience or
feeling produced by the action.

The Happiness Paradox-

a) The source of UNHAPPINESS is the constant Striving for HAPPINESS.
b) JOHN STUART MILL- “Ask yourself whether you are Happy and you cease to be so. The process
of optimizing happiness is like finding your way.
c) Travel from A to B, it is not always good idea to constantly focus on B, keep your eyes on the
road and direct to relevant sign post. In the same way to do the most good you can do, do not
focus constantly on the abstract goal, consider the rules norms and values established precisely
to help us produce the most happiness possible.

JOHN STUART MILL - Not only the quantitative amount of pleasure is a measure for the right action,
there are different qualities of pleasure.

Example the Reading of Books/ chess is a better quality than enjoying eating ice cream. Make sure to
take both quality and quantity into account when considering the consequences of an action.

There should be Basic Norm to establish is to set the happiness of others as something that makes you
happy yourself.

“If He is Happy, I am Happy”

BENTHAM- Higher Pleasures in mind such as intellectual pleasure as something for us to make a priority,
not because they have a better quality than so called simple pleasures but because in the long run,
intellectual pleasures tend to produce even more happiness

Eating Ice Cream- a short term pleasure- can also lead to displeasure (fat) if too much

Reading books - long term pleasure, crucial to your ability to become wiser and creates happiness
throughout the rest of your life.

Teleological ethics, says that one’s ethical decisions should be based on final goals and ends
• Deontology- say that ethics should be based on commitments to moral principles, without regard for
ends.

• A teleologist- would say that one should kill an innocent person if that would save two other innocent
lives

• A deontologist would say that if killing is wrong, it remains wrong, even if it could save lives

 Star Trek film Mr. Spock before he died mentioned “the needs of the many outweigh the needs
of the few or one,” justifying a variety of heroic sacrifices and risks.
 Consequences of action - Good/Bad — This idea embodies teleological ethics, or
consequentialism.
 Utilitarianism- The end results of an action—the salvation of many lives—justifies the sacrifice of
one life

3. VIRTUE ETHICS
"We are what we repeatedly do. Excellent then, is not an act, but a habit." -Aristotle
IMAGINE A PERSON-
• ALWAYS KNOWS WHAT TO SAY
• CAN DIFFUSE A TENSE SITUATION
• DELIVER TOUGH NEWS GRACEFULLY
• CONFIDENT WITHOUT BEING ARROGANT
• BRAVE BUT NOT RECKLESS
• GENEROUS BUT NEVER EXTRAVAGANT

The type of person that everybody wants to be around and to be like

Someone who has mastered the art of being a person
RARE THESE PEOPLE DO EXIST, and they are what we should aspire to be: VIRTUOUS.

VIRTUE THEORY
• Ethical theory that emphasises an individual’s character rather than
following a set of rules.
• It is all about character.
• Rather than saying “follow these rules so that you can be a good person. If we can just focus
being good people, the right actions will follow, effortlessly.

WHY SHOULD YOU BE A VIRTUOUS PERSON?

 EUDAIMONIA. It means a life well lived. It is sometimes translated as “Human
flourishing”
 A life of Eudaimonia is a life of striving. It is alive of pushing yourself to your limits, and
finding success.
 A eudaimonistic life will be full of the happiness that comes from achieving something
really difficult rather than just having it handed to you.
 Choosing to live a eudaemonistic life means that you’re never done improving, you’re
never to point where you can just coast. You are constantly setting new goals and
working to develop . Choosing to live life in this way also means you will face
disappointments and failures
 Proper functioning- everything has a function , and It is sometimes translated as “thing
is good to the extent that is fulfils its function, and bad to the extent that it doesn’t
 Objects created by human: Knife is to cut, so dull knife is a bad knife. A flower is to grow
and reproduce, so a flower that doesn’t do that is just bad of being a flower.
The same goes for Humans: we’re animals- so all the stuff that would indicate proper
functioning for an animal holds true for us as well- we need to grow and be healthy and fertile.
We’re also the Rational Animal and a social animal, so our function also involves using reason
and getting along with our pack.

WHAT EXACTLY DOES IT MEAN TO BE VIRTUOUS?

Aristotle said that having virtue just means doing the right thing, at the same time, in the right
way, in the right amount, toward the right people.
There’s no need to be specific, because if you’re virtuous, you know what to do. All the time.
You know how to handle yourself and how to get along with others, you have good judgment,
you can read a room, and you know what is right and when.

❖ Virtue as the midpoint between 2 extremes, which Aristotle called vices.

❖ Virtue is just the right amount, the sweet spot ( Golden Mean) between the extreme of
excess and the extreme of deficiency.

❖Acorns are built with the drive to become oak tree

COURAGE
Walking home from a movie, you see a person being mugged. What is the courageous action
for you to take?
Your impulse might be to say that courageous person would run over there and stop the
mugging, because courage means putting yourself in harm’s way for a good cause , Right?
SIZING UP THE SITUATION
A virtuous person in Aristotelian sense - would first take stock of the situation. If you size up the
mugger and have a good reason to believe that you can safely intervene, then that probably the
courageous choice. But if you assess the situation and recognize that intervention is likely to
mean that both you and the victim will be in danger, the courageous choice is not to intervene,
but to call for help instead.

❖ According to Aristotle, Courage is the midpoint between the extremes of cowardice and
recklessness.

❖ Cowardice is a deficiency of courage and recklessness is an excess of courage and both are
bad.

❖ You definitely can have too much of a good thing.

COURAGE IS FINDING THE RIGHT WAY TO ACT

• Courageous person will assess the situation, they‘ll know their own abilities, and they will take
action that is right in the particular situation.
• Part of having courage is bing able to recognize.
• When rather than stepping in, you need to find an authority who can handle a situation that I
that is too big for you to tackle alone.

HONESTY- Midpoint between Brutal honesty and failing to say things that need to be said
- The virtue of Honesty means knowing what needs to be put out there, and
what you should keep quiet about.

❖ Honesty also means knowing how to deliver hard truths gracefully.

❖ How to break bad news gently, or to offer criticism in away that is constructive , rather
than soul -crushing.

GENEROSITY - It Avoids the obvious vice of stinginess but also doesn’t give too much.
 - It is not generous to give drugs to an addict or to buy a round of drinks for
everyone when you need that money to pay the rent or tuition fee
- If you have to figure out what virtue is in every situation, how can you possibly
learn to be virtuous?
- Aristotle said- Virtue is a skill, a way of living, and that is something that can
really only be learned through experience.
- Virtue is a kind of knowledge that he called Practical Wisdom.

Aristotle said your character is developed through habituation. If you do a virtuos thing over
and over again, eventually it will become part of your character. So you learn virtue by watching
it and then doing it

4. ETHICAL PRINCIPLES
AUTONOMY
Greek word: Autos (self)
Nomos ( governance)

AUTONOMY
 Refers to one’s moral power or right to self-governance and determination to make
decisions in directing one’s own life. It presupposes the exercise of freedom upon which
autonomy is incumbent to determine the course of action to choose and take in
pursuing that which upholds human dignity and life.
 The term self determination is often used synonymously with autonomy.
 In health care milieu, the patient’s autonomy should be exercised to facilitate his
implicit or explicit participation in the treatment of his illness, alleviation of his suffering,
and restoration of his health for a quality for a quality life.

IMPLICATIONS OF PATIENT’S AUTONOMY

1. THE PATIENT IS RESPONSIBLE FOR HIS CHOICES AND DECISIONS
2. HIS HUMAN DIGNITY IS UPHELD AND RECOGNIZED
3. HIS PERSONAL VALUE AND WORTH ARE AFFIRMED
4. HIS PATIENT’S RIGHTS ARE PROTECTED AND ARE NOT UNDULY INTERFERED WITH
5. HE CANNOT BE CONSTRAINED OR FORCED TO MAKE DECISIONS AND PERFORM
ACTIONS AGAINST HIS WILL

PATIENT’S RIGHTS - This refer to the moral power incumbent upon the dignity of
the patient as a human person which is enjoined by both natural law and positive
law requiring that what is due must be rendered to the patient as justice
demands.
PATIENT’S BILL OF RIGHTS
1. Right to Appropriate Medical Care and Humane Treatment
2. The Right to Informed consent. Except in the following cases:
a. emergency cases
b. when the health of the population is dependent on the adoption of a mass health program to
control epidemic
c. when the laws makes it compulsory for everyone to submit to a procedure
d. when the patient is either a minor or legally incompetent, where third party consent is
required
e. when disclosure of material information to patient will jeopardize the success of treatment
f. when the patient waives his right in writing.
3. Right to Privacy and Confidentiality
4. Right to information
5. Right to Choose Health Care Provider and Facility
6. Right to Self Determination
7. Right to Religious Belief
8. Right to Medical Records
9. Right to Leave
10. Right Refuse Participation in Medical Research
11. Right to Correspondence and to Receive visitors
12. Right to Express Grievances
13. Right to be Informed of His Rights and Obligations as a Patient
- A patient is brought in ER dept with a history of sudden onset of abdominal pain. On
examination had abdominal guarding and rigidity and has air under diaphragm on X-ray. He was
advised laparotomy and was explained the details of the procedures.
- Despite understanding the procedure in detail, he refused to undergo the procedures. What is
the most appropriate step at this point?

INFORMED CONSENT - Informed consent in health care refers to the patient’s deliberate
and voluntary acceptance of a health care procedure which presupposes sufficient
disclosure of the nature and goals of the procedure, its possible side effects , risks and
benefits and the available medical options.
The procedure can be diagnostic, preventive, curative and/ or research for experimentation
that may have some effects on the patient’s bodily integrity and human dignity. That is
why, informed consent is sought in agreement with the principle of autonomy.
FORMS OF CONSENT –
a. Proxy Consent/ Legally Acceptable Representative This is done when the patient is not capable of
giving informed consent and is legitimately represented by a competent surrogate who acts on his
behalf.

The patient may either be unconscious, insane or a minor/ child who is out of reason or not at the age of
reason. The competence of the representative primarily resides in his manifested motivation to serve
the best interest of the patient.

b. Consent by presumption- This is reasonably presumed to be present in the subsequent employment

and series of procedures as they are aligned with the primary procedure to which explicit consent is
expressed.

Attributed to the patient who in his current biological condition, cannot utterly articulate consent. The
judgment of prudence and reason takes a sufficient ground for the consent of the most appropriate
medical procedure to serve the best interest of the patient.

PRIVACY
Confidentiality

An important aspect of the trust that patients place in health care professionals. If the patient felt that
information in regard to his body or condition was the subject of public conversation used to brighten
the coffee break in the cafeteria or was subject to release to publications, a great barrier between
practitioner and patient would exist. This fear of disclosure has, in the past led minors with sexually
transmitted disease to suffer without care rather than seek to aid , knowing that the system required
the health care system to notify their parents.

VERACITY
Binds both the health practitioner and the patient in an association of truth. This patient must tell the
truth in order that appropriate care can be provided. The practitioner needs to disclose factual
information so that the patient can exercise personal autonomy.

FIDELITY
 By fidelity, we mean the obligation to act in good faith and to keep vows and promises, fulfill
agreements, maintain relationships and fiduciary responsibilities.
 Fiduciary responsibility refers to the contract of relationship we enter into with the patient.
 Fiduciary responsibility bank on trust and confidence.
 This means that once the physician or nurse enters into a relationship with the patient, these
professionals become the trustees of the patient health and welfare.
  Hence both the physician and the nurse are obligated to maintain the contract of care. The
model for fidelity is keeping one’s word of honor, loyalty to commitments and oaths , and
reliability.
 The model of fidelity leans on the values of loyalty and trust as well as standing true to one’s
word. In popular Spanish parlance, known as palabra de honor. With fidelity goes the traits of
maturity and commitment of the person.

JUSTICE/ FAIRNESS
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.

Aristotle: equals must be treated equally and un-equals must be treated unequally.

In health care we are confronted by distribution problems that seem to provide better care to he rich
than to the poor, the urban dweller over the rural, the middle aged over the child or elderly.

Compensatory justice- in which individuals seek compensation for a wrong that has been done. Recent
cases where cigarette smokers have received compensation from tobacco companies for their lung
cancer or emphysema suggest how large an issue this may become. Fines or compensation for injury,
are requested.

Retributive justice- an eye for an eye and a tooth for a tooth. Requires equal suffering.

BENEFICENCE
 The term beneficence suggest acts of mercy and charity,although it certainly may be expanded
to include any action that benefits another.
 Most health care professions have statements that echo the Hippocratic oath, which states that
“the physician will apply means for the benefit of the sick”.
 In the pledge of American nurses association this is clearly stated the nurse’s primary
commitment is to health, welfare and safety of the client.
 One ought to prevent evil or harm, one ought to remove evil or harm , one ought to do or
promote good.

 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
necessary benefit another.
NON- MALEFICENCE
Most health care professional pledges or codes of care echo the principle paraphrased from the Hippocratic oath
statement- I will never use treatment to injure or wrong the sick.

One ought not to inflict evil or harm.

All the statements of the beneficence involved positive action toward preventing or removing harm, and
promoting the good.in the non-maleficence statement, the admonition is stated in the negative, to refrain from
inflicting harm.

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.

6. PRINCIPLE OF DOUBLE EFFECT

Keep in Mind! - There is a difference between performing a GOOD act, which has both good
and evil effects and performing an EVIL act in order that good may result.
GUIDING ELEMENTS
a. The Nature of the act - the course chosen must be good or at least morally neutral
b. b. Not means to an end - the good must not follow as a consequence of the
secondary harmful effects
c. The right intention -the harm must never be intended but merely tolerated as
casually
d. Proportionality- the good must outweigh the harm
APPLICATION
•A little boy cuts his hand, His mother applies iodine to the injury. This action has 2 effects: it gives the
boy pain and it wards off infection. Although she did not recognize it

•Did the mother apply the four principles that we mentioned

GOOD ACT/EVIL ACT Make a reaction in the following situation

 The officials of a state decree that a necessary new highway shall be built. Some individuals are
required to move away to make room for the highway.
 The government decrees that all insane people shall be killed in order to decrease taxes.
 Sterilizing a woman so that she can not add additional members to her financially overburdened
family.

EXAMPLE:
 This is a case of a woman in a non-viable stage of pregnancy, with cancer of uterus, when immediate
hysterectomy is indicated to save her life.
 Is this operation morally permissible or morally justified by reason of the principle of double effect?
Example
 A mother is experiencing hyperemesis gravidarum/ pernicious vomiting because of this the mother is in
pain and suffers a lot. This is easily solved by the termination of pregnancy.
 Is the action morally good/evil?

PRINCIPLE OF COMMON GOOD

Common Good
“The sum total of social conditions which allows people, either as groups or as individuals, to reach their
fulfillment more fully and more easily.”

God created the world for all and the goods of the world should in principle, be at the disposal of all and for
the good of all, without preferential treatment.

PRINCIPLE OF SUBSIDIARITY -
 What can be done by an individual or lower group should not be done by a higher group
 Every task of society should be assigned to the smallest possible group that can perform it. Only if the
smaller group is unable to resolve the problem itself should a group at a higher level assume responsibility.

Example: If a nursing school is capable on an efficient training program and willing to do so, then the state or any
federation of nursing should not interfere

Summary: Importance of moral principles in the practice of health care