Chapter 4

Ethical Issues

“ In some significant respects, moral distress is embedded in the historical and structural fabricof the nursing profession.” (Hamric, 2000)

The Management Challenge

Because personal, organizational, subordinate, and consumer responsibilities differ, there is great potential for managers to experience intrapersonal conflict.

Ethics

The systematic study of what a person’s conduct and actions ought to be with regard to him- or herself, other human beings, and the environment; it is the justification of what is right or good and the study of what a person’s life and relationships ought to be, not necessarily what they are.

ETHICS

In general terms is the philosophic sciences that deal with human acts.

ETHICS

A study of morality’s effect on conduct; the study of moral standards and how they affect conduct.

Is a practical and normative science, based on reason, which studies human acts and provides norms for their goodness or badness.

Reminder

The way managers approach and solve ethical dilemmas is influenced by their values and basic beliefs about the rights, duties, and goals of all human beings.

Ethical Dilemma

Defined as making a choice between two or more equally undesirable alternatives

The individual who must solve an ethical dilemma is the only person who can ascertain if actions taken were congruent with personal values.

Leah Curtin (1982) maintained that in order for a problem to be an ethical dilemma, it

needed to have three characteristics:

1. The problem cannot be solved using only empirical data.

2. The problem must be so perplexing that it is difficult to decide what facts and data need to be used in making the decision.

3. The results of the problem should have far-reaching effects.

Three Approaches toEthical Decision Making

1. Deontological— duty-focused normative approach centered on rules from which all action is derived.

2. Teleological— outcome- focused approach that places emphasis on results and protects the interest of the majority.

3. Situational— no prescribed rules, norms, or majority-focused results that must be followed.

Frameworks for Ethical Decision Making

1. Utilitarianism2. Duty-based

reasoning3. Rights-based

reasoning4. Intuitionism

Principles of EthicalDecision Making

1. Autonomy2. Beneficence3. Paternalism4. Utility5. Justice6. Truth telling (veracity)7. Fidelity8. Confidentiality

Autonomy

Promotes self-determination/ freedom of choice

Self governance, ability to choose and carry out one’s decision without undue pressure or coercion from anyone.

BENEFICENCE(Doing Good)

The actions one takes should be done in an effort to promote good.

Refers to action that benefits others based on the Hippocratic Oath to “apply measures that will benefit the sick”

beneficence

Is the practice of doing acts of goodness, kindness, and charity. The beneficence principle may thus be stated: “DO NO HARM AND PRODUCE THE GOOD” or “DO GOOD AND DO NO HARM”

NON-MALEFICENCE

This principle imposes the duty to avoid harming the patient based on the Hippocratic Oath of “do no harm”

Non-maleficence

Refers to prevention of harm and the removal of harmful conditions.

PaternalismOne individual assumes the right to make decisions for another.

paternalism

From the Latin word pater “father” or paternus “fatherly”- paternalism means the act of being fatherly to someone, as if the latter were one’s own offspring. Strictly speaking, it consist in acting like a father to a person for the latter's own good and interest.

Justice

Seeks fairness. Treats “equals” equally.Treats “unequals” according to their differences.

JUSTICE- it signifies fairness which also to give to each one what he deserves.

JUSTICE

In general, justice refers to what is owed or due to the individual members of society.

When considering the concept of JUSTICE, it is important to distinguish between four different types of justice:

– 1. COMMUTATIVE JUSTICE– 2. CONTRIBUTIVE JUSTICE– 3. LEGAL JUSTICE– 4. DISTRIBUTIVE JUSTICE

1. COMMUTATIVE JUSTICE

Refers to that which is owed between individuals, e.g. in conducting business transactions

2. CONTRIBUTIVE JUSTICE

Refers to what individuals owe to society for the common good

3. LEGAL JUSTICE

Refers to rights and responsibilities of citizens to obey and respect the rights of all and the laws devised to protect peace and social order

4. DISTRIBUTIVE JUSTICE

Refers to what society owes to its individual members; – i.e. the just allocation of resources

SOME INFLUENCIAL THEORIES THAT GO WITH THE PRINCIPLE OF JUSTICE:

1. UTILITARIAN

Emphasizes a mixture of criteria for the purpose of maximizing public utility.

2. LIBERTARIAN

Emphasizes rights to social and economic liberty, invoking fair procedures rather than substantive outcome.

3. COMMUNITARIAN

Stresses the principles and practices of justice that evolve through traditions in a community.

4. EGALITARIAN

Emphasizes equal access to goods in life that every rational person values.

NON-MALEFICENCE

Refers to prevention of harm and the removal of harmful conditions.

BENEFICENCE

Is the practice of doing acts of goodness, kindness, and charity. The beneficence principle may thus be stated: “DO NO HARM AND PRODUCE THE GOOD” or “DO GOOD AND DO NO HARM”

Veracity

The obligation to tell the truth.

VERACITY

Meaning TRUTHFULNESS. TO BE TRUE is to accept one’s self as one

is. To respect veracity in relationships is to deal honestly to patients and colleagues as they are.

FidelityThe need to keep promises.

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.

THE MODEL FOR FIDELITY:

Keeping one’s word of honor Loyalty to commitments and oaths reliability

Fiduciary responsibilities refers to the contract of relationship we enter into with the patient.

Fiduciary relationship 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’s health and welfare.

ConfidentialityKeeping privileged information private.

Utility The good of

the many outweighs the wants/needs of the individual.

PRINCIPLE OF DOUBLE EFFECT

An action that is good in itself that has two effects- an intended and otherwise not reasonably attainable good effect, and an unintended yet foreseen evil effect– is licit, provided there is a due proportion between the intended good and the permitted evil.

To make appropriateethical decisions:

The manager must use a professional approach that eliminates trial and error and focuses on proven decision-making models or problem-solving processes.

The MORAL Decision Making Model (Crisham, 1985)

M—Massage the dilemma. O—Outline options. R—Review criteria and resolve. A—Affirm position and act. L—Look back. Evaluate the

decision-making.

Murphy and Murphy (1976) Approach to Ethical Problem Solving

1. Identify the problem.2. Identify why the problem is an ethical problem.3. Identify the people involved in the ultimate decision.4. Identify the role of the decision maker.5. Consider the short- and long-term consequences of each alternative.6. Make the decision.7. Compare the decision with the decision maker’s

philosophy of ethics.8. Follow up on the results of the decision to establish a baseline for future decision making.

Another error made by managers in ethical problem solving is using the outcome of the decision as the sole basis for determining the quality of the decision making.

Ethics in Action

In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse–managers involves some ethical component.

“If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with a poor outcome, the manager should accept that the best possible decision was made at that time with the information and resources available.”

The following forces ensure that ethics will become an even greater dimension in

management decision making in the future:

increasing technology, regulatory pressures, and competitiveness among healthcare providers;

national nursing shortages; reduced fiscal resources; spiraling costs of supplies and

salaries; and the public’s increasing distrust

of the healthcare delivery system and its institutions.

Health care profession

Is defined as a profession in which a person exercises skill and judgment or provides a service related to:– A. the preservation or improvement of the

health of an individual– B. the treatment or care of individuals who are

sick, injured, harmed, disabled or infirmed.

Health care professionalism

Profession and professional come from the Latin word “profession” which means a public declaration with the force of a promise.

Professionalism in health care requires that one strives for excellence in the following areas which becomes part of the attitudes, behaviors and skills integral to patient care:

A. ALTRUISM

A health care professional is obligated to attend to the best interest of patients rather than self interest.

B. ACCOUNTABILITY

A health care professional is accountable to their patients, to society on issues of public health and to their profession.

C. EXCELLENCE

Health care professionals are obligated to make a commitment to life-long learning.

D. DUTY

A health care professional should be available and responsive, accepting a commitment to service within the profession and the community.

E. HONOR AND INTEGRITY

Health care professionals should be committed to being fair, truthful and straightforward in their interactions with patients and the profession.

F. RESPECT FOR OTHERS

A health care professionals should demonstrate respect for patients and their families and to the other members of the team.

BASIC ETHICAL PRINCIPLE

PRINCIPLE OF STEWARDSHIP

Stewardship requires us to appreciate the two great gifts that a wise and loving God has given: the earth, with all its natural resources and our own human nature, with its biological, psychological, social, and spiritual capacities. This principle is grounded in the presupposition that God has absolute Dominion over creation, and that, in so far as human beings are made in God’s image and likeness (Imago Dei), we have been given a limited Dominion over creation and are responsible for its care.

The principle of stewardship includes but is not reducible to concern for scarce resources, rather, it also implies a responsibility to see that the mission of Catholic health care is carried out as ministry with its particular commitment to human dignity and the common good.

Principles of integrity and totality

These principles dictates that the well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified only by a proportionate benefit to the patient.

INTEGRITY refers to each individuals duty to “preserve a view of the whole human person in which the values of the intellect, will, conscience and fraternity are pre-eminent”

TOTALITY refers to the duty to preserve intact the physical component of the integrated bodily and spiritual nature of human life, whereby every part of the human body “exists for the sake of the whole as the imperfect for the sake of the perfect”.

Moral and spiritual responsibilities of nurses

Principles or rules

1. THE GOLDEN RULE

• God said “do unto others what you would like others do unto you.”

2. The two-fold effects

When a nurse is faced with a situation which may have both good and bad effects, how should she choose which one to follow? The basis of action may be the following:– That the action must be morally good– That the good effect must be willed and the bad effect

merely allowed– That the good effect must not come from evil action but

from the initial action itself directly; and – That the good effect must be greater than the bad effect.

It is not morally good if a boy steals in order to alleviate his hunger because the action itself is already bad. On the other hand, if a patient who has cancer of the uterus submits to hysterectomy she will not be able to bear a child. If she does not have the operation, she will die. It is the gynecologist’s intention to help the mother and no to harm the her. The surgeon’s action is morally good since saving the mother’s life is of primary importance. Also the doctor himself did not will that the patient lose her child-bearing function.

3. The principle of totality

The whole is greater than any of its parts. Suppose a man’s foot is gangrenous, should he

consent to an amputation? Since the amputation will save the patient’s life and he can still walk through the aid of crutches or artificial limbs, he can consent to an operation.

4. EPIKIA

“exception to the general rule” It is a reasonable presumption that the authority making

the law will not wish to bind a person in some particular case, even though the case is covered by the letter of the law.

if a mental patient went berserk and the doctor could not be contacted, the patient may be restrained by the virtue of epikia. Another example is allowing a relative to see a seriously ill patient who expresses the desire to see the former although it is not yet visiting hours.

5. One who acts through an agent is himself responsible

For example, a patient wants to have an abortion and asks a nurse if she can do it. The nurse refuses, but then recommends a doctor who is capable of performing an abortion. The nurse becomes liable to such crime, since he/she is an accomplice of the said doctor.

6. No one is obliged to betray himself/herself

In testifying before a court, no one can force any person to answer a question if such will incriminate him/her.

7. The end does not justify the means

Giving a sleeping tablet to a chronically ill person so he/she can die in peace is morally wrong. A physician in the US assisted a woman, diagnosed as having Alzheimer’s disease, in committing suicide. This is both legally and morally wrong.

8. Defects of nature may be corrected

Patients with a cleft palate may have their defects corrected by plastic surgery. What shall be the role of the nurse in a case in which parents of a severely deformed newborn child (Down’s Syndrome with intestinal atresia) refuse to feed and allow their child to starve to death?

Withholding nutrition can constitute nursing neglect and expose the nurse to criminal charges of negligence or conspiracy to commit suicide.

9. If one is wiling to cooperate in the act, no injustice is done to him/her

Suppose a patient subjects himself/herself willingly to an experimental drug and he/she has been told of the possible effects of the same, is of right age, and is sane, there is no violation of human rights.

10. A little more or less does not change the substance of an act

If a nurse gets a medicine from a hospital stock without permission or without prescription, he/she will be guilty of theft even if he/she got only one tablet of the same.

11. No one is held to the impossible

To promise that a patient with heart transplant will live may be an impossibility. Yet, such procedures are done in the hope of saving or prolonging a patient’s life. The doctor or the nurse cannot be held to the impossible if they have done their best to take care of the patient and the latter dies.

12. The morality of cooperation

Formal cooperation in an evil act is never allowed. Immoral operations such as abortion shall not be participated upon by a nurse even if the doctor commands

13. Principle relating to the origin and destruction of life

“thou shall not kill” If God has given man a life, will it mean

that God has already ceded his right to man?

Assuming that God gave life to man, who will know that God does abhor a man who takes his own life?

Basic moral criteria 1. the object of the act must not be intrinsically

contradictory to one’s fundamental commitment to God and neighbor, 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.

Principle of subsidiarity

Often considered a corollary of the principle of the common good, subsidiarity requires those in positions of authority to recognize that individuals have a right to participate in decisions that directly affect them, in accord with their dignity and with their responsibility to the common good.

Decisions should be made at the most appropriate level in a society or organization, that is, one should not withdraw those decisions or choices that rightly belong to the individuals or smaller groups and assign them to a higher authority.

MORAL PRINCIPLES

The principle of beneficence

Principle of beneficence provides that good must be done either to oneself or to others.

The principle of non-maleficence

Provides that evil or harm should not be inflicted either on oneself or on others.

This fundamental moral principle binds and urges everyone to avoid inflicting harm as a moral obligation.

It mandates the right not to be killed, right not to have bodily injury, or pain inflicted (on) oneself, and right not to have one’s confidence revealed to others.

Some violations of the principle of non-maleficence:

Physically harming a person as in suicide, abortion, infanticide, mutilation, torture, and violence;

Exposing a person to physical harm as in subjecting a person to unnecessary treatment or to a dangerous procedure without a commensurate important goal; and

Harming a person’s reputation, honor, property or interests as by revealing confidential information.

The principle of double-effect

A good act may have several good effects and is worthy of being performed thereby increasing its goodness or even adding new goodness. An evil act may also have several evil effects and is unworthy of being chosen.

The four conditions:

1. The act must be good in itself, or at least, morally indifferent. Being the primary moral determinant, the act

by it very nature must be good. Its goodness proceeds from within itself. If it not possible to be good, the act must not be evil in itself. At least, it is morally indifferent.

2. The good effect must directly proceed from the act itself and not from the evil effect. At the very least, both effects must occur simultaneously.

it indicates the fact that the good effect is the one that is being directly willed and not the evil effect in the performance of an act. The good effect is the very purpose for which the act is done, and as such, it is produced not by the evil effect but by the act itself. In fact, it comes ahead of the evil act.

3. There must be sufficient reason for the performance of an act in its attainment of the good effect.

As determined by the nature of the act and its circumstances, sufficiency of reason exists when there is no other means by which the desired good effect is as equally important as to permit the occurrence of the evil effect.

4. The motive of the agent must be holy and honest.

how can the agent be honest in his intention?

By directly willing to obtain the good effect and not the evil effect of the act. This can be proven when the evil effect just follows after the good effect is achieved.

When can the principle of double effect not be invoked?

1. When the act by its nature is evil.2. When the good effect directly proceeds

from the evil effect and not from the act itself.

3. When there is no sufficient reason for the performance of an act with two effects, one-good, the other-evil.

4. When the motive of the agent is not honest.

The principle of indirect voluntary act

Aside from an act with two-effects-one, good as directly intended and the other, evil as unintended-there is also an act that is directly intended with an evil effect that is not directly intended though foreseen or foreseeable.

Sometimes, in the performance of human act which is of course a willed act as freely determined by the will, an evil effect sprouts which is not directly willed. That is why, oftentimes, remarks like: “sorry, I did not truly mean it,” or “sorry, it was not really intended” are at once addressed by the one who performs the act, with an evil effect which does not directly intend, to the other who suffers from the said effect. This is what INDIRECT VOLUNTARINESS of an act is all about.

The three conditions:

1. The evil effect must be foreseen or foreseeable in the performance of the act at least in a general way. Common sense gives anyone the capacity to

foresee that an evil effect, though indirectly willed, may happen as it proceeds from a human act that is to be performed.

2. There must be freedom to choose not to do the act which is the cause of the evil act.

A free act is elicited by the will having the power to choose to do or not to do it. However, freedom cannot be exercised if there is no light of knowledge in the intellect.

3. Refraining from doing the act which is the cause of the evil effect holds the agent morally bound.

Reason dictates that when the evil effect is foreseen or foreseeable and that the agent is free, he is morally obliged not to pursue the performance of an act which serves as the cause of the evil effect.

The principle of stewardship

STEWARDSHIP refers to the expression of one’s responsibility to take care of, nurture and cultivate what has been entrusted to him.

In health care practice, STEWARDSHIP refers to the execution of responsibility of the health care practitioners to look after, provide necessary health care services, and promote the health and life of those entrusted to their care.

The principle of justice

JUSTICE- simply means the rendering of what is one’s due. A person who is justly doing an act to another person gives the latter what is his due.

Principle of justice refers to a moral principle by which certain actions are determined and deemed as just or unjust, as due or undue.

RIGHT – is a moral power of performing, of possessing, or of requiring something which is due.

DUTY – is defined as a moral obligation incumbent upon a person of doing or omitting (avoiding) something.

Main duties and obligations of health care practitioners:

1. Preservation of life and health2. Protection of bodily integrity from harm.3. Respect for human dignity.

Distributive justice

Pertains to a fair scheme of distributing society’s benefits and burdens to its members.

In health care milieu, benefits refers to various health care services, while burdens include the necessary payment for the delivery of health care and participation in medical experimental research.

Two alternatives:

1. THE UTILITARIAN ALTERNATIVES These represents maximizing strategies to

achieve the greatest amount of good or minimizing strategies to reduce the amount of potential harm.

a. The medical success principle

Gives priority to those for whom treatment has the highest probability of medical success. If the condition of the patient shows favorable prognosis and that he has the utmost possibility of being cured, his right to medical treatment prevails over the other.

b. The principle of immediate usefulness

Gives priority to the candidate who is of greatest immediate service to the larger group under the circumstances. In case of typhoon-related health problems in the community, the social worker or the community leader has the greater right to medical assistance than the community folks.

c. The principle of conservation

Gives priority to those candidates who require proportionally smaller amount of resources and therefore more lives would be saved. If a group of patients needs smaller quantity of health benefits proportionate to each of them, all members in that group are entitled to medical interventions. Minimizing health care resources is equivalent to maximizing the number of health care recipients. Hence, more patients are treated.

d. The parental role principle

Gives priority to those who have the largest responsibility to dependents. The father with dependent children would be given priority over a bachelor with no dependents.

e. The principle of general social value

Gives priority to those believed to have the greatest general social worth thus leading to the good of society. The municipal or city mayor has a right to medical treatment deemed greater than an ordinary citizen.

2. The egalitarian alternatives:

These represent maintaining or restoring the equality of the person in need.

a. The principle of saving no one

Gives priority to no one because not all can be saved. If there are no enough resources for all who need them, then no one should receive any.

b. The principle of medical neediness

Gives priority to the candidates with the most pressing medical needs. Patients who are the most seriously ill are the one who benefit from the limited health care resources.

c. The principle of general neediness

Gives priority to the most helpless or generally neediest in an attempt to bring them as nearly as possible to the level of well-being equal to that enjoyed by others. The poorest candidate would receive the available resources.

d. The principle of first come, first serve basis

Gives priority to those who arrive first. This principle is practical. It may apparently convey a message of giving one what is his due as determined by the time he arrives. It also helps establish order in the distribution of health care goods.

e. The principle of random selection

Gives priority to those selected by chance or random. The candidate chosen in a lottery receives the resources.

Health care burdens

Burden may involve the necessary payment for the health benefits patients receive, their being subjected, from time to time, to medical and experimental research, their donation of organs, and risks involved in a recommended treatment. It is in accordance with the principle of justice to let patients know both the due and undue burdens hat they are to undergo as they accept and submit for health care intervention.

DUE BURDEN- refers to a certain sense of pain or discomfort necessarily associated with one’s submission for health care intervention.

Ex: buying medicines at the pharmacy as prescribed, the pain brought about by intravenous insertion and injections, and others.

UNDUE BURDEN- refers to a certain sense of pain or discomfort brought about by a certain medical, experimental or surgical proceeding which is of no direct benefit to the subject. It may be deemed unnecessary as far as the subject is concerned.

Ex: donation of one’s organ, paying for somebody else’s hospital bill, and others.

The principle of cooperation

Cooperation comes from the Latin word cum which means “with” and operari which means “to work”.

COOPERATION is working with another in the performance of an action.

Various degrees of cooperation

The degrees of cooperation may vary according to the gravity or essentiality of the shared act in the performance of an evil action.

1. Formal and material

FORMAL COOPERATION- consists of an explicit intention and willingness for the evil act. The one formally cooperating categorically wills and intends the evil action.

Ex: a medical director who wills and intends the evil act of contraception by means of hysterectomy at the request of an interested party, by arranging with the members of the O.R. team as to the operation and its schedule.

MATERIAL COOPERATION- consists of an act other than the evil act itself but facilitates and contributes to its achievement. The one materially cooperating may provide means apart from the evil act itself which is used to carry out the performance of an evil act.

2. Direct and indirect

DIRECT COOPERATION- consists of direct participation in the performance of an evil act. The one directly cooperating gets involved by openly and straightforwardly taking part in the practice of an evil action.

INDIRECT COOPERATION- consists of an act that is not intimately connected with the performance of an evil act as in formal and direct cooperation but whose effect may have an indirect bearing upon it.

3. Proximate and remote

PROXIMATE COOPERATION- consists of an act that is intimately linked with the performance of an evil action due to its close bearing.

REMOTE COOPERATION- consists of an act with a distant bearing upon or connection with the execution of an evil act.

Moral rules governing cooperation

a. No one should formally and directly cooperate in the performance of an evil action.

b. If a reason sufficiently grave exists, material cooperation in the performance of an evil action may be morally excused.

c. If the material cooperation is proximate, a reason sufficiently graver should exist so as to be morally excused without which evil is incurred.

The principle of totality

The whole implies the existence of its parts. The existence of its parts indicates the existence of the whole.

Parts as such should continuously be connected with the whole of which they are parts without which they cease to be.

However, if its state of condition and continuous existence as part pose a threat to do more harm than good leading to the destruction of the whole and that there is no other means by which the problem can be addressed, the principle of totality provides that it be removed and sacrificed for the sake of the whole.

Ex: a patient is admitted with a gangrenous leg. The attending doctor reasons out, based on scientific medical basis, that there is no other way which the patient can be saved but to amputate the gangrenous part of the patient’s body.

It is morally permissible for the doctor to do the amputation?

Principle of subsidiarity

The principle of subsidiarity is a kind of sociological discipline adhered to and advocated by the church. Its moral implication is embedded in its meaning.

PRINCIPLE OF SUBSIDIARITY- means that what an individual, lower or smaller group can achieve within his/her or its capacity should not be taken away and transmitted to the custody and performance of a higher or bigger group.

Ex: in an effort to control the apparent rapid population growth in the country, the State formulates program on responsible parenthood which rebounds to the enactment of a law mandating every family to just limit the number of its offspring only to one or two under pain of penalty. And so, the State through the Department of Health conducts contraceptive programs and distributes various forms of contraceptive methods to ensure the State-directed number of children every family ought to raise.

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