BIOETHICS-finals Ppt Edited

MAJOR ETHICAL PRINCIPLES

1. StewardshipOur bodies, our life, our human nature and everything in this earth are gifts we have dominion over.

We should not, as faithful stewards, harm but rather improve and care for them. We have to treat them with utmost respect, use originality and creativity to cultivate them, know and respect their limits.


2. TotalityTotality refers to the whole. Every person must develop, use, care for and preserve all his parts and functions for themselves as well as for the good of the whole.

If a part or lower function harms the whole, this part or lower function may be sacrificed for the good or better function of the whole.

MAJOR ETHICAL PRINCIPLES3. Double effect

When an act is foreseen to have both good and bad effects, the principle of double effect is applied. In order that such act be permissible, the following conditions should be met:

1. The direct freely chosen effect of the act must be morally good while the other indirect not freely chosen effect may be physically harmful.

2. The action itself must be good or at least neutral.

In order that such act be permissible, the following conditions should be met:

3. The foreseen beneficial effect must be equal to or greater than the foreseen harmful effect.

4. The beneficial effect must follow from the action or least as immediately as the harmful effect. The good effect must not be produced by the bad effect.


4. Cooperation Cooperation is the participation of one

agent with another agent to produce a particular effect or joint effect.

Cooperation becomes a problem when the action of the primary agent is morally wrong.

Cooperation may be:1. Formal-when the secondary agent willingly participates

as when one agrees, advices, counsels, promotes, or condones.

2. Material-when the secondary agent is not willing to participate.

A. Immediate-when the action of the secondary agent is inherently bound to the performance of the evil action.

B. Mediate-when the action of the secondary agent is not inherently bound to the performance of the evil action. Formal cooperation is not allowed. Material immediate cooperation is also a rule not allowed.

When there is significant reason, and scandal is avoided, material mediate cooperation, may be permitted to prevent a greater harm.


5. Solidarity

Solidarity means to be one with others. In the provision of the healthcare, it is most important for the provider to be in solidarity with the patient when seeking, always, the latter’s best interest.

In a country like the Philippines, this is most important while dealing with the poor, the uneducated, the disadvantaged and the marginalized.

MAJOR BIOETHICAL PRINCIPLES1. Respect for person

Respect for person is the recognition of the equality possessed by very human being as a unique, worthy, rational, self-determining creature, having the capacity and right to decide what is best for himself. It is not undermined by states of suffering, disability or disease.

Respect for person is the responsibility of all to treat persons as an end and never as means.

Respect for person is manifest in autonomy (self- governance) or the right of noninterference. A person should be allowed to determine his own destiny, to deliberate about his plans, choose according to his own values, and to act accordingly.

He should be allowed to be his own person without constraints from the actions of others or from physical or psychological limitations.

X has a right to determine his course of action.

Y has an obligation not to constrain X.

This is best practiced in the principle of free and informed consent.

2. Justice• Justice, also termed fairness, means to give to each one what

he deserves or what is his due.

X has a right to his due

Y has the obligation not to deprive X of his due

• But man lives in a finite world. There are limits to funds, medical supplies, healthcare services. The needs of everyone, even if it is his due, cannot all be served.

• Justice also means to treat equals equally

X & Y are equal

X & Y should have equal benefits/burdens

Creating a healthcare policy helps decide how limited resources are to be distributed. It should consider the principles of equality (distributive justice), social justice, and solidarity. The policy should state in clear terms the criteria for consideration, rank ordering, etc. and this should be made public.

3. The inviolability of life

The principle of the inviolability of life is also proposed as the sanctity, the dignity, or respect for human life.

From the Judeo Christian tradition human life has “dignity” because life is God’s gift. Man comes directly from God, is created according to God’s plan and destiny. It is God who is the source, who sustains and perfects man’s life.

From a humanistic point of view the experience of being alive or the fear of losing life is evidence of its sacredness.

• The principle of the “inviolability of human life” means that life, in itself is sacred. It is not to be violated opposed or destroyed but is to be affirmed, cherished, respected, defended, and preserved. • “Commitment” to the principle of the inviolability of life means

choosing life and fighting to protect it. Commitment to life overcomes commitment to death. It is to be against violence, pollution of environment, drug and alcohol addiction, treachery in human relations.

X has a right to life.

Y has duty NOT to kill X.

These principles also includes measures for the survival of the human species, and freedom to have children.

4. Non Maleficence

Non-maleficence means to do no, to prevent, to remove or not to risk harm.

X has a right not to be harmed.Y has an obligation not to harm X

Harm may be physical, mental, psychological, social, financial, spiritual, etc.

5. Beneficence

Beneficence is the positive pole of nonmaleficence. It means to do good, to provide a benefit. Beneficence hinges on other duties such as fair play, keeping promises, role commitments, reciprocity.

Applied together with nonmalefiscence it entails weighing benefits versus burdens then choosing the action that brings the most benefit and the least burden to those affected. This is the principle of utility.

X has duty to benefit Y provided

Y is at significant risk

X’s action is needed

X’s action is likely to succeed

There is no significant risk for X

The benefit to Y outweighs any harm for X

APPLIED HEALTH ETHICS

A. Informed consent – is an ideal connected to the principle of autonomy and respect for a person. Any procedure to be done on a person may only be administered with his free and informed consent. This gives valid permission for others to act in certain specific ways.

Two main functions:1. Protective – to safeguard against intrusion of

integrity.2. Participative – to be involve in medical decision

making.

B. The Beginning of Life

Both the Catholic Church and the Philippines Constitution recognize the sacredness of life from the time of conception. From fertilization through fetal life, until birth the human being must be protected. Equally important is the respect for the dignity of parents and newborn expressed in the method new life is created. A child must be the fruit of the conjugal union between husband and wife.

Artificial methods of reproduction which assist the conjugal act praiseworthy procedures to help “infertile” couples. Those that substitute or replace it are not acceptable

Caring for the pregnant patient is unique. Treating the mother automatically treats the child and vice versa so that when decisions are made, the health the health and welfare of the other.

C. The end of life

• Life is a gift, which as good stewards, we have to protect and defend. But life can be sustained for only so long; ultimately, death claims us all. Furthermore, life is not the highest value and can be given up for higher values.

C. The end of life

Many healthcare providers have difficulties accepting death and managing the dying patient.

• They see death as a failure of treatment, are influenced by the technologic imperative to use everything available, are more comfortable “treating” than “not treating” and hesitate to bring the “bad news’ of his condition to the dying patient.

•Every healthcare provider must learn how to face death and help his patient accept death when dying is the only option open. •No one needs to die neglected, alone, shunted

aside by disease, hooked on tubes and to machines, or isolated from families and loved ones, death with dignity, humane death and a good death must be available.

An “environment” must be created wherein the patient, his family, and healthcare providers can accept death calmly and peacefully with the knowledge that appropriate care is being given. They must be assured that the patient will not be abandoned and that he is forgiven for dying.

To attain these the healthcare provider therefore must:

Communicate compassionately, tell “bad” news early enough to provide time for the patient to accept it and make the best use of this most important limited time of his: to say goodbye, settle material matters, to mend broken relationships, to express love etc.

Use technology prudently. Recognize the realm of medical futility and avoid disproportionate means to maintain life at all costs.

Relieve pain effectively. The dying man often fears dying with pain. It limits freedom and independence, causes anxiety, rejection and marginalization, and sense of identity.

The healthcare provider must relieve pain effectively at the same time accepting that intractable and severe pain relief may necessarily decrease consciousness and even risk the shortening of life. He must also help the patient understand the gift of pain and utilize pain for good.

THE NEED TO REDEFINE DEATH

There is a widespread and increasing use of new device for prolonging life (life support machines, intravenous or feeding machines).

One element of the moral issue here is this: with the use of these life-sustaining devices, we are able to prolong life for a considerable period, or even to save a person’s life from impending death.

There are occasions or situations however, when instead of prolonging or saving life, we are only prolonging the dying process, hence prolonging likewise the suffering of the dying individual.

Definitions of Death:

1. Physiological- a person is dead when the heart has stopped beating. This is often called the traditional understanding of death. since blood and breath are essential to the continuation of life, when people stopped breathing and pulsation stops, they are pronounced dead. With the use of a mechanical respirator, however, which can keep blood and oxygen circulating almost indefinitely, an individual’s dying process is prolonged.

Definitions of Death:2. Religious or philosophical definition- death means the separation

of the soul from the body. The question is: “How do we know that the soul has already left the body?”

3. Brain death- this refers to a condition in which the brain is completely destroyed and in which the cessation of function of all other organs are imminent and inevitable. By and through the use of electro-encephalography (EEG) and electrocardiogram (ECG), health professionals can determine the total or irreversible loss of circulatory and respiratory functions. others include absence of receptivity and responsiveness, absence of movement or breathing and absence of reflexes.

Definitions of Death:

4. Cellular definition- refers to the disintegration of the metabolic processes of the body’s substance. This definition considers the irreversible loss of neo-cortical activity as the only significant criterion because it eliminates all capacity for consciousness and all social integration possible. An EEG is needed for this definition.

In the Medical Context

The brain death definition is very significant. Most suitable donor organs come from patient’s who die from injuries or diseases of the brain. In such patients, blood circulation may be artificially maintained after brain death, so that the organs needed can be extracted with minimal ischemic damage.

Inasmuch as destruction of the brain is the cause of the donor’s death, there is a good reason to remove these transplantable vital organs before cessation of the donor’s artificially supported circulation. To avoid any legal restraints and complications, however, this matter requires the enactment of statutes recognizing the use of brain-oriented criteria for pronouncing death.

• A DNR Form used in the Commonwealth of Virginia• In medicine, a "do not resuscitate" or "dnr", sometimes

called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. The term "code" is commonly used by medical professionals as a slang term for "calling in a Code Blue" to alert a hospital's resuscitation team. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. In the health care community "allow natural death" or "AND" is a term that is quickly gaining favor as it focuses on what is being done, not what is being avoided.

• Some criticize the term "do not resuscitate" because it sounds as if something important is being withheld, while research shows that only about 5% of patients who require ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive.• Patients who are elderly, are living in nursing homes, have multiple

medical problems, or who have advanced cancer are much less likely to survive.

•Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation." This alteration is so that it is not presumed by the patient/family that an attempt at resuscitation will be successful. Since the term DNR implies the omission of action, and therefore "giving up", some have advocated for these orders to be retermed Allow Natural Death. New Zealand and Australia (and some hospitals in the UK) use the term NFR or Not For Resuscitation. Typically, these abbreviations are written without periods between the letters, i.e. AND/DNR not A.N.D./D.N.R..

• DNR compared with advance directive and living will• Advance directives and living wills are documents written

by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves.• In contrast, it is a physician or hospital staff member who

writes a DNR "physician's order," based upon the wishes previously expressed by the individual in his or her advance directive or living will. • Similarly, at a time when the individual is unable to express

his wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent.• These various situations are clearly enumerated in the

"sample" DNR order presented on this page.

• It should be stressed that, in the United States, an “advance directive or living will” is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his wish, as neither an advance directive nor a living will is a legally binding document. It is also the case that the wishes expressed in an advance directive or living will are not binding.

When is CPR not of beneficial?

•One approach to defining benefit examines the probability of an intervention leading to a desirable outcome. •CPR has been shown to be have a 0% probability of

success in the following clinical circumstances:

•Septic shock •Acute stroke •Metastatic cancer •Severe pneumonia

In other clinical situations, survival from CPR is extremely limited: • Hypotension (2% survival) • Renal failure (3%) • AIDS (2%) • Homebound lifestyle (4%) • Age greater than 70 (4% survival to discharge from

hospital) How should the patient's quality of life be considered?• CPR might also seem to lack benefit when the patient's

quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability.

• Usage by countryMiddle East• DNRs are not recognized by Jordan. In Israel, it is possible to sign a DNR form as long as the patient is dying

and aware of their actions.United Kingdom• In England, for DNR as for any medical treatment, by default only the

patient can give informed consent, if they have capacity as defined under the Mental Capacity Act 2005; if they lack capacity relatives will often be asked for their opinion out of respect but it does not have hard legal force on the doctors' decision. In this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. Alternatively, patients may specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'.

• United States• In the United States the documentation is especially complicated in that each state

accepts different forms, and advance directives and living wills are not accepted by EMS as legally valid forms. If a patient has a living will that states the patient wishes to be DNR but does not have an appropriately filled out state sponsored form that is co-signed by a physician, EMS will attempt resuscitation. This is a little known fact to many patients and primary care physicians that can cause patients to receive treatments they do not want, and this law is currently being evaluated for a constitutional challenge.

• The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare. Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive that results in a DNR/DNI code status in the hospital.

• In the U.S., cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many US states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is appropriately filled out and cosigned by a physician.

Application of Moral Theories

• Natural Law ethics- regards death as a part of nature; it declares that a person is dead once the soul leaves the body. When all vital functions of the brain completely disappear or stop, extraordinary medical measures may not be necessary but, in fact, useless. Hence, it is morally wrong to prolong the suffering of the dying individual by means of life-sustaining machines in such circumstances.

Utilitarianism- the brain death definition seems to be in keeping with the utility precept, i.e, promoting as much good as possible and avoiding harm or pain, if the dying patient is detached from all life-support machines. The pragmatist’s notions of practicality, usefulness and beneficiality may justify the application of the of the brain death definition issue in the medical context. Joseph Fletcher, with his situation ethics, accepts brain-related criteria for pronouncing death in conjunction both with both euthanasia and organic transplantations.

• Rawl’s concept of justice may also justify the unplugging of life-sustaining machines if- and when they are no longer useful to the dying person—at least in fairness to the patient so that they will not prolong his suffering.• The same holds true of Ross twofold principle by which to resolve

conflicting duties.

• Approach the patient holistically; focusing on the entire person; giving physical, psychological, mental, emotional, moral and spiritual support. The dying patient is lonely, has needs, and worries about loss of control. The healthcare provider must provide palliative or comfort care, minimize the patient’s symptoms, and maximize his interaction with others. He should provide support, protection and if possible, security, pray for and with his patient.

In summary, the healthcare provider must be, a companion in his patient’s final journey, be in solidarity with his patient, and be present to receive the gift of the dying.

D. Suffering

Suffering is inevitable. A fundamental tenet of healthcare tradition is the commitment of the healthcare provider to relieve suffering. Without understanding suffering, however, the healthcare provider cannot fulfill this obligation. He may even cause harm by denying or ignoring suffering especially when this is not amenable to pharmacologic or technologic intervention, or by considering the relief of pain as equivalent to the relief of suffering.

D. Suffering Suffering is wider than physical pain or

sickness, more complex, more deeply rooted in humanity itself. It is damage to the integrity of a patient’s personhood.

The capacity for suffering, the effect suffering has, and the response to it, varies from person to person.

D. Suffering

• Suffering is wider than physical pain or sickness, more complex, more deeply rooted in humanity itself. It is damage to the integrity of a patient’s personhood.

• The capacity for suffering, the effect suffering has, and the response to it, varies from person to person.

•The healthcare provider must first recognize the particular suffering of his patient and carefully listen to what the patient says. His presence must manifest awareness of, bear witness to, and validate the suffering. He must sit with the patient and touch him. He must respond to it with compassion: to alleviate whenever possible, to lend strength and support always.

•He must help the patient locate it spiritually, join Him with his suffering; let it in and awaken his love for God and fellowman. He must help the patient make suffering meaningful and peace filled by seeing it not as a moral evil in itself, but with human and supernatural benefits when rightly used.

Health professional relationships

•A health professional deals not only with his patient and his patient’s family but also with colleagues in his profession, other healthcare professionals, his professional organization and society. Each of these relationships carry mutual responsibilities and benefits.

•He should, with colleagues both in his own profession and in the other healthcare professional, recognize that they all have a common goal: better health for everyone. They should work as a team in a climate of mutual responsibility, support and respect.

•Mutual responsibility means each one doing his best and helping the others do their best. It means older members being powerful role models whose behavior are living examples of what younger members might aspire to be.

•Mutual support means senior members teaching junior members. Healthy members assisting impaired colleagues and repairing defects caused by them.

•Mutual respect means listening to others’ suggestions, encouraging others to play their roles and acknowledging their contribution. Mutual respect means preservation of the other’s good name and avoidance of unfair competition and solicitation of patients.

•The healthcare professional must work towards uplifting the standards of his profession through Continuing Nursing Education program participation and self regulation with correction of erring members.

•The healthcare professional, as a member of society, must work towards the creation of a safe environment, the implementation of a just healthcare program and discovery of truth through research.

Virtues of the Healthcare provider

•The manner healthcare is delivered often rests on the kind of person the healthcare provider is. Actions intrinsically neutral became good or bad, helpful or harmful depending on the person concerned. A patient trusts or mistrusts, depending on what he thinks of a healthcare provider’s character.

Virtues of the Healthcare provider

Virtues are acquired habits or dispositions to do what is morally right. They are traits of character that dispose its possessor to act in accordance with moral principles, rules and ideas. They catalyze action.

Everyday the healthcare provider is called upon to act righteously: to do so, he must posses virtues. These guide his decisions about where priority ought to be given. The most common virtues cited as necessary for a healthcare provider are fidelity, honesty, integrity, humility respect, compassion, prudence, and

courage.

Virtues of the Healthcare Provider

1. Fidelity is faithfulness. In the relationship of trust every patient must know that his healthcare giver will keep his promises and keep the patient’s best interest first in his mind.

2. Honesty is truthfulness. It is telling the patient, the family, colleagues, and society the truth about an illness, its nature, prognosis, effectivity of care, and research findings.


3. Integrity is wholeness. It is acting in the same way one says he should act and believes he should act. A healthcare provider who tells his patient smoking is bad should himself not smoke.

4. Humility is recognizing one’s capabilities and limitations. It is doing one’s best and asking for help as needed. It is accepting deserved praise graciously and denying underserved praise. It is recognizing that the patient knows what is best for himself.


5. Respect means paying attention to others. It is listening attentively to a patient’s complaints, or a colleague’s opinion.

6. Compassion is loving kindness, a feeling for those who suffer. It is self sacrifice voluntarily given for the benefit of another, or given with no hope of return, gain, recognition, or payment but given because the other’s needs are greater. It is leaving the comforts of home to sit with a dying patient.


7. Prudence is foresight: A habitual deliberateness, caution and circumspection in action. It is “to look before you leap” or to consider how different options may affect others before making a decision.

8. Courage is doing what one sees as right without undue fear, or standing up against what one sees as wrong even if it means standing up alone.

Vices of the Healthcare Provider

The authority and power of the healthcare provider over the vulnerable patient, the respect he gets from society, the economic rewards of his profession sometimes lead to the development of vices. The most common of these are pride and greed.

Pride is inordinate self-esteem, conceit. It is a behavior of superiority over others.

Greed is inordinate acquisitiveness, often for wealth but also for power or position.

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BIOETHICS-finals Ppt Edited