1. To be, or not to
be--that is the
question!

2. Ethico – Moral Aspect
of
Nursing Practice
Nelia B. Perez RN, MSN
PCU - MJCN

3. ETHICS DEFINED
• Ethics is a study of good conduct,
character, & motives & is concerned
with determining what is good or
valuable for all people

4. NURSING ETHICS
• A nurse assumes responsibility and
accountability for nursing care
provided.

5. • Morals define personal
character,
while ethics stress a social
system in which those
morals are applied.

6. VALUES VS VIRTUES
• Values are principles, standards, or
qualities considered worthwhile and
desirable.
• Values are beliefs that a person or
group holds and in which they have
emotional investment and heartfelt
commitment.

7. VALUES VS VIRTUES
• Virtues, on the other hand, are
moral excellencies and
qualities of righteousness
corresponding to the nature
and character of God.

8. VALUE SYSTEM
• A value system is a set of consistent
ethics value (more specifically
the personal and cultural values) and
measures used for the purpose of
ethical or ideological identity.
• A well defined value system is a moral
code.

9. Value System
• A personal value system is held by and applied
to one individual only.
• A communal or cultural value system is held
by and applied to a community/group/society.
Some communal value systems are reflected
in the form of legal codes or law.

10. Goals of Value-Clarification :
• The goal of "values-clarification" is for you to
become fully conscious of influences, and to
explore and honestly acknowledge what you
truly value at this time in your life.
• Your values are your ideas about what is most
important to you in your life What you want to
live by and live for. They are the silent forces
behind many of your actions and decisions.

11. Criteria of Values
Choosing:
- Freely from alternatives after thoughtful
consideration of the consequences of each
alternative
Prizing:
- cherishing, being happy with the choice ; willing to
affirm the choice publicly
Acting:
- doing something with the choice repeatedly, in some
pattern of life

12. ETHICAL THEORIES

14. Varieties of Ethical Theory
• Ethical Egoism
• Virtue Ethics
• Natural Law
• Utilitarianism
• Deontology
• Situation Ethics
• …

15. Ethical Egoism
• Needs no deep exploration
• My goals
• My wants
• My needs
• My desires…
• All actions (however they appear)
– Are self-serving

16. Virtue Ethics
• Located in character
– Not reasoning
• Aristotle’s ethics
– ‘golden mean’ eg
• Cowardice (too little)
• Courage
• Recklessness (too much)
– Renewed by MacIntyre in 20th c – Beyond Virtue

17. • Virtue ethics describes the character
of a moral agent as a driving force for
ethical behaviour, rather than rules
(deontology),consequentialism, or
social context (pragmatic ethics),
which derives rightness or
wrongness from the outcome of the
act itself rather than character.

18. Natural Law (1)
• Everything has a nature – which makes it what it is,
governs how it should be and how it should act.
• A good thing is that which is living out its nature
– A good wombat does its ‘wombat things’ well
– It would be a bad thing for wombats to ride bicycles
– (and we would be doing evil to train wombats…)
• There is a purpose, goal (telos) for everything
• The goal is meant to be achieved, the theory is
teleological.

19. Natural Law (2)
• To deny the attainment of the goal is bad
• (intrinsically bad – bad in itself)
• purpose and potential
– If an entity has potential to become…
– NL says good actions enable the potential to be
reached (actualised)
• We can discover the ‘nature’ of something
– Reflection, observation, revelation
– Consistent understandings

20. NL Good points
• There is a purpose and meaning to existence
(principles and absolutes)
• Arbitrary behaviour is unjustified/unjustifiable
• Absolute goods understood in terms of
‘nature’, realising potential

21. NL: Bad/unclear points
• Is there only one nature for any entity
– Male/female
– Heterosexual/homosexual
• Is there only one purpose.
– Sex for procreation only
– Or sex as expression of love
• intimacy
• Procreation
• Pleasure
• Conventionalism/Static world
• Can we be sure we’re right about nature?
– Eg evangelicals and the fallen world

22. Utilitarianism
• Bentham – maximise pleasure, minimise pain
• Need a scale of pleasure & pain
• Simple arithmetic tells you what to do
• Mill – maximise happiness – for the greatest
number
• Or good, or justice, or…

23. Utilitarianism
• Consequentialist – we consider (all) the
consequences
• what we should do is what brings the best
consequences

24. Utilitarianism – an Example?
• From Bagaric and Clark “Not Enough (Official) Torture
in the World”
• “…a neat little formula. It measures up factors such
as whether the person is a terrorist, whether it is
probable they have information and how many lives
will be lost if that information is not extracted. It
then divides that figure by the time available before
disaster, multiplied by whether the information can
be obtained elsewhere.”
(http://www.cageprisoners.com/articles.php?id=7454)

25. From the article (USFLR 39)
• The variables are
• (1) the number of lives at risk;
• (2) the immediacy of the harm;
• (3) the availability of other means to acquire
the information;
• (4) the level of wrongdoing of the agent; and
• (5) the likelihood that the agent actually does
possess the relevant information.

26. Utilitarianism: Good Points
• Scientific
• Objective
• Repeatable

27. Util: Bad/unclear points
• Tyranny of the majority
• How do we/can we set an accurate scale?
• ‘Simple’ Arithmetic?
– All consequences?
– For every person?
– For every course of action?
• Arbitrary – why should we maximise
pleasure/happiness/good…

28. Deontology
• Good will – intention not result
– response based on reason/rationality
– Not personal desire
• Categorial Imperative has two forms
– Universality
– Respect for persons

29. Deontology: Good Points
• There are absolutes, general laws of conduct
• They can be discovered by reason
• People are of value

30. Deontology: Bad/Unclear points
• Does reason enable us to discover the good?
• How do we prioritise several ‘goods’
– Telling the truth
– Preserving life
– Not stealing

31. Situation Ethics
• One absolute principle
– ‘to love one another as I have loved you’
• Laws in SE are ‘illuminators’
• People are central
• Situations /contexts are of great importance.
• What is the most loving thing to do?

32. SE: Good Points
• Love (agapé - as Jesus showed)
• Centrality of people
• Responsiveness to circumstances
• A place for principle
– (and faith)

33. SE: Bad points
• The details (as for utilitarianism)
• (Mis) understanding of ‘love’
• No absolutes

34. Sample Questions
• “Three major approaches to ethical decision-
making are consequentialist (utilitarian),
deontological and metaethical”. Taking a
controversial issue, present a clear and
reasoned analysis of the major principles,
concepts and issues associated with one
approach to ethical decision making. What are
the weaknesses of this approach?

35. Sample Questions
• Outline the major arguments involved in a
debate over a controversial ‘ethical issue’. In
choosing a controversial community or global
moral issue, ensure that you define what you
understand by the terms ‘ethics’ and ‘ethical
controversies’. Present a clear and reasoned
analysis of the major arguments involved in
the debate as well as the major principles,
concepts and issues associated with the
differing approaches.

36. Sample Questions
• What does it mean to be morally right or wrong? Explain one
approach to what is right in relation to the ethical issue you
have studied. (4, 5, 8)
• What do you understand by ‘ethics’ and ‘ethical
controversies’? Nominate an ethical issue and use it to
critically examine some of the major ‘approaches’ adopted in
ethical decision-making. (5, 6, 8)
• Using the example of a current ethical issue critically examine
and evaluate at least two of the major ethical approaches that
could be adopted in ethical decision-making. (5, 8, 9)

37. Examinable Criteria
• Criterion 4 Use evidence to support a point of view.
• Criterion 5 Demonstrate understanding of relevant
terminology.
• Criterion 6 Demonstrate understanding and
appreciation of the implications and significance of
philosophical or religious positions.
• Criterion 8 Demonstrate knowledge and
understanding of religious or philosophical concepts.
• Criterion 9 Critically analyse and evaluate ideas and
information.

38. One nature?
• " Then Mary stood up, greeted them all, and said to
her brethren, "Do not weep and do not grieve nor be
irresolute, for His grace will be entirely with you and
will protect you. But rather let us praise His
greatness, for He has prepared us and made us into
men." When Mary said this, she turned their hearts
to the Good, and they began to discuss the words of
the [Saviour].
Gospel of Mary Magdalene
(http://www.pbs.org/wgbh/pages/frontline/shows/religion/maps/primary/mary.html)

39. Categorial Imperative (1)
‘Act so that the maxim of your
action can be a universal law’
• Are you willing to carry out the rule
yourself?
• Can you wish all people would obey
the principle you act on?
• Would all rational people of good-will
agree?
• Is it self contradictory?

40. Categorial Imperative (2)
‘Act in such a way that you always treat
humanity, whether in your own
person or in the person of any other,
never simply as a means, but always
at the same time as an end.’
• People are rational and therefore have
intrinsic worth. The value of a person is not
determined by their usefulness.
• Does the action you propose result in USING
someone?

42. Ethical Principles
• Autonomy • Consequences/consequ
• Responsibility entialism
• Absolutes/standards/pri
• Respect
nciples
• Quality of life • Arbitrary/relative
• Slippery slope • Ends, Means
• Benefit • Objective, Subjective
• Justice • Teleology
• Equity • Duty, deontology
• Slippery slope, straw
man, ad hominem

43. Ethical Principles
• Autonomy- refers to a person’s
independence, self-determination, self-
reliance. A patient has the right to make
decisions about her/her care. Ex. Signing a
consent form for surgery
43

44. Means independence and the ability to be self-
directed.
** Incorporates principles of freedom of
choice, self-determination, and privacy.
e.g Consent
(How)
9/8/2011

45. • It respects the P.T choice of accepting or refusing
medical or surgical treatment

46. Ethical Principles
• Nonmaleficience - refers to the avoidance of
causing any harm to clients. Try to balance the risks
and benefits of a plan of care, while striving to do no
harm. Ex: bone marrow transplant promises to bring
a cure but there may be a long period of pain and
suffering.
46

47. Is the avoidance of harm.
-When work with client nurses must not cause
injury or suffering by maintaining competency
in clinical practice.
-Promote balance of potential risk included
harms with benefits
9/8/2011

48. Ethical Principles
• Beneficence- means promoting good or doing
good for others. Take positive steps to help others. It
helps to guide difficult decisions where the benefits
of a treatment maybe challenged by the risk to the
client’s well-being or dignity. The best interests of the
client must be upheld. Ex: immunization
48

49. Refers to taking positive actions to help others.
Or Means doing or promoting good.
Nurses duty to help promote the well-being of
others.
e.g Administer pain medication and dressing
and emotional support and Child’s
immunization.
9/8/2011

50. Ethical Principles
• Justice- refers to fairness or equity. Clients need to
be treated in a manner that they deserve. Ex. Both
clients receive the same treatment when being
admitted for surgery, fair resources etc.
50

51. Refers to fairness (treat all clients equally and
fairly).
- Relates to the distribution of services and
resources (resource allocation throughout a
society of group).
9/8/2011

52. -Nurses commonly face issues of justice when
organizing care for a group of clients
- how much time is spent with each client?
(Based on client need).
-Fair distribution of resources.
-Dilemmas arise when resources are
insufficient to meet the needs of everyone.
9/8/2011

53. Information about a client must be kept private.
-Client’s record is accessible only to those providing
care to that client.
-Discussing clients outside the clinical setting, telling
friends or family about clients must be avoided.
-Medical records may not be copied or forwarded
without a client’s consent.
9/8/2011

54. *** Breaking confidentiality can be if there is a
well-defined reason to share information.
(Benefit outweigh harm).
9/8/2011

55. 9/8/2011

56. • ( e.g.. Privacy of P.T is cared for when closing the
room door when performing nursing care ,
confidentiality is cared for by not discussing that
care with some one that is not a member of that P.T
health care team)

57. Means telling the truth.
Or
Accuracy or conformity to truth.
- Truthfulness may be challenged during the
delivery of health care.
9/8/2011

58. Means being faithful to one’s commitments
and promises.
- Nurse’s commitments to clients include
providing safe care and maintaining
competence in nursing practice.
9/8/2011

59. RESPONSIBILITY
• Refers to the execution of duties
associated with the nurse’s particular
role. A nurse who acts in a responsible
manner gains the trust of clients & other
professionals. A responsible nurse
remains competent in knowledge & skills
& demonstrates a willingness to perform
within the ethical guidelines of the
profession.

60. RESPONSIBILITY (example)
• When administering medications, the nurse is
responsible for assessing clients’ need for the
drugs, giving them safely & correctly, and
evaluating the responses.

61. ACCOUNTABILITY
• Being answerable for one’s own actions. A
nurse is accountable to self, the client, the
profession, the employer, and society

62. ACCOUNTABILITY (example)
• If a wrong dose of medication is given, the
nurse is accountable to the client who
received it, the physician who ordered it, the
nursing service that set standards of expected
performance, & society which demands
professional excellence.

63. ACCOUNTABILITY (example cont’d)
• Thus, when an error is made, the nurse
reports it and initiates care to prevent further
injury. Accountability calls for an evaluation of
a nurse’s effectiveness in practice.

64. ACCOUNTABILITY PURPOSE
• 1. To evaluate new professional practices & reassess
existing ones.
• 2. To maintain standards of health care.
• 3. To facilitate personal reflection, ethical thought, &
personal growth on the part of health care
professionals.
• 4. To provide a basis for ethical decision making.

65. ETHICAL CODES

66. What does a code of ethics do?
• Gives guidance for decision making about
ethical matters by providing a set of values
that are basic to nursing practice.
66

67. The Code of Ethics
• Provide rules of ethical or moral behavior for
every circumstance.
• Offer guidance about which values should
take priority or how they can be balanced in
practice.
67

68. Values and The Code of Ethics
Primary values that are central to ethical nursing
practice.
The 7 values include:
1. Providing safe,
2. Compassionate competent and
3. Ethical care,
4. Promoting health and well-being,
5. Promoting and respecting informed decision-
making,
6. Maintaining privacy and confidentiality,
7. Promoting justice and being accountable
68

69. Providing Safe, Compassionate
Competent and Ethical Care
• Nurses value the ability
to provide safe,
compassion, competent
and ethical care that
allows them to fulfill their
ethical and professional
obligations to the people
they serve.
69

70. Promoting Health and Well Being
• Nurses value health promotion
and well being and assist
persons to achieve their
optimum level of health in
situations of normal health,
illness, injury, disability or at
the end of life.
70

71. Promoting and Respecting
Informed Decision-Making
• Nurses provide persons
with appropriate
information and services so
they can make informed
decisions. Ensure nursing
care is given with informed
consent
71

72. Preserving Dignity
• Recognize and respect the inherent worth of
each person and advocate for respectful
treatment of all persons.
72

73. Maintaining Privacy and
Confidentiality
• Nurses safeguard the trust of
clients that information learned
in the context of a professional
relationship is shared outside the
health care team only with the
clients permission or as legally
required or where failure to
disclose would cause significant
harm.
73

74. Promoting Justice
• Nurses apply and promote principles of equity
and fairness to assist clients in receiving
unbiased treatment (social justice) and a share
of health services and resources proportionate
to their needs. Safeguard human rights.
74

75. Being Accountable
• Nurses act in a manner consistent with their
professional responsibilities and standards of
practice and are answerable for their practice.
75

76. THE CODE OF ETHICS FOR FILIPINO
NURSES
• First approved in 1982, 5 decades after it was
formed in 1922.
• March 21, 1984: PRC adopted the ICN Code of
Ethics and subsequentle was approved by the
Board on March 21, 1984 pursuant to RA No.
877 and PD No. 223.

77. THE CODE OF ETHICS FOR FILIPINO
NURSES (cont)
• Unanimously approved through BON
Resolution No. 633 on March 21, 1984.

78. THE ICN CODE OF ETHICS FOR
NURSES
An international code of ethics for
nurses was first adopted by the
International Council of Nurses
(ICN) in 1953. It has been revised
and reaffirmed at various times
since, most recently with this
review and revision completed in
2005.

79. PREAMBLE
Nurses have four fundamental responsibilities: to
promote health, to prevent illness, to restore health
and to alleviate suffering. The need for nursing is
universal. Inherent in nursing is respect for human
rights, including cultural rights, the right to life and
choice, to dignity and to be treated with respect.
Nursing care is respectful of and unrestricted by
considerations of age, color, creed, culture, disability
or illness, gender, sexual orientation, nationality,
politics, race or social status. Nurses render health
services to the individual, the family and the
community and co-ordinate their services with those
of related groups.

80. 1. NURSES AND PEOPLE
The nurse’s primary professional responsibility is to people requiring
nursing care.
• In providing care, the nurse promotes an environment in which the
human rights, values, customs and spiritual beliefs of the individual,
family and community are respected.
• The nurse ensures that the individual receives sufficient information on
which to base consent for care and related treatment.
• The nurse holds in confidence personal information and uses
judgement in sharing this information.
• The nurse shares with society the responsibility for initiating and
supporting action to meet the health and social needs of the public, in
particular those of vulnerable populations.
• The nurse also shares responsibility to sustain and protect the natural
environment from depletion, pollution, degradation and destruction.

81. 2. NURSES AND PRACTICE
• The nurse carries personal responsibility and
accountability for nursing practice, and for maintaining
competence by continual learning.
• The nurse maintains a standard of personal health such
that the ability to provide care is not compromised.
• The nurse uses judgement regarding individual
competence when accepting and delegating
responsibility.
• The nurse at all times maintains standards of personal
conduct which reflect well on the profession and
enhance public confidence.
• The nurse, in providing care, ensures that use of
technology and scientific advances are compatible with
the safety, dignity and rights of people.

82. 3. NURSES AND THE PROFESSION
• The nurse assumes the major role in determining and
implementing acceptable standards of clinical
nursing practice, management, research and
education.
• The nurse is active in developing a core of research-
based professional knowledge.
• The nurse, acting through the professional
organization, participates in creating and maintaining
safe, equitable social and economic working
conditions in nursing.

83. 4. NURSES AND CO-WORKERS
• The nurse sustains a co-operative relationship
with co-workers in nursing and other fields.
• The nurse takes appropriate action to
safeguard individuals, families and
communities when their health is endangered
by a coworker or any other person.

84. What is a Dilemma?
• A difficult problem seemingly incapable of a
satisfactory solution.
• A situation involving choice between equally
unsatisfactory alternatives.
Aroskar et al
• Perplexing situation.
Merriam Webster Dictionary

85. Definitions 0f Ethical Dilemmas
• Ethical dilemmas are situations involving
conflicting morals claims, and give rise in such
questions as :
– What ought I to do?
– What harm and benefit result from this decision
or actions?
– What is good (virtue) or what is duty (right)?
Aroskar et al

86. Bioethical Dilemmas: Life, Death, and
Dilemmas In Between
• Definition
– Dilemmas that pose a choice between perplexing alternatives in the
delivery of health care because of the lack of a clear sense of right or
wrong
– Nurses should consider the dilemmas that might arise in a given
practice setting.

87. Bioethical Dilemmas: Life, Death, and
Dilemmas In Between
• Life
– Bioethical abortion issue
• When does life begin?
• Nurses serving in women’s and children’s health
settings must be prepared to face this morally laden
issue.
– Reproduction issue—influenced by genetic screening, genetic
engineering, and cloning

88. Bioethical Dilemmas: Life, Death, and
Dilemmas In Between
• Death
– Quality of life and definition of death issues: With advances in health
care, what is usual and what is heroic care has become unclear.
– Euthanasia and assisted suicide also present new ethical questions.
– Nurses in every setting must be prepared to consider end-of-life
questions.

89. Bioethical Dilemmas: Life, Death, and
Dilemmas In Between
• Dilemmas in between
– Right to health care
• Health care system has become more selective in the
amount and type of treatment offered as a result of
managed care.
• Is each person entitled to the same health care
package?
• Does ability to pay affect specific level of entitlement?
• How ethical is gatekeeping in the new managed care
system?
• Access to health care and respect for human dignity
are at the core of nursing practice.

90. Bioethical Dilemmas: Life, Death, and
Dilemmas In Between
– Allocation of scarce resources
• Should the recipient of scarce resources be selected
on the basis of quality of life? Ability to pay? Best
prognosis? First-come, first-served?
• Nurses should be prepared to consider questions
regarding allocation of scarce resources.

91. Ethical Dilemmas in
Nursing • The challenge of decision
making .
• The sanctity of life vs the
quality of life.
• Informed consent
• Truth-telling – the question
“am I going to die? This
raises important issues
about truth telling.

92. Ethical Challenges
• The challenge of veracity
– Issues of alternative treatments and acknowledgment of uncertainty
test truth-telling.
– Which treatment among two or more is best for the patient?
– Which of the new drugs should be used?
– Should every patient be subjected to every possible form of
diagnostic treatment?
– Should the patient be made aware of questions and various options
surrounding care?
– Is disclosure of uncertainty beneficial or detrimental?

93. Ethical Challenges
• The challenge of paternalism
– Provider tries to act on behalf of the patient and believes that his or
her actions are justified because of a commitment to act in the best
interest of the patient
– Interferes with a patient’s right to self-determination

94. Ethical Challenges
• The challenge of autonomy
– Makes way for the crucial legal step of informed consent
– When are patients competent to make informed consent decisions?
Can family members or surrogates make decisions by proxy?
– Questions about informed consent are raised for minors, confused
elderly, mentally compromised, imprisoned, inebriated, unconscious,
and those in emergency situations.
– Nurses also must take responsibility for understanding and educating
people about advance directives.

95. Ethical Challenges
• The challenge of accountability
– Nurses have an obligation to uphold the highest standards of
practice, to assume full and professional responsibility for every
action, and to commit to maintaining quality in the skills and
knowledge base of the profession.
– The obligation to denounce a harmful action or a potentially
threatening situation may fall to a fellow member of the profession;
to remain silent is to consent to the action of the threatening
situation.

96. VARIABLES AFFECTING ETHICAL
DECISIONS
• Because ethical problems occur in situations
involving people who have different
approaches to “moral reasoning”, it is helpful
if the nurse can sort through the various
factors that influence a persons’ thinking.

97. VARIABLES (cont’d)
• Emotions
• Legal considerations
• Cultural diversity
• Religious/Spiritual convictions
• Education level
• Past life experiences
• Developmental level

98. VARIABLES (cont’d)
• Societal changes
• Race
• Gender
• Class
• Economic level
• Sexuality orientation
• Current state of “health”

99. ETHICAL DECISION MAKING METHODS
• Each ethical situation or dilemma will be
different, but the nurse in any setting can use
the following guidelines for ethical processing
and decision making.

100. METHODOLOGY (cont’d)
• Presume good will
• Identify all important persons
• Gather relevant information
• Identify important ethical principles
• Propose alternative courses of action
• Take action

101. Situation on Truth Telling
A Patient’s Right to Know the Truth
Carolyn , age 21, is dying of leukemia. She
wants to know what is happening to her.
However, her devoted mother believes in
shielding Carolyn from this prognosis. Nurse A
believes client, who repeatedly ask about her
worsening signs and symptoms, has a right to
know the truth. Carolyn’s mother , a wealthy,
influential woman, threatens to sue the hospital
if her daughter finds out that she is dying.

102. Situation cont.
Nurse A wishes to support the patient’s right
to know the truth. Nurse B wishes to
acquiesce to the mothers wishes.
As a professional nurse, what would you do in
this situation??

103. Nursing Students’
• Resolution of the
Experiences
conflict.
• Rational for resolution.
Conflict about the right
thing to do.
Unethical attitudes and
behaviors of practicing
nurses and doctors.

104. Questions

105. SENSITIVE ETHICAL SITUATIONS
• Bio-technology
• Surrogate Pregnancy Contracts
• Adoption
• Abortion
• Substance Abuse
• AIDS/HIV
• Death & Dying
• Living Wills/Health Care Surrogates
• Organ Donations

106. To know even one life
has breathed easier
because you have
lived – this is to have
succeeded!