Flexible Learning Course Syllabus

College of Nursing
Bachelor of Nursing
Semester/Term First Semester; AY 2020 - 2021
I. Course Information
Course Code  NCM 108 Course Description This course deals with the application of ethico-moral concepts and
Course Title HEALTH CARE ETHICS principles affecting care of the individuals, families, population
(BIOETHICS)  group and community. It involves discussion of issues and
concerns in varied health care situations. The learners are
expected to apply ethical decision-making in varied health
scenarios.
 
Prerequisite(s)   Course Learning Outcomes At the end of the course and given the actual and relevant
 Ethics, NCM 103 simulated situations/ conditions, the learners will be able to
explain the concepts, theories and principles of bioethics in nursing
and health. Apply relevant bioethical principles in nursing and
health related situations. 
II. Instructor's Information
Instructor Name  Raul Niño V. Moran RN, MAN Corporate Email rnmoran@uv.edu.ph 
Title:  Clinical Instructor Phone  

III. Course Syllabus

Wee Dat Course Topics Intended Required Suggeste Other Mode of Assignment
k No. e Learning Learning d Recommende Instruction/ s Due
Outcomes Materials Learning d Learning Delivery
and Materials Materials Tools
Resource and
s Resource
s
1   Theories and Principles of Health
         
 Course Packet  
  Ethics          Printed  
 Lesson 1  Timbreza,  Digital - Weekly
   Integrate relevant   Microsoft Teams
Module F. T., Jouranal
A. Ethics principles of social,
(2010). 
1. Deontology physical, natural
2. Teleology and health sciences
Bioethics 
and Moral
3. Utilitarianism and humanities in a
Decisions.
given health and
 nursing situation

Apply the concepts

of the different
ethical theories I
specific scenarios.
2   Virtue Ethics
         
 Course Packet  
1. Virtues Ethics in  Demonstrate      Printed  
 Lesson 2  Timbreza,  Digital
  Nursing caring as the core   Microsoft Teams
2. Core Values of a of nursing, love of Module F. T.,
     
Professional Nurse God, love of (2010).
country and love of Bioethics
people. and Moral
Decisions.

Manifest
professionalism,
integrity and
excellence

Project the positive

professional image
of a Filipino Nurse:

3   Ethical Principles          
 Course Packet  
1. Autonomy      Printed  
   Patient’s Rights  Adhere to ethico-    Digital
legal considerations
 Lesson 3  Timbreza,
   Patient’s Bill of   Microsoft Teams  
in varied personal Module F. T.,
Rights  
and professional (2010).
 Informed Bioethics
 
consent applications.
and Moral
 Proxy Consent/ Decisions.
Legally
Acceptable Apply ethical
Representative reasoning and
 Confidentiality decision -making
 Privacy process to address
2. Confidentiality situations of ethical
3. Veracity distress and moral
 Truth telling dilemma:
 and Rights to - Discern
Information ethical from
4. Fidelity unethical
5. Justice practice in
6. Beneficence the care of
7. Non-maleficence clients.

Adhere to
established norms
of conduct based
on legal, regulatory
and institutional
requirements
relevant to safe
nursing practice.

Implement
strategies related
to informed
consent as it
applies in multiple
context

4   Other Relevant Ethical

          Course Packet  
       Printed  
  1. Principle of Double    Digital
  Effect  Lesson 4  Timbreza,   Microsoft Teams  
 Display
2. Principle of Legitimate Module F. T.,  
communication
Cooperation (2010).
skills with client  
3. Principle of Common Bioethics
and /or support
Good and Subsidiarity and Moral
system based on
Decisions.
Principles of Bioethics trust, respect and
1. Principle of shared decision-
Stewardship and Role making using
appropriate
 of Nurses as Stewards
communicate/
 Personal
interpersonal
 Social
techniques/
 Ecological
strategies
 Biomedical

Conduct ethical
assessment in a
given case
scenario.

IV. Grading System

Components of Evaluation Assessment Type Numerical Grade Equivalent
1. Minor Task (i.e., Essay, Report, Problem Solving) Preliminary Grading Period - 100%-90% - 1.00
20% 89%-80% - 1.25
Mid-Term Grading Period - 79%-70% - 1.50
20% 69%-60% - 1.75
Semi-Final Grading Period - 59%50% - 2.00
20% 49%-40% - 2.25
2. Major Task (i.e., Case-Analysis/Studies, Articles, Final Grading Period - 39%-30% - 2.50
Portfolio, Projects, Journal, simulation, virtual labs) 40% 29%-20% - 2.75
100 19%-10% - 3.00
%

V. Approval
Prepared by Reviewed by Approved by
     
Instructor Program Chair   Librarian Dean
 LESSON 1
Theories and
Principles of Health
Ethics At the end of the lesson, the student should be able to:
1. Integrate relevant principles of social, physical, natural and health sciences and humanities in a given health and nursing situation
2. Understand the definition of ethics and its sub topics
Theories and Principles of Health Ethics
The ethical principles that nurses must adhere to are the principles of justice, beneficence, nonmaleficence, accountability, fidelity,
autonomy, and veracity.

 Justice is fairness. Nurses must be fair when they distribute care, for example, among the patients in the group of patients that they
are taking care of. Care must be fairly, justly, and equitably distributed among a group of patients.

 Beneficence is doing good and the right thing for the patient.

 Nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional or unintentional.

 Accountability is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions.
They must accept all of the professional and personal consequences that can occur as the result of their actions.

 Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by
providing high quality, safe care in a competent manner.

 Autonomy and patient self-determination are upheld when the nurse accepts the client as a unique person who has the innate
right to have their own opinions, perspectives, values and beliefs. Nurses encourage patients to make their own decision without any
judgments or coercion from the nurse. The patient has the right to reject or accept all treatments.

 Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to
patient distress.

The most commonly occurring ethical issues and concerns in healthcare include the allocation of scarce resources and end of life issues.

Bioethics is a subcategory of ethics. Bioethics addresses ethical concerns like those that occur as the result of advancing science and
technological advances. Some of the most common, current bioethical issues revolve around stem cells, cloning, and genetic engineering.
Ethics

Health care ethics is the field of applied ethics that is concerned with the vast array of moral decision-making situations that arise in the practice of medicine
in addition to the procedures and the policies that are designed to guide such practice. Of all of the aspects of the human body, and of a human life, which are
essential to one’s well-being, none is more important than one’s health. Advancements in medical knowledge and in medical technologies bring with them new
and important moral issues. These issues often come about as a result of advancements in reproductive and genetic knowledge as well as innovations in
reproductive and genetic technologies. Other areas of moral concern include the clinical relationship between the health care professional and the patient;
biomedical and behavioral human subject research; the harvesting and transplantation of human organs; euthanasia; abortion; and the allocation of health
care services. Essential to the comprehension of moral issues that arise in the context of the provision of health care is an understanding of the most important
ethical principles and methods of moral decision-making that are applicable to such moral issues and that serve to guide our moral decision-making. To the
degree to which moral issues concerning health care can be clarified, and thereby better understood, the quality of health care, as both practiced and received,
should be qualitatively enhanced.
DEONTOLOGY

Deontology is a theory that suggests actions are good or bad according to a

clear set of rules.
Its name comes from the Greek word deon, meaning duty. Actions that obey these rules are ethical, while actions that do not, are not. This ethical
theory is most closely associated with German philosopher, Immanuel Kant.

His work on personhood is an example of deontology in practice. Kant believed the ability to use reason was what defined a person.

From an ethical perspective, personhood creates a range of rights and obligations because every person has inherent dignity – something that is
fundamental to and is held in equal measure by each and every person.

This dignity creates an ethical ‘line in the sand’ that prevents us from acting in certain ways either toward other people or toward ourselves (because
we have dignity as well). Most importantly, Kant argues that we may never treat a person merely as a means to an end (never just as a ‘resource’).

Watch this video: https://www.youtube.com/watch?v=WoHJhwh4mVQ&feature=emb_title

From that video, what are your takeaways?

Kant’s ethics isn’t the only example of deontology. Any system involving a clear set of rules is a form of deontology, which is why some people call it a
“rule-based ethic”. The Ten Commandments is an example, as is the Universal Declaration of Human Rights.

Most deontologists say there are two different kinds of ethical duties, perfect duties and imperfect duties. A perfect duty is inflexible. “Do not kill
innocent people” is an example of a perfect duty. You can’t obey it a little bit – either you kill innocent people or you don’t. There’s no middle-ground.

Imperfect duties do allow for some middle ground. “Learn about the world around you” is an imperfect duty because we can all spend different
amounts of time on education and each be fulfilling our obligation. How much we commit to imperfect duties is up to us.

Our reason  for doing the right thing (which Kant called a maxim) is also important. We should do our duty for no other reason than because it’s the right
thing to do.

Obeying the rules for self-interest, because it will lead to better consequences or even because it makes us happy is not, for deontologists, an ethical
reason for acting. We should be motivated by our respect for the moral law itself.

Deontologists require us to follow universal rules we give to ourselves. These rules must be in accordance with reason – in particular, they must be
logically consistent and not give rise to contradictions.

It is worth mentioning that deontology is often seen as being strongly opposed to consequentialism. This is because in emphasising the intention to
act in accordance with our duties, deontology believes the consequences of our actions have no ethical relevance at all. Political philosopher Michael
Walzer gives a soundbite version of this idea – “justice though the heavens fall”.

The appeal of deontology lies in its consistency. By applying ethical duties to all people in all situations the theory is readily applied to most practical
situations. By focussing on a person’s intentions, it also places ethics entirely within our control – we can’t always control or predict the outcomes of
our actions, but we are in complete control of our intentions.

Others criticise deontology for being inflexible – by ignoring what is at stake in terms of consequences, some say it misses a serious element of ethical
decision-making. De-emphasising consequences has other implications too – can it make us guilty of ‘crimes of omission’? Kant, for example, argued it
would be unethical to lie about the location of our friend, even to a person trying to murder them! For many, this seems intuitively false.
One way of resolving this problem is through an idea called threshold deontology, which argues we should always obey the rules unless in an
emergency situation, at which point we should revert to a consequentialist approach.

TELEOLOGY

Teleological ethics, (teleological from Greek telos, “end”; logos, “science”), theory of morality that derives duty
or moral obligation from what is good or desirable as an end to be achieved. Also known as consequentialist ethics,
it is opposed to deontological ethics (from the Greek deon, “duty”), which holds that the basic standards for an
action’s being morally right are independent of the good or evil generated.
Modern ethics, especially since the 18th-century German deontological philosophy of Immanuel Kant, has been
deeply divided between a form of teleological ethics (utilitarianism) and deontological theories.
Teleological theories differ on the nature of the end that actions ought to promote. Eudaemonist theories
(Greek eudaimonia, “happiness”), which hold that ethics consists in some function or activity appropriate to man as
a human being, tend to emphasize the cultivation of virtue or excellence in the agent as the end of all action. These
could be the classical virtues—courage, temperance, justice, and wisdom—that promoted the Greek ideal of man as
the “rational animal”; or the theological virtues—faith, hope, and love—that distinguished the Christian ideal of man
as a being created in the image of God.

UTILITARIANISM

Utilitarianism is one of the most powerful and persuasive approaches to normative ethics in the history of philosophy. Though not fully articulated until
the 19th century, proto-utilitarian positions can be discerned throughout the history of ethical theory.
Though there are many varieties of the view discussed, utilitarianism is generally held to be the view that the morally right action is the action that
produces the most good. There are many ways to spell out this general claim. One thing to note is that the theory is a form of consequentialism: the right
action is understood entirely in terms of consequences produced. What distinguishes utilitarianism from egoism has to do with the scope of the relevant
consequences. On the utilitarian view one ought to maximize the overall good — that is, consider the good of others as well as one's own good.
The Classical Utilitarians, Jeremy Bentham and John Stuart Mill, identified the good with pleasure, so, like Epicurus, were hedonists about value. They
also held that we ought to maximize the good, that is, bring about ‘the greatest amount of good for the greatest number’.
Utilitarianism is also distinguished by impartiality and agent-neutrality. Everyone's happiness counts the same. When one maximizes the good, it is the
good impartially considered. My good counts for no more than anyone else's good. Further, the reason I have to promote the overall good is the same
reason anyone else has to so promote the good. It is not peculiar to me.

LESSON 2

Virtue Ethics

At the end of the lesson, the student should be able to:

 Demonstrate caring as the core of nursing, love of God, love of country and love of people.

 Manifest professionalism, integrity and excellence

  Project the positive professional image of a Filipino Nurse

Virtue Ethics
Virtue ethics is a broad term for theories that emphasize the role of character and virtue in moral philosophy rather than either doing one’s duty or
acting in order to bring about good consequences. A virtue ethicist is likely to give you this kind of moral advice: “Act as a virtuous person would
act in your situation.”
Most virtue ethics theories take their inspiration from Aristotle who declared that a virtuous person is someone who has ideal character traits.
These traits derive from natural internal tendencies, but need to be nurtured; however, once established, they will become stable. For example,  a
virtuous person is someone who is kind across many situations over a lifetime because that is her character and not because she wants to
maximize utility or gain favors or simply do her duty. Unlike deontological and consequentialist theories, theories of virtue ethics do not aim
primarily to identify universal principles that can be applied in any moral situation. And virtue ethics theories deal with wider questions—“How
should I live?” and “What is the good life?” and “What are proper family and social values?”
Since its revival in the twentieth century, virtue ethics has been developed in three main directions: Eudaimonism, agent-based theories, and the
ethics of care. Eudaimonism bases virtues in human flourishing, where flourishing is equated with performing one’s distinctive function well. In
the case of humans, Aristotle argued that our distinctive function is reasoning, and so the life “worth living” is one which we reason well. An
agent-based theory emphasizes that virtues are determined by common-sense intuitions that we as observers judge to be admirable traits in other
people. The third branch of virtue ethics, the ethics of care, was proposed predominately by feminist thinkers. It challenges the idea that ethics
should focus solely on justice and autonomy; it argues that more feminine traits, such as caring and nurturing, should also be considered.

Here are some common objections to virtue ethics. Its theories provide a self-centered conception of ethics because human flourishing is seen as
an end in itself and does not sufficiently consider the extent to which our actions affect other people. Virtue ethics also does not provide guidance
on how we should act, as there are no clear principles for guiding action other than “act as a virtuous person would act given the situation.”
Lastly, the ability to cultivate the right virtues will be affected by a number of different factors beyond a person’s control due to education, society,
friends and family. If moral character is so reliant on luck, what role does this leave for appropriate praise and blame of the person?
 Virtues Ethics in Nursing

Virtue ethics is an approach that focuses on character with the assumption that a person of good character will tend to behave in
ways that are consistent with their character. A virtue ethics for nursing is therefore concerned with the character of individual
nurses and seeks ways to enable nurses to develop character traits appropriate for actions that enhance wellbeing. This chapter
offers some insights into the nature of virtue ethics from an Aristotelian perspective and includes an outline of the virtue
of phronesis (practical wisdom) which provides guidance in situations where it is not obvious what action would be the virtuous
action. Virtue ethics is contrasted with modern ethical theory (deontology and utilitarianism) and some ways in which virtue ethics
can enhance professional nursing practice are considered.

A virtue ethics for nursing is therefore concerned with the character of individual nurses and seeks ways to enable nurses to
develop character traits appropriate for actions that enhance wellbeing

WHAT'S THE RIGHT THING TO DO in situations such as these?

1. A favourite neighbour of yours is admitted to your unit with a life-threatening condition. When a mutual friend asks about his status, what should you say?
 
2. An older patient admits that she's agreed to have surgery in a few hours because her daughter wants her to have it, not because she wants it. What should you
do?
Nurses face ethical dilemmas such as these every day, often with little to guide them. In this article, I'll provide a practical road map to sorting through difficult ethical
issues by focusing on two perspectives: your obligations as a professional nurse and the virtues needed to make morally sound decisions, such as honesty,
compassion, and self-respect.
 

Four obligations, six virtues

By addressing the ethical obligations and duties of nurses, the Code of Ethics for Nurses helps you answer the question, "What should I do in this situation?" It
identifies four primary obligations you must meet to fulfill the contract between nursing and the public:
 
* respecting the patient's privacy and protecting confidentiality
 
* communicating honestly about all aspects of the patient's diagnosis, treatment, and prognosis
 
* conducting an ethically valid process of informed consent
 
* advocating for the patient's expressed interests or best interests.1
 
 
A related concept, virtue theory, addresses the question, "How should I be?" It deals with moral questions from the model of what a good man or woman would do.
Although it doesn't ignore the question, "What should I do?," it focuses on questions of character rather than action.
 
Virtues are best understood as qualities a person possesses that motivate her to act in a moral or ethical way. The Code defines virtues as character traits that incline
people to do the right thing.1 These six virtues apply to nursing:
 
* professional competence
 
* honesty and integrity
 
* caring and compassion
 
* fairness and justice
 
* respect and self-respect
 
* courage.
 
 
Provision 5 in the Code speaks directly to importance of character. A nurse owes the same duties to herself as to others, including the responsibility to preserve
integrity and safety, to maintain competence, and to continue personal and professional growth. For more discussion of these points, see How key virtues apply to
nursing.
 

Meeting your obligations

Now let's look at how your four primary professional obligations to patients are influenced by the six virtues.
 
1. Protecting privacy and confidentiality. The basic obligation to maintain a patient's privacy and confidentiality has existed since the time of Hippocrates, yet many
nurses violate this principle without thinking. For example, suppose a friend asks you about your neighbor who's been admitted to the hospital unit where you work.
Even a casual reply about his condition violates his privacy. In fact, so does simply verifying his admission to the hospital.
 
Respecting the patient means not invading or denying his privacy. If you commented about your patient to your friend, even though you weren't acting out of
malevolence, you'd fail to demonstrate the virtue of respect and integrity.
 
Your patient has a right to expect that you'll hold his diagnosis, prognosis, and personal history in utmost confidence. Share information about his condition only with
those involved in his care who need to know.
 
2. Communicating honestly. Veracity is the ethical principle that obligates you to tell the truth. At times the truth may be painful for the patient or his family to hear,
but honesty is a core virtue; only under unusual circumstances is violating it acceptable. To act from the virtues of honesty and compassion requires you to make sure
that bad news is delivered in an honest and compassionate way. Here's a six-step model to help you discuss unwelcome news in a competent way.2
 
* Help the physician get the physical context right. Ask the patient if he'd like to have any family members present when the physician discusses the results of tests or
surgery. As much as possible, prevent interruptions to the conversation. Encourage the physician to sit down to deliver news to the patient or his family. Have a box
of tissues close by.
 
* Find out what the patient and family already know. For example, when the physician leaves and the patient begins to ask you questions, you can ask, "What do you
understand about your illness?" This is the time to assess the ability of the patient and family to comprehend more bad news.
 
* Determine how much the patient wants to know (or not know). Ask him, "Did you receive enough information to understand your condition?" Also find out if he wants
a family member or other surrogate to communicate on his behalf.
 
* Communicate the distressing information in a sensitive, straightforward manner. As a nurse, you won't be the first person to break bad news about a diagnosis, a
prognosis, or test results. But the patient may ask you to clarify the message he's received. For example, you may need to say, "I'm sorry to have to tell you this. Yes,
your physician said the scan did show a tumor in your abdomen."
 
 
Then pause and wait for his reaction. Don't try to soften or minimize the severity of the situation because this may confuse him.
 
* Give the patient and his family time to react and be prepared for an emotional outburst. You could say, "This is difficult news. How can I help you now?"
 
* Develop a plan for the next steps and follow-up needed. Discuss potential sources of support. Assess the safety of the patient if he's leaving after receiving bad
news.
 
 
You'll sometimes need the virtue of courage when you tell the truth to a patient or family and in many other circumstances you encounter as a nurse. I've defined
moral courage as the capacity to overcome fear and stand up for one's core values.3 It's the willingness to speak out and do what's right in the face of forces that
influence you to act in some other way. Besides physical harm, these forces include the threat of humiliation, rejection, ridicule, unemployment, and loss of social
standing.4 But nurses who fail to act ethically experience personal losses of self-respect, integrity, and justice.
 
3. Conducting an ethically valid informed-consent process. What's your responsibility in the process of informed consent? Most nurses believe they're
responsible only for witnessing the signature of the patient. But according to the Code, you're responsible for ensuring much more (see Criteria for informed
consent).1 For example, you're obligated to assess the patient's ability to make an informed decision about his care. His cognitive abilities may fluctuate because of
medication, surgery, unfamiliar surroundings, or his disease. As his nurse, you're in the best position to assess his ability to understand issues related to his care and
give valid consent.5
 
This relationship also helps you determine if his consent is truly voluntary. Imagine that an 82-year-old patient with diabetes confides that she doesn't really want to
have an above-knee amputation; she's doing it only to please her daughter, who's unwilling to face her death. She asks you not to tell her daughter and says she
feels better just telling someone her true feelings. She's already signed the consent form and is scheduled for surgery in the morning. What should you do?
 
This situation calls for patient advocacy and probably a family meeting as well. The virtue of caring will likely trigger the nurse's desire to help the patient, but the
virtue of courage will be needed to confront this difficult situation. The nurse now experiences an ethical conflict between maintaining confidentiality and supporting a
valid informed consent. The nurse is obligated to contact the surgeon because of possible coercion by the patient's daughter. According to the Code, "duties of
confidentiality [aren't] absolute and may need to be modified[horizontal ellipsis]to protect the patient."1
 
The family meeting, orchestrated by patient relations, the ethics committee, or an ethics consultant, could be uncomfortable for all concerned. However, as her nurse
you must take responsibility for caring for the patient, respecting the truth, and advocating for the patient. Such a meeting is time-consuming, and the surgeon and the
patient's daughter aren't likely to welcome it. But the question is simple: How will you feel if you send the patient to surgery without speaking up, knowing what you
know? The treatment decision could change from surgery to a referral for hospice care, which would provide family support for the patient's daughter.
 
4. Advocating for the patient's best interests. This is what puts action into your obligations. Being passive or active is a choice. Positioning yourself as the patient's
advocate in the case we just discussed would be very difficult, especially if you suspect the surgeon will be angry and know that the patient may back down in the
face of pressure from her daughter.
 
I hope that you would choose to act with courage, which involves supporting your professional obligations, standing up to an angry physician, and doing what you
think is right for the patient.
 
Advocacy is often inhibited by the institutional bureaucracy. Nurses must feel free to engage in advocacy roles in health care environments; otherwise, patient self-
determination will be truly lost in the morass of rules, regulations, and nurse timidity. Standing up in advocacy requires overcoming the challenges of moral blindness,
moral complacency, and moral distress.6 (See A question of morals.)

  Ethics in action
To act ethically, you need to know more than your professional obligations outlined in the Code.1 Your actions and decisions as a nurse are manifestations of your
true character. Virtue theory provides a framework for key areas of character development. You can learn obligations and strengthen your character. Both require
education, perseverance, and often the virtue of courage.
 

How key virtues apply to nursing

The virtue of professional competence calls for continual professional growth and a commitment to lifelong learning. You must practice nursing that's evidence-
based, be knowledgeable about the scope and standards of nursing practice, and have the necessary skills to perform nursing tasks effectively. For example,
consider the current evidence and skills required for professionally competent patient transfers. Research shows that best practices include having peer safety
leaders on each shift to coach ergonomics and the use of lifts. What does this have to do with ethics? To follow best practices for patient transfer, you must have
the courage to demand lifts and the integrity to use them consistently. When nursing actions are in sync with the evidence, your practice environment supports
integrity.
 
Because of cost and access constraints in today's health care environment, the virtues of honesty and integrity are constantly under assault. Integrity can be
preserved only if nurses' actions are consistent with the values and ethics of the profession. If honesty and integrity are compromised, we lose self-respect, which
further menaces the wholeness of character.
 
The Code of Ethics for Nurses supports your right to conscientious objection "in situations of compromise that exceed acceptable moral limits or involve violations of
the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice."1 Expressing a conscientious objection isn't just stating
a personal preference or making an arbitrary choice. It's refusing to participate because you find the requested action morally unacceptable.
 
Caring and compassion and fairness and justice are also addressed in the Code: "Excellences such as compassion, patience, and skill are habits of character of
the morally good nurse."1
 
Nurses are obligated to create and sustain a nursing practice environment that enables them to fulfill their ethical obligations. This could involve participating on an
ethics committee or practice council, acting as a preceptor for new nurses, or working to change unfair polices within or outside the organization.
 
Your obligation to justice extends beyond the walls of the workplace because nurses have a responsibility to address broader health disparity concerns, such as
world hunger, violation of human rights, and inequitable distribution of health care resources.1
 

Criteria for informed consent

 
1. Capacity (to understand and decide)
 
2. Voluntariness (in deciding)
 
3. Disclosure (of information)
 
4. Recommendation (of a plan)
 
5. Understanding (of plan, risks, and recommendation)
 
6. Decision (in favor of plan)
 
7. Authorization (of chosen plan)
 
Source: Fletcher JC, et al., Fletcher's Introduction to Clinical Ethics, University Publishing Group, 2005.
 

A question of morals
Here are three ways of responding to moral problems. To practice ethically, all must be overcome.
 
Moral blindness describes seeing a dilemma as an administrative or clinical quandary rather than an ethical issue. For example, the understaffing of the unit doesn't
allow for time-consuming comfort care to terminally ill patients, but the problem is considered an administrative staffing problem rather than a moral problem. Or
inadequate pain control might be seen as lack of pain management expertise instead of a nurse's lack of awareness of her ethical obligation to manage pain.1
 
Moral complacency indicates a general satisfaction with one's own opinion of a situation. For example, a nurse might conclude that all terminally ill patients are
naturally depressed. This contentment with one's opinion can lead to a lack of action in advocating to treat a patient's depression. A nurse who lacks the virtue of
competency doesn't think through the problem critically.
 
Moral distress can be described as "the conflict between the nurse's knowledge of the ethically appropriate action and the institutional constraints that prevent or
make the action difficult."7 This definition speaks to the organization's responsibility for providing an ethical work environment. However, no matter how difficult, the
nurse's ethical duty is to advocate for patients. This requires the virtues of integrity, respect, caring, and courage.

Core Values of a Professional Nurse

Caring is best demonstrated by a nurse's ability to embody the five core values of professional nursing. Core nursing values essential to baccalaureate
education include human dignity, integrity, autonomy, altruism, and social justice. The caring professional nurse integrates these values in clinical practice.

For those looking to find a career that involves helping, healing, and nurturing those around them, nursing is a great path to
success. Becoming a nurse is one of the most rewarding, fulfilling career paths students can pursue, with each professional hour
dedicated to helping those around you. A competent nursing school instills in its students core values that will carry them into
their future careers. If you’re thinking about pursuing a nursing degree, here are some of the core values of nursing that we
think are fundamental to your nursing education.
Empathy and Caring

A nursing school should teach its students the true value of empathy and compassionate care. At Goodwin University, we
believe empathy is a nurse’s ability to understand, be aware of, be sensitive to, and vicariously experience the feelings,
thoughts, and experiences of the patient and their family. The faculty believes that it is the nurse’s ability and willingness to
“tune in” to and focus on the patient’s experiences that is fundamental to the methods nurses use to manage care. Empathy is
based upon respect for the dignity of the client and an appreciation for the independence and self-actualization of the patient.

As a foremost nursing school in CT, we believe caring involves knowing and trusting the patient, an interest in their growth and
well-being, honesty, courage, and humility. A caring nurse knows that he or she does not know all there is to know about the
patient, and projects the confidence and patience to help them maintain hope or the sense of continued possibility for growth
and change. Caring involves the planning and provision of culturally sensitive and appropriate care.

Communication

We believe communication—the exchange of thoughts, messages, or information—is of vital importance to the nursing
process. A nurse uses communication skills—speech, signals, writing, and behavior—during patient assessment, as well as the
planning, implementing, and evaluating of nursing care. A nurse communicates with patients, families, groups, and members of
the health care team. They are competent in oral and written forms of communication, as well as in techniques of therapeutic
communication.

Teaching

We believe one of the most important roles of a nurse is to assist patients and their families with receiving information
necessary for maintaining a patient’s optimal health. A nurse provides patients and families with information that is based on
their assessed learning needs, their abilities, their learning preference, and their readiness to learn. Fundamental to the provision
of patient education is a nurse’s belief that patients have the right to make informed decisions about their care. Nurses provide
information that is accurate, complete, and relevant to client needs. A nurse often clarifies information provided by other
members of the health care team.

Critical Thinking

Nurses are constantly involved with making accurate and appropriate clinical decisions. We believe nurses must be able to
think critically and make decisions when patients present problems for which there may not be clear, textbook solutions. A
nurse must question, wonder, and be able to explore various perspectives and possibilities in order to best help patients. Critical
thinking involves an active, organized cognitive process designed to allow a nurse to explore and challenge assumptions.
Nurses that engage in critical thinking reflect on past experiences, think independently, take risks based on knowledge,
persevere in the face of difficult problems, are curious, creative, and ethical.

Psychomotor Skills

We believe that fundamental to nursing is the “laying on of hands” to provide comfort, and the use of specific skills to
accomplish client assessment and to provide and evaluate nursing care. Nursing skills are utilized in a manner that maximizes
client comfort and dignity, optimizes the client’s ability to respond positively, provides the highest level of accuracy of
information, and provides for the most favorable patient outcomes. Psychomotor skills are best learned through practice after
achieving an understanding of the basic principles of skills as part of a nurse’s education at an exceptional nursing school like
Goodwin University.

Applied Therapeutics

A nurse applies medically-ordered therapeutic modalities, like pharmacological and nutritional interventions, etc. A nurse’s
application of these modalities is based on a knowledge base regarding their therapeutic uses, as well as skills in patient
assessment and evaluation. The competent application of nutritional knowledge also involves its use in health and wellness, as
well as when therapeutic diets are prescribed.

Ethical and Legal Considerations

A nurse plans, provides, and evaluates nursing care guided by specific ethical and legal boundaries. We believe the Code of
Ethics for Nurses provides the ideal framework for safe and correct practices and behavior. Ethical behavior also involves
accountability, responsibility, confidentiality, truthfulness, fidelity, and justice. Nurses who clarify their values are enhanced in
their ability to practice ethically.

Legal parameters of nursing are defined by statutory, regulatory, and common law. In addition, professional standards of care
provide the legal guidelines for nursing practice. Legal considerations in the care of clients involve issues like negligence,
malpractice, abandonment, assault, battery, and informed consent. Nurses must understand legal boundaries to protect their
patients’ and their own rights.

Professionalism

Professionalism involves the characteristics of a nurse that reflects his or her professional status. These characteristics involve
behaviors with regard to self, patients, others, and the public as they reflect the values of the nursing profession. Professional
personas are knowledgeable in their subject matter, conscientious in their actions, and responsible for themselves and others.
Written standards for practice and professional performance guide the behaviors of professional practitioners. We believe
nurses enhance their professionalism by understanding history, educational choice, professional research and theory, and their
professional organizations and standards.

Click the link: https://www.youtube.com/watch?v=wUISJZ0JA3Q&feature=youtu.be

What are your takeaways in the video?

LESSON 3

Ethical Principles

At the end of the lesson, the student should be able to:

 Adhere to ethico-legal considerations in varied personal and professional applications.

  Apply ethical reasoning and decision -making process to address
situations of ethical distress and moral dilemma:
 Discern ethical from unethical practice in the care of clients.
 Adhere to established norms of conduct based on legal, regulatory and institutional
requirements relevant to safe nursing practice.
 Implement strategies related to informed consent as it applies in multiple context

What are the core ethical principles of nursing practice?

A number of core ethical principles are recognised in the healthcare setting. These provide a basis for complex decision-making by weighing up
multiple factors and consequences of the care process. The number of core principles varies; however, four key principles are generally
recognised: non-maleficence, beneficence, autonomy, and justice.

Non-maleficence

Non-maleficence means 'do no harm'. Any action should not cause unnecessary harm or suffering to the patient and should be justified by
ethical and professional judgement and guidance. This includes both physical and psychological harm. Evidence-based practice is vital, as it can
minimise the risk of harm. Nurses must be able to appraise the risk to the individual, and use interventions and treatments to minimise risk and
maximise benefits.

Examples of non-maleficence include stopping a medication that is causing harmful side effects, or discontinuing a treatment strategy that is not
effective and may be harmful.

Beneficence
Beneficence means 'do good', and promotes actions that benefit the patient. Nurses should support patients during their healing and recovery.
This applies to all care processes, including administering medication and providing patients with information and education. There is often a
need to balance the potential for a treatment to do good and do harm, particularly when administering drugs with side effects, or in patients with
complex care needs. Balancing non-maleficence and beneficence is important, and requires careful consideration.

Beneficence can be frequently seen in practice, and includes the use of vaccines, providing patients with health advice and counselling, and
providing emergency care.

Autonomy

Autonomy states that patients should be able to act independently and should be in control of their fate. Patients should make decisions
regarding their care or act intentionally, without being controlled or excessively coerced. Nurses may try to influence patients to adopt a
particular treatment strategy when that is the strategy with the strongest evidence base, but must not prevent patients making their own
decisions. Preserving autonomy for patients can be achieved through patient-centred care and involving patients in their own care decisions.

An example of behaviours that promote autonomy is presenting all treatment options to a patient and providing them with sufficient information
such that the patient can make an informed choice in concert with medical advice.

Justice

'Justice' entails obligations to act in a manner considered equitable, fair and consistent with the rights of the individual. Justice ensures fairness in
the treatment of all patients; they have the right to be treated equally, regardless of their background or condition, and should not be
discriminated against based on personal characteristics, beliefs or values.

Examples of justice in practice include offering the same treatment options to two patients, even where one may have a condition through no
fault of their own and the other through personal behaviour (e.g. lung cancer and smoking), and allocating resources equally among members of
the population.

Other ethical principles

Other ethical principles should also be considered. One is fidelity, which stands for dedication, advocacy and truthfulness towards patients and
other professionals. Nurses should never attempt to deceive or manipulate patients, and should maintain the confidence of the patient and
honour any commitments made. For instance, fidelity applies in a scenario where a patient asks a nurse to withhold a terminal diagnosis from
their family. In this instance, the nurse should recognise the need to maintain confidential information for the patient, while also supporting the
family.

Totality and integrity are additional ethical principles. Totality and integrity suggest that the entire patient should be considered when planning
care. This is important where serious side effects may be associated with a treatment, despite the potential to relieve certain symptoms or alter
the management course. Not all actions can be considered in terms of beneficence or non-maleficence, as many treatments may lead to adverse
effects despite their effectiveness in other areas. Nurses need to balance the risks and benefits of the intervention in a holistic manner to justify
their use.

LESSON 4

Other Relevant Ethical

At the end of the lesson, the student should be able to:

 Display communication skills with client and /or support system based on trust,
respect and shared decision-making using appropriate communicate/
interpersonal techniques/ strategies
 Conduct ethical assessment in a given case scenario.
4. Principle of Double Effect
 5. Principle of Legitimate Cooperation
6. Principle of Common Good and Subsidiarity

Principles of Bioethics
2. Principle of Stewardship and Role of Nurses as Stewards
 Personal
 Social
 Ecological
 Biomedical

Principle of Double Effect

This doctrine says that if doing something morally good has a morally bad side-effect it's ethically OK to do it
providing the bad side-effect wasn't intended. This is true even if you foresaw that the bad effect would probably
happen.
 The principle is used to justify the case where a doctor gives drugs to a patient to relieve distressing symptoms even
though he knows doing this may shorten the patient's life.

This is because the doctor is not aiming directly at killing the patient - the bad result of the patient's death is a side-
effect of the good result of reducing the patient's pain.

Many doctors use this doctrine to justify the use of high doses of drugs such as morphine for the purpose of relieving
suffering in terminally-ill patients even though they know the drugs are likely to cause the patient to die sooner.

Factors involved in the doctrine of double effect

 The good result must be achieved independently of the bad one: For the doctrine to apply, the bad
result must not be the means of achieving the good one. So if the only way the drug relieves the patient's pain is
by killing him, the doctrine of double effect doesn't apply.
 The action must be proportional to the cause: If I give a patient a dose of drugs so large that it is certain
to kill them, and that is also far greater than the dose needed to control their pain, I can't use the Doctrine of
Double Effect to say that what I did was right.
 The action must be appropriate (a): I also have to give the patient the right medicine. If I give the patient
a fatal dose of pain-killing drugs, it's no use saying that my intention was to relieve their symptoms of vomiting if
the drug doesn't have any effect on vomiting.
 The action must be appropriate (b): I also have to give the patient the right medicine for their symptoms.
If I give the patient a fatal dose of pain-killing drugs, it's no use saying that my intention was to relieve their
symptoms of pain if the patient wasn't suffering from pain but from breathlessness.
 The patient must be in a terminal condition: If I give the patient a fatal dose of pain-killing drugs and they
would have recovered from their disease or injury if I hadn't given them the drugs, it's no use saying that my
intention was to relieve their pain. And that applies even if there was no other way of controlling their pain.
Problems with the doctrine of double effect
Some philosophers think this argument is too clever for its own good.
 We are responsible for all the anticipated consequences of our actions: If we can foresee the two
effects of our action we have to take the moral responsibility for both effects - we can't get out of trouble by
deciding to intend only the effect that suits us.
 Intention is irrelevant: Some people take the view that it's sloppy morality to decide the rightness or
wrongness of an act by looking at the intention of the doctor. They think that some acts are objectively right or
wrong, and that the intention of the person who does them is irrelevant. But most legal systems regard the
intention of a person as a vital element in deciding whether they have committed a crime, and how serious a
crime, in cases of causing death.
 Death is not always bad - so double effect is irrelevant: Other philosophers say that the Doctrine of
Double Effect assumes that we think that death is always bad. They say that if continued life holds nothing for the
patient but the negative things of pain and suffering, then death is a good thing, and we don't need to use the
doctrine of double effect.
 Double effect can produce an unexpected moral result: If you do think that a quicker death is better than
a slower one then the Doctrine of Double Effect shows that a doctor who intended to kill the patient is morally
superior to a doctor who merely intended to relieve pain.
The Sulmasy test
Daniel P. Sulmasy has put forward a way for a doctor to check what their intention really is. The doctor should ask
himself, "If the patient were not to die after my actions, would I feel that I had failed to accomplish what I had set
out to do?"

Principle of Legitimate Cooperation

If we were to try to avoid any and all cooperation with evil we would be unable to act. Obviously such a
goal is noble, but unreasonable. Moral reasoning guided by moral principles and enlightened by grace
can guide us to choose the best possible good even when evil is unavoidable. One important guiding
principle is the principle of legitimate cooperation with evil.
In an attempt to understand any principle, Saint Thomas Aquinas teaches us that the first step is to define
our terms. Thanks to Sister Renee Mirkes, OSF, PhD for her guidance in writing this article. The
definitions in this article are based on her work (Creighton Model FertilityCare™ System – Advanced
Teaching Skills. Chapter 22: “Principle of Legitimate Cooperation: Applications”).
When you are performing an action that is intertwined with evil, you can use the following criteria to judge
how legitimate your cooperation with the evil is

 The moral object of your action is good and you are operating out of good intentions.
 The evil is only tolerated as a side effect of your action
 Your cooperation is only material cooperation, not formal
 Your cooperation is remote rather than proximate so it causes minimal evil effects
 Your action does not cause scandal

Moral Object
The moral object of an action is the objective goal of the action. It is the good that you are trying to attain
(or the evil you are trying to avoid) through the action, and how well the action is ordered toward that
good.

Intention
The intention is the reasons why you choose to act. Your intention may coincide with your choice of the
moral object, or you may have intentions beyond the simple object. For example, you may choose to give
money to charity (the moral object to help those in need), but your intention may be to impress people
with your generosity.
Legitimate
The term “legitimate” refers to moral acceptability, not the legal meaning of conforming to a set of
standards and requirements to be acceptable.

Cooperation
Cooperation with evil as understood in the context of this principle does not mean working together in
agreement with all aspects of the act. Rather, it means working together despite disagreement about the
ends or means of the act. In other words, cooperation does not imply condoning the evil.

Wrongdoer and Cooperator

The wrongdoer is the party who initiated the wrongdoing, directly intending the specific evil. The
cooperator is involved with the wrongdoing by means of some action that is distinct from the evil act
initiated by the wrongdoer. The cooperator intends a specific good and only tolerates the evil as a
necessary side effect.

Formal Cooperation
Formal cooperation occurs when the evil end or evil means are directly chosen by means of
encouragement, praise, advice, or other forms of support.

Material Cooperation
Material cooperation occurs when the evil end and means are indirectly chosen by a person who has
chosen a good end and good means. Material cooperation can be mediate or immediate. Mediate
material cooperation is when the cooperator’s involvement is only contingent or accidental to the
wrongdoing. In other words, the cooperation does not contribute to the perpetuation of the evil.
Immediate material cooperation is when the cooperator’s involvement is necessary for the evil to
continue. Immediate material cooperation is morally equivalent to formal cooperation. The best way to
know if your cooperation is immediate is to ask yourself if the evil would cease if you did not cooperate in
the act.

Proximate vs. Remote Cooperation

The moral proximity to evil is a measure of how contingent or mediate the cooperation would be to the
evil. In other words, how much does the cooperator’s action contribute to the action? The closer the
cooperation with the evil, the more likely the act is to cause evil results. Remote cooperation is preferable
to proximate cooperation.

Proportionate Good
The good object that one chooses and intends when performing an action that cooperates with evil, and
the good effects resulting from the action, should be at least as great as (morally proportionate to) the
foreseen evil effects. This consideration can only be applied if the other conditions for legitimate
cooperation are met.

Scandal
Scandal is when your actions or words create a temptation to sin for others. By observing your behavior,
others may erroneously think that there is nothing wrong with the evil involved with the action. Even if you
judge your action to be legitimate cooperation with evil, you should avoid performing it if there is
likelihood of causing grave scandal.

Principle of Common Good and Subsidiarity

our Principles: Personhood, Common Good, Solidarity and Subsidiarity

Four Principles: Personhood, Common Good, Solidarity, Subsidiarity

With these four principles we can grasp human society in its entirety and consider this reality truthfully. They are interrelated and we, as human
beings, must act in accordance with them. No human can reasonably situate himself outside of social life. We have responsibility through the
Commandment of love of God and neighbour to help others, to serve the common good, to help every individual live a dignified life, and to
protect the intrinsic rights of groups and associations.

Personhood

This is covered in the previous section, under The Dignity of the Human Person.

Common Good

Vatican II defined the Common Good as “the sum total of social conditions which allows people, either as groups or as individuals, to reach their
fulfilment more fully and more easily.” It is about the progress of persons.

A society that wishes and intends to remain at the service of the human being at every level is a society that has the common good – the good
of all people and of the whole person as its primary goal.
We must be interested in the good of all, even of people nobody thinks about because they have no voice and no power. The goods of the earth
are there for everyone. The common good consists not only of the material or external good of all human beings; it also includes the
comprehensive good of the human being, including even the spiritual good.

The common good of society is not an end in itself. It is only part of a bigger picture, the ultimate end of which is God. The common good, as a
mere materialistic socio-economic ideal, would count for little without any transcendental goal.

The Common Good and Politics

The Catechism of the Catholic Church clearly states that “it is the role of the state to defend and promote the common good of civil society, its
citizens, and intermediate bodies.”

The common good, in fact, is the very reason that political authority exists.

It is the role of political institutions to make available to persons the necessary material, cultural, moral and spiritual goods required to allow
each individual to achieve their full development. Among the duties of government is the need to harmonise different sectoral interests with
the requirements of justice. It is an extremely delicate task but one of great importance.

The Universal Destination of Goods

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. John Paul II in the encyclical letter Centesimus Annus  states: “the earth, by reason of its fruitfulness and its capacity to satisfy human
needs, is God’s first gift for the sustenance of human life.”

Every person has the right to what is vitally necessary and this must not be withheld from him. The Church accepts that there is a right to
property and that there will always be differences in how much people own, but if some have more while others lack the bare necessities there
is a need for charity and also for justice.

Is private property permissible? It is reasonable for there to be private property; through work and the acquiring of private property a person
shapes the earth and makes a piece of it his own. Private property encourages freedom and independence and it also encourages the individual
to preserve and care for his property. The Second Vatican Council, in Gaudium et spes, states that private property and other forms of private
ownership of goods “assure a person a highly necessary sphere for the exercise of his personal and family autonomy and ought to be
considered as an extension of human freedom….stimulating exercise of responsibility, it constitutes one of the conditions for civil liberty.”
It is, however, important that owners of private property make use of it in a manner consistent with the common good; that is, the good of all.
Property includes intellectual property, knowledge, and technology. This is particularly important in the context of wealthy nations and their
obligations to poorer nations.

Preferential Option for the Poor

The principle of the universal destination of goods requires that the poor and the marginalised should be the focus of particular concern. We
imitate Christ by a loving preference for the poor, inspiring us to embrace the hungry, the needy, the homeless, those without healthcare, and
those without hope of a better future.

The Catechism (103) makes this abundantly clear: “Our Lord warns us that we shall be separated from him if we fail to meet the serious needs
of the poor and the little ones who are his brethren.” It further states (2248) that the Church, “since her origin and in spite of the failing of many
of her members, has not ceased to work their [the poor] relief, defence and liberation through numerous works of charity which remain
indispensable always and everywhere.”

The Church’s love for the poor is inspired by the Gospel of the Beatitudes, the poverty of Jesus and his attention to the poor. The Church
teaches that one should assist one’s fellow man in his various needs and fill the human community with countless works of corporal and
spiritual mercy.

‘When we attend to the needs of the poor, we give them what is theirs, not ours. We pay a debt of justice.’ (St Gregory the Great, Regula
Pastoralis)

Subsidiarity

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. This idea is summed up in the principle of subsidiarity.

For example, if a family is experiencing problems, the state can intervene only if the family or the parents are overburdened and cannot resolve
them. It helps to avoid too much centralisation. Being able to help oneself is an important component of the dignity of the human person.

Pope Pius XI’s encyclical letter Quadragesimo Anno, which introduced the principle, goes as far as to say that ‘it is an injustice and a grave evil and
disturbance of right order to assign to a greater and higher association what lesser and subordinate organisations can do.’

It is the same for politics. Only where local government cannot resolve a problem by itself may the federal/central government claim
competence.
 

Participation

We, as Christians, are called to participate in society so that we may contribute to the cultural, economic, political and social life of the
community. We have a responsibility to seek and work for the common good, and with this in mind we must become involved in all areas of life,
using our Christian values as a basis for our participation and encouraging others to do the same.

In a political sense, we may simply exercise our right and our moral duty to vote, or we may even contact our local elected representative to
discuss a particular issue. We may even become a member of a political party. These, and many others, are examples of participation.

Solidarity

No human being can live for himself alone; he is always dependent on others. There are two complimentary aspects to solidarity: social
principle and moral virtue. As a moral virtue solidarity determines the order of institutions ensuring no “structures of sin” dominate
relationships between individuals and peoples and where they do exist purifying and transforming them into structures of solidarity. It involves
very deliberate practical support for the wellbeing of all people. Vague words of compassion do not help, we are called to act!

Solidarity is a social principle because it is a matter of justice and it is directed to the common good, and a commitment to the good of others.

 
Principle of Stewardship and Role of Nurses as Stewards

 Personal
 Social
 Ecological
 Biomedical