ETHICO-LEGAL ASPECTS IN MATERNAL & CHILD CARE

Mrs. Ma. Imelda O. Javier, RN, MAN

Basic Ethical Principles

STEWARDSHIP

Our bodies, our life, our human nature and everything in this earth are gifts we have dominion over. This means we are responsible for them. 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. We cannot contradict human nature.

 TOTALITY

Totality 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. The basic capacities which define human personhood, however, are sacrificed only when there is need to preserve life.

 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 action itself must be good or at least neutral.

2. The intention is for the good effect and the bad effect merely allowed. 3. The foreseen beneficial effect must be equal or greater than the foreseen harmful effect. 4. The beneficial effect must follow from the action at least as immediately as the harmful effect. The good effect must not be produced by the bad effect.

Examples
Hysterectomy done in order to remove a cancerous

uterus while woman is pregnant.

Abortion done to terminate pregnancy after rape. Cleaning an infected wound.

 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.A. Formal - when the secondary agent willingly participates as when one agrees, advices, counsels, promotes, or condones. B. Material when the secondary agent does not willingly participate 2.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 as a rule not allowed. When there is significant reason, and scandal is avoided, material mediate cooperation, may be permitted tater harm.

 SOLIDARITY

Solidarity means to be one with others. In the provision of health care, it is most important for the provider to be in solidarity with the patient when seeking, always, the latters best interest. In a country like the Philippines, this is most important while dealing with the poor, the uneducated, the disadvantaged and the marginalized. They are the ones most in need of the concerned healthcare provider.

Major Bioethical Principles

RESPECT FOR PERSON

Respect for person is the recognition of the equality possessed by every 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 a means.

Respect for person is manifest in: autonomy (self-governance) right of non-interference. allowed to determine his own destiny. to deliberate about his plans. choose according to his own values. act accordingly. 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.

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 Issues arise in deciding who is equal, in the criteria to determine equality and in, who should make these decisions.

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

THE INVIOLABILITY OF LIFE The principle of 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 Gods gift. Man comes directly from God, is created according to Gods plan and destiny. It is God who is the source, who sustains and perfects mans life.

From a humanistic point of view the experience of being alive or the fear of losing life is evidence of its sacredness. If one is not alive, discussions about the exercise of his rights become irrelevant.

The principle of the inviolability of human life means that life, in itself is sacred. It not to be violated, opposed or destroyed but is to be affirmed, cherished, respected, 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 a duty NOT to kill X. The principle also includes measures for the survival of the human species, and the freedom to have children.

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.

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 nonmaleficence 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 a duty to benefit Y provided Y is at significant risk Xs action is needed Xs action is likely to succeed There is not significant risk for X The benefit to Y outweighs any harm for X

APPLIED HEALTH ETHICS

INFORMED CONSENT

Informed consent is an ideal connected to the principles of autonomy and respect for 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.

Originally introduced in the context of research to avoid abuse on research subjects, it was a means to morally justify the burdens and risks given to them by their agreement to accept such burdens/risks.

Recognizing that every person is primarily responsible for his own body, free and informed consent was later introduced into patient care as a means of protecting a patients personal integrity and enhancing the patients active role in his own care.

Informed consent therefore has two main functions: 1. Protective - to safeguard against intrusion of integrity. 2. Participative to be involved in medical decision making. With the introduction of informed consent in healthcare, there has been a shift from the paternalism of doctor knows best and decides to patient knows best and decides.

Elements of Informed Consent 1. Knowledge 1.1. Information disclosure by the healthcare giver: The truth of the proposed action, its nature, probable benefits, possible risks and alternative options or information relevant to a meaningful decision making process must be given to the patient.

1.2. Comprehension by the subject. The information must be given in words and manner that can be easily understood by the subject. Distorted, unfamiliar and unsuitable information, poor information processing, overload, selective perception, etc. must be avoided. It may lead the subject to accept the information given without appreciating it.

2. CONSENT 2.1. Subject competence: The subject must be able to make decisions based on rational reasons. 2.2. Subject freedom. The subject must be able to choose and act without undue pressure of time, emotional upset, confusion, persuasion, coercion, threat, deception, manipulation, fear or other forms of control by others.

When informed consent cannot be given by the patient, the patients family or guardian or representative provides it. This is proxy consent. Decisions by the proxy should be based on what the patient would have chosen had he been competent or it the patients preferences are not known, based on the patients best interest.

THE BEGINNING OF LIFE

Both the Catholic Church and the Philippine 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 dignity of parents and new born expressed in the method new life is created. A child must be the fruit of the conjugal union between husband and wife.

Artificial method of reproduction which assist the conjugal are 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 and welfare of one must be mutually balanced by the health and welfare of the other.

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.

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 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 the 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 health provider therefore must:
1. 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 life: to say goodbye, settle material matters, to mend broken relationships, to express love, etc.

2. Use technology prudently. Recognize the realm of medical futility and avoid disproportionate means to maintain life at all cost. 3. Relieve pain effectively. The dying man often fears dying with pain. It limits freedom and independence, causes anxiety, rejection and marginalization, and often robs a person of his dignity 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.

4. 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 patients 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 patients final journey, be in solidarity with his patient, and be present to receive the gift of dying.