principles introduction

PRINCIPLES AND RULES Dr. E. T. Acevedo, MD, MPA, MPA

PRINCIPLES AND RULESINTRODUCTION

ETHICAL PRINCIPLES -* basic and obvious moral truths that guide deliberation

and action. Consistent adherence to principle is an important basis for ethical practice in health care.

RESPECT FOR PERSONS* basic for all ethical principles.* the cornerstone of any caring profession.

PRINCIPLES AND RULES: PHILOSOPHICAL FOUNDATIONETHICS (moral philosophy) practical and normative science,

based on reason, which studies human acts and provides norms for their goodness or badness.

As a practical science – deals with a systematized body of

knowledge that can be used, practiced, and applied to human action.

As a normative science – establishes norms or standards for

the direction and regulation of human actions. Normative principles are action guides specifying which type of

action are morally required, prohibited, or permitted. Sometimes moral obligations are expressed as principles, other

times, as rules.

PRINCIPLES AND RULES: INTRODUCTION

PRINCIPLES RULESMore General & frequently Specify in more details

serve as source or the foundations of rules. type of prohibited, required

or permitted action.

BOTH General action guides specifying that some type of action is prohibited, required or permitted in certain circumstances.


PRINCIPLES

RULES

PARTICULAR JUDGMENTS

MORAL JUSTIFICATION Some dilemmas may result from the different viewpointsabout the meaning and nature of moral principles and rules:1. conflict between moral principles and self-interest;2. an apparent conflict among moral principles, some indicating that an act is right, others that it is wrong;3. conflict between moral principles persisting even after careful and imaginative reflection.


Dispute in the use of Normative Principles maybe resolved by the following

GUIDE QUESTIONS

1. Which principles and rules are APPLICABLE?

2. How they should be INTERPRETED (what they IMPLY for

particular cases)?

3. How much WEIGHT and STRENGTH they should be

accorded;(especially if they are in conflict)?

4. Which have PRIORITY in a conflict; and In what RELATIONS and SITUATIONS they apply ?


MEANING AND WEIGHT OF PRINCIPLES/RULES

Deontological/nonconsequentialist principles are

given “co-equal ranking” in relation to each other and “lexical ranking” over the teleological principles.

However, the assignment of weight or priority

depends on the situation rather than on an abstract, a

“priori ranking”.

PRINCIPLES AND RULES

Case No. 1 For the last 3 years a 5 yr. old girl has suffered from progressive renal failure as a result of glomerulonephritis. She was not doing well in chronic renal dialysis, and the staff proposed transplantation after determining that there was a “clear possibility” that a transplanted kidney would not undergo the same disease process. The parents accepted this proposal. It was clear from tissue typing that the patient would be difficult to match. Her two siblings, ages two and four, were too young to be organ donors and her mother was not histocompatible, but her father was quite compatible. When the nephrologist met with the father and informed him of the test results, as well as the uncertain prognosis for his daughter even with a kidney transplant, the father decided not to donate one of his kidneys to his daughter. He gave several reasons for his decision. In addition to the uncertain prognosis for his daughter, there was a great deal of suffering, and he lacked the courage to make the donation. However, the father was afraid that if the family knew the truth, they would blame him for allowing his daughter to die and then the family itself would be wrecked. Therefore, he asked the physician to tell the members of the family that he was not histocompatible, when in fact he was. The physician did not feel comfortable about carrying out this request, but he finally agreed to tell the man’s wife that the father could not donate a kidney “for medical reasons”.

PRINCIPLES AND RULES

Moral dilemma: - the physician felt uncomfortable in carrying out the father’s request.

In this particular dilemma, the physician has to apply a set ofethical principles, consider their meaning and their weight. Which principles and rules are to be applied: * Truthfulness (veracity) - not lying, acting in the daughter’s

interest. * Confidentiality - protecting the father and preserving the

family, because the information was given to him in private.. * Respect for person - respects the autonomy of the father. * Utility - maximizing welfare, not wrecking the family. The physician’s action could be assessed from several differentstandpoints -

Re – aspects of human act. Page 3

PRINCIPLES AND RULES:


Deontological theories - affirm principles regarding the inherent or intrinsic rightness or wrongness of actions - holding that some inherent or Intrinsic features of actions make them right or wrong, not simply their ends and their consequences.

* the father violated an implicit commitment to his daughter when he refused to accept the risk of organ donation for her;

* the physician’s actions did not violate the rule against lying. As a deontologist, the physician might have argued that the rule of confidentiality outweighed the rule of truthfulness.


Teleological Theories – emphasize the ends of action, (production of good )while

Consequentialist Theories emphasize the consequences or effects of action. (avoidance of bad consequences of actions).

* Both of these theories downplay or even deny the importance of intrinsic or inherent features of actions, such as whether actions are in accord with a moral rule against lying, in order to concentrate on what actions are intended to produce or actually produce.


* The physician’s actions might be assessed as means to his goal of not wrecking the family. Then it would be necessary to determine whether the means would probably be effective, and also whether if effective the actions would produce other bad consequences that might outweigh the good ones.

* The physician’s compromise decision can be justified by the application of two opposing principles:truthfulness and confidentiality. He did not directly lie because “medical reasons” may include psychological reasons, but he did not disclose the full truth in order to protect the confidentiality of the information he had gained, and in order to avoid wrecking the family.


FOUR MAIN MORAL CONSIDERATIONS IN THE USE OF PRINCIPLES:

1. Medical indications - Principles: (Examples)

Beneficence and Nonmaleficence

2. Patient preferences - Principles:

Respect for person and Autonomy

3. Quality of life - Principles:

Beneficence and Nonmaleficence

4. External factors - Principles:

Utility; Justice ; Confidentiality; Fidelity;

Veracity/truthfulness; & Professional Communication


CLASSIFICATION OF PRINCIPLES

I. NATIONAL COMMISSION for the PROTECTION OF HUMAN SUBJECTS of Biomedical and Behavioral Research :

1. PRIMARY PRINCIPLES (Basic Bioethical Principles)

2. SECONDARY/DERIVATIVE PRINCIPLES:


A.PRIMARY PRINCIPLES (Basic Bioethical Principles)

1. Autonomy *

2. Nonmaleficence *

3. Beneficence *

4. Utility

5. Justice *

6. Veracity

7. Fidelity (Contract-keeping)

8. Confidentiality & Therapeutic Privilege


B. SECONDARY/DERIVATIVE PRINCIPLES:

1. Universalizability - Accepted as a principle of morality with affinity to the Golden Rule.

2. Resource Allocation

3. Double effect

4. Legitimate cooperation

5. Professional communication

6. Totality of the Human Body

7. Personalized sexuality

8. Stewardship and Creativity


I I. CHRISTIAN PRINCIPLES OF ETHICAL ACTION: (Ashley & O’Rourke)

Practical generalizations derived from human expe-rience of our basic human needs and confirmed by the Gospel.

A. Principles of Christian Faith

B. Principles of Christian Love

C. Principles of Christian Hope


A. PRINCIPLES OF CHRISTIAN FAITH: These principles instruct us how to form a prudent conscience thrua process of knowing, strengthening and deepening of humaninsight and reason. We are guided in making prudent decisionsby six principles: 1. Well-formed conscience - We must take care to inform our own

conscience. 2. Free and Informed Consent - Enable others to do the same 3. Moral Discernment - Apply this information to our actual decisions. 4. Double Effect - taking special care when our actions, although good in

themselves, may involve bad side effects. 5. Legitimate Cooperation - Involve us in cooperation with others who do something we would prevent if we could. 6. Professional Communications - As professionals, we must respect

the right of others to privacy when they confide their own moral problems to us.


B. PRINCIPLES OF CHRISTIAN LOVE:The fundamental motivation of these principles is the drive toself fulfillment through relationships with other humanbeings, and above all with the three divine persons, Father,Son and Holy Spirit. Three particular norms to define thecontent of Christian love:1. Human Dignity - Every person must be valued as a unique,

irreplaceable member of the human community.2. Common Good, Subsidiarity and Functionalism - Every

person must be encouraged to play a role in the common life and fully share its fruits.

3 .Totality of the Human Person -All persons must be helped to realize their full potential.


C. PRINCIPLES OF CHRISTIAN HOPE:

The eschatological aspect of ethics – looking to the final coming of Jesus Christ in the fully realized kingdom of God thru dynamic relations - loving, growing, developing, and evolving.

Eschatology - study of the individual’s final destiny on

three levels:

1. as the individual person2. the whole human race3. the entire material cosmos

In health care the sense of hope is the source of all healing, so that to be a health care professional is constantly to affirm the possibility of turning suffering into a victory over disease and death.


1. Growth Thru Suffering - Our hopes enables us not only to endure the sufferings of life courageously but to grow

as persons through the experience.

2. Personalized Sexuality - Hope enables Christians to entrust themselves to another in the lifelong commitment

of marriage and to look forward to sharing this gift of life and love with a family and the future.

3. Stewardship and Creativity - Not only do we have hopes for our families but for the whole of human society and the

good earth which is its home.

PRINCIPLES OF CHRISTIAN FAITH

MORAL DISCERNMENT

Moral Discernment is inherently present in all human becauseThey are all capable of rational comprehension.

Definition:It is the capacity of every person to make (almost naturally)

rational judgment on actions that are essentially moral or ethical innature and distinguish them from the immoral or unethical.

No matter how untrained or uneducated a person is, he posses-Ses that capacity to discern what is right or wrong, although suchdiscernment can be at times deficient or incipient.

A person is a moral being and can make prudential judgment,no matter how imperfect.

CHRISTIAN FAITH: MORAL DISCERNMENT

This principle distinguishes prudential personalism from otherforms of theological ethics.

Prudential Personalism: (consistent with the teaching of the Catholic Church) Based on moral discrimination and not on the principle of proportion. (Teleological Theory)

* Maintains that some basic human values, corresponding to the basic needs of the human person are non-negotiable, which can never be violated.

Prudential, because it takes full account of the circumstances and

purposes of human actions; but it is Personalism because it protects the dignity and basic rights of the Person

against violation by anyone or by society.

FAITH: MORAL DISCERNMENT

To make a conscientious ethical decision, one must do the

following:

1. Prayerful and insightful attitude/manner: Prayer makes one person honest with God and himself.

2. Proceed on the basis of a fundamental commitment to God

& the authentic dignity of human person, including oneself.

The person must subscribe to values that must not only be human but transcendent.

3. Among possible actions that might seem to be means of fulfil-ling that commitment, exclude any which are in fact intrinsically evil. Ex. Abortion, transsexual surgery (intrinsically evil)


3. Also consider how one’s motives and other circumstances may contribute to or nullify the effectiveness of the other possible actions as means to fulfill one’s fundamental commitments. The patient’s dignity, rights and informed consent must always be taken into consideration as non-negotiable as his other basic human needs. Ex. A surgeon faced with a problem of recommending brain surgery to a patient with brain tumor:

a. Guides his action by his overriding sense of responsibility before God for the welfare of his patient. - underlying motivation: commitment to God and the dignity of the human person.

b. Consider possible ways of treating the patient’s condition with or without surgery, & exclude which are risky,

experi-mental, or ineffective as to be contradictory to the patient’s non- negotiable right to life or other such basic needs.


3. Consider whether his judgment may be prejudiced by financial considerations or ambition to make a name for himself and whether in the circumstances of the patient’s life and the available medical facilities, the possible value

of the surgery may be nullified.

4. Among the possible means not excluded or nullified, select one most likely to fulfill that commitment, and act upon it.

FAITH: MORAL DISCERNMENT Example:

4. Among the remaining possibilities choose and act on

one that will most likely benefit the patient and reflect a real concern on the surgeon’s part for the patient as a person.

FAITH: PRINCIPLE OF DOUBLE-EFFECT

A rule of conduct frequently used in moral theology to determine when a person may lawfully perform an action from which two effects will follow, one good and the other bad.

HISTORICAL DEVELOPMENT:– Developed by the theologians of the 16th and 17th centuries,

especially by the Salmaticensis. However, the greatest credit in modern times for the thorough exposition of this principle as a norm applicable to the whole field of moral theology is owed to the Jesuit theologian Jean Pierre Gurry.

FAITH: DOUBLE-EFFECT

Some Important Distinctions: 1.When we perform various actions, they are followed by various

effect, some of which we desire: Wish - a desire; longing or strong inclination for a specific thing.

Intend - to have in mind, plan; to signify or mean.Want - to desire greatly, wish for.Will - the mental faculty by which one deliberately chooses

or decides upon a course of action; deliberate intention, others of which we do not desire but merely allow.

Permit - to allow the doing of something.Tolerate - to allow without prohibiting or opposing; to recognize

and respect. 2.There is a difference between performing a good act, which has both

good and evil effects, and performing an evil act in order that good may result.


When an act is foreseen to have both ethically beneficial and physically harmful effects, the following conditions should be met:

1.The directly intended object of the act must not be intrinsically evil; Action must itself be morally good or at least indifferent.

Some criteria to be considered to determine an act to be morally good:a. An act directed toward the right ultimate end;b. Choose an effective means to achieve that goal;c. The act chosen is an appropriate means to the ultimate

end.


2. The good effect must be the one intended and as far as possible to avoid the harmful effects (indirectly intended);Good effect must be willed “primus in intentione” (first in intention), and the evil never intended but merely allowed.

3. The foreseen good effects must be equal to or greater than the foreseen harmful effects; - Principle of Proportionality.

Good effect must be at least equivalent in importance to the evil effect.

St. Paul’s words – Rom. 3: 8 - “we should not do evil that good may come”.


4. The good effects must immediately follow the action and not result from the harmful effects.

Good effect must come directly from the good action and must not come from the evil effect.

Indirect evil effects of an action can be tolerated under certain conditions, provided they are not intended. – Veatch p. 14


ACTIONS

DESIRE WE DO NOT DESIRE (wish, intend, want,) BUT MERELY ALLOW will) (permit, tolerate) SIN

ACT OF THE WILL

Willed or Tolerated orIntended merely permitted

MORAL JUDGMENT

Performing a good act Performing an evilWhich has both good VS. act in order that and evil effects good may result.


Example of Application:

An operation to remove the cancerous uterus of a pregnant woman, which will also kill her unborn child.

1. Direct intention is morally good - to save the woman’s life from cancer.

2. The intention is to save the woman’s life. The foreseen harmful effect is the killing of the unborn child which was not intended but could not be avoided.

3. The value of the mother’s life is equivalent to that of the child’s; 4. Saving the woman’s life directly resulted from the removal of

the cancerous uterus and not from the killing of the child.


Principle does not apply when (violation)

1. The action is not morally good or even indifferent; it is evil. It is a direct attack upon an innocent life.

2. The end never justifies the means. We may not do evil in order that good may come of it.

FAITH: PRINCIPLE OF LEGITIMATE COOPERATION

To achieve a well-formed conscience, one should always judgeit unethical to cooperate formally with an immoral act but onemay sometimes judge it an ethical duty to cooperate materiallywith an immoral act when only in this way can a greater harm beprevented, provided:a. that the cooperation is not immediate; and b. that the degree of cooperation and the danger of scandal are

taken into account.Health care is essentially a cooperative work. No doctor

or nurse or any health care professional can be an island by himself. The expertise of each one in the profession works in tandem with others to elicit the best possible results.

FAITH: LEGITIMATE COOPERATION

The Ethical CpmpromiseOne cooperates on what he regards the correct conduct on prin-ciple, although only in order to avoid still greater evil and injustice.

Ethical compromises are those which touch on moral principles, values and actions.

An ethical compromise is conceivable as a compromise when an individual person makes with himself:* between ends and reseources (between desirable

charitable aid and limited means);* between two tasks (between the demands of the

profession and the needs of the family);* between two values (between truthfulness & the

protection of secrets).


COOPERATION- from Latin words:

Cum - - “with”Operari - “to work with another in the performance of

action, whether it may be good or evil. ” One of the first theologians to provide insight into this principle wasSt. Thomas Aquinas, when he observed that the actions weperform may have two effects:• One that is good and corresponds to the moral object of the act;• Another, because it is beyond the intention of the moral object,

has no moral value, even though it may have a negative physical effect.


The Essence of Evil Action:* The essence of an evil action is determined neither by the

attitude or motive of the agent performing the action nor by the agent’s recognition (or lack of recognition) that the action is wrong.

* Rather, the fundamental morality is revealed if a moral act is found in the formal object of the action performed (goal of the action).

* This fundamental morality is revealed in the question “What are you doing?” not in the question “Why are you doing it?”

When we speak about evil actions, we are not making a judgment about the moral guilt or subjective motives of those who perform them, but only about the moral object of the action.


Morality of Cooperation in Evil: 1. Social nature of man entails a broad net-work of interpersonal

relationship - each person needs help of other persons for his own betterment and the frequent need of cooperation among many different persons for the attainment of common goals.

2. Each individual has the responsibility to do good and to avoid giving an occasion to others a means to do evil.

3. There are certain situations, however, when persons take advantage of the good works of others for their own evil activity. The lawfulness of cooperation in evil in certain circumstances is based on the pursuit of the good.

4. In such situations (3), appropriate means have to be employed: prayer, mortification, professional example and prestige, friendship with colleagues, dissemination of sound doctrine. etc.


TYPES: 1. Formal Cooperation - when one directly intends the

evil action by: * agreeing with; the objectively * advising;* counseling; evil action* promoting; or* condoning of another.Formal cooperation is when one is identified with the

purpose of the evil act. Formal cooperation is immoral.Example:A physician who refused to perform abortion to his patient because he be-lieves it is wrong, yet referred her to an abortionist because the patientdemands. (formal cooperation).


2. Material Cooperation: When cooperation is with the good that is being done and only indirectly with evil, which we would prevent if we could, then such cooperation is permissible and even obligatory if:

a) the refusal to cooperate would result to a greater evil than if we cooperate, and

b) if the cooperation is not immediate and is more remote.

Material cooperation is when one is identified with the act but not the purpose of the act.

Example:A patient approach a nurse after an abortion, requesting for her. The nurse took care of the patient and attended to her nursing needs. (material cooperation)

FAITH: PRINCIPLE OF LEGITIMATE COOPERATION(Material Cooperation)

Material cooperation:

* applies to a situation where an action involves more than one person, and sometimes when the persons have different intentions.

* is one in which the cooperator performs an act without desiring or consenting to the principal agent’s sin, though it is used by the principal agent to help him commit sin.


Material cooperation may either be:

1. Immediate or direct contribution to the act; the cooperator shares the responsibility for the act.

2. Mediate or indirect - if it provides some means that are used by another to sin, even though there is no necessary relationship between the means and the sin.a. proximate - that which is quite intimately connected with the immoral operation.b. Remote - less intimately connected with the evil act, is morally allowable for lesser reasons.


Example:A scrub nurse who assisted in a tubal ligation. Because of the very intimate connection of proximate cooperation with the evil act, a very grave reason is necessary in order that such cooperation be morally permissible. The threat of being dismissed immediately, combined with the knowledge that a new position will be almost impossible to obtain in the foreseeable future, is a very grave situation and would constitute a sufficient reason for proximate cooperation in a particular case.

Even if cooperation is the only possible means to obtain a given good, it does not follow that it is necessarily licit to do so. The moral judgment has to be made in each case in the light of all the conditions required for the indirect voluntary (double effect)


PROPORTIONATE REASON REQUIRED FOR COOPERATION IN EVIL:

What constitutes a sufficient reason will vary according to the proximity to the immoral act itself.

MATERIAL COOPERATION

PROXIMATE REMOTE

That which is quite Being less intimately intimately connected connected with the

with the immoral evil act, is morally operation allowable for lesser reasons.


General Rule which may be given regarding material cooperation:

1. Material cooperation in an immoral operation is morally

permissible when a sufficient reason exists.2. No medical condition is sufficient reason for the performance of

an immoral operation.3. Certain circumstances may exist however, which would

constitute a sufficient reason for material cooperation.4. The more necessary one’s material cooperation is to the

performance of the act, the graver must be the reason to justify it morally.

To justify material cooperation, the conditions under the principle

of “double effect” must be satisfactorily complied with.


RESOLVING DOUBTS REGARDING COOPERATION

* consultation is required from a priest or pastor, if possible. * The physician may also find it necessary to use his own

judgment in accordance with his conscience if it is impossible to consult a priest/pastor.

FAITH: PROFESSIONAL COMMUNICATION, VERACITY, &CONFIDENTIALITY

COMMUNICATION - a process in which people affect one another through the exchange of information, ideas

and feelings. ELEMENTS REQUIRED IN GOOD COMMUNICATION: 1. Trust2. Contact among people who have the needed information3. Clear formulation and expression of this information4. Continuous feedback by which failures in communication can be

corrected. 5. Courtesy6. Privacy and confidentiality

FAITH: PROFESSIONAL COMMUNICATION

CRITERIA TO BE FOLLOWED ON WHOM TO BE INFORMED: 1. The patient 2. Relatives or legal representatives 3. Other persons - friends, acquaintances, health care

professionals, etc.

Obligations of the physicians to their patients: 1.To listen to the patient. – No matter how busy the physician is,

he has the responsibility to dialogue with the patient;2. Obtain the patient’s cooperation by explaining the purpose of

questions, since unexpected and cryptic questions are often threatening and confusing.3. Confidentiality: - Physicians have a serious obligation to maintain

confidences that protect the patient’s right to confidentiality. Can be violated if non-disclosure might lead to serious harm to the patient.

FAITH: PROFESSIONAL COMMUNICATION - Responsibilities

Responsibilities of Health Professionals:

1. To establish and preserve trust at both the emotional and rational levels.

Emotional level: (affective)* sympathy - sharing the feelings of another* compassion - feeling of deep sympathy for

another’s suffering.* empathy - identification with the feelings of another

(putting yourself in somebody’s shoes)Rational Level: (cerebral in nature)* information about the patient’s condition

COMMUNICATION Responsibilities

2. To share such information which is legitimately needed by others in order to have an informed conscience.* respect the patient’s conscience;* patient’s free and informed consent

3. To refrain from lying or giving misinformation. (Veracity)* tell patient the truth about his disease

4. To keep secret information which is not legitimately needed by others and if revealed might harm the patient.* Principle of Confidentiality and Privacy

PRINCIPLE OF VERACITY (Truthfulness)

Professionals have a duty to be honest and trust worthy in their dealings with people.

When a patient agrees to place himself under the care of a health professional, a physician/nurse - patient relationship develops and this involves the moral issue of truth telling and confidentiality. Veracity binds both the health practitioner and the patient in an association of truth.

Two approaches to Truth telling:

1. Person-centered2. Problem-centered

PRINCIPLE OF VERACITY

Person-centered:

It lends importance to the patient as a person. It considers thepatient as a person with a problem, but not as a problem himself.The patient is a person with feelings of hope and despair, withpurpose and defeat. As such, one has the right to know thenature of one’s disease, and the physician is morally obligated torespect that right. The physician owes the patient the truth, just asthe patient owes the physician’s skill and technical powers.Moreover, caring for a person is a moral relationship in which thephysician’s attitude should be an utmost concern for the patient.


Problem-centered:

Considers the patient’s problem, illness, or condition. The health professional may not tell the truth when it is for the best interest of the patient. Thus, if only for the best interest of the patient’s failing or worsening condition, the physician may withhold the truth from the patient.

Therapeutic Privilege - privilege of the physician to withhold information with the patient if by telling him will only worsen the condition.


What is Truth and honesty?

Truth is “the state of being the case; fact”.Honesty is “fairness and straightforwardness of conduct or

adherence to the facts”. It is a dynamic concept about being truthful and is based on one’s ‘sincere and objective attempt to appraise a total situation and that is limited by his inability to be totally unbiased’.

Being honest or telling the truth means relating the facts as one knows and understands them.

Professional opinion, be it medical, nursing, legal or theological, does not necessarily equate with truth.


Classification of Truth: 1. Scientific truth - defined by natural laws or factual

measurement. 2. Moral truth - determined by God or man. Justifications for truth-telling: 1. As patients, their human and moral quality as persons is taken

away from them if we they are denied whatever knowledge is available about their condition, as the case may be;

2. As patients, they have entrusted to the physician any knowledge

he has about them, so the facts are theirs and not his/her, hence to deny is like stealing these from them.


3. The highest conception of the physician-patient relationship is a personalistic one which is based on mutual confidence and respect for each other’s rights;

4. To deny a patient pertinent knowledge about himself, especially

in a life and death situation, is to deprive him the ample time to prepare for his own death or to carry out responsibilities that are based solely on his decisions or actions.

PRINCIPLE OF CONFIDENTIALITY and PRIVACY

An ethical principle that requires nondisclosure of private or secret information with which one is entrusted.

A breach and violation against the confidentiality of

patient’s records and privacy of a person is also a breach

against his dignity and person.* The Oath of Hippocrates on Confidentiality:

* Scope of Confidentiality: (Medical Secrecy)

Patient’s Records: (everything directly related to the illnes)

1. prognosis2. complications3. circumstances of time, place and persons

CONFIDENTIALITY and PRIVACY

Patients have a right to expect that you will not disclose any perso-nal information which you learn during the course of your profes-sional duties, unless they give permission. Without assurancesabout confidentiality patients may be reluctant to give doctors theinformation they need in order to provide good care.* When you are responsible for confidential information you must

make sure that the information is effectively protected against improper disclosure when it is disposed of, stored, transmitted or received.

* When patients give consent to disclosure of information about them, you must make sure they understand what will be dis-closed, the reasons for disclosure and the likely consequences;


• Make sure that patients are informed whenever information about them is likely to be disclosed to others involved in their health care, and that they have the opportunity to withhold permission.

• Respect consent by patients whenever the information about them is likely to be disclosed to others involved in their health care, and that they have the opportunity to withhold permission;

• that information should not be disclosed to third parties, save in exceptional circum-stances (for example, where the health or safety of others would otherwise be at serious risk);

* If you disclose confidential information you should release only as much information as is necessary for the purpose;

* You must make sure that health workers to whom you disclose information understand that it is given to them in confidence which they must respect.


Medical Secrecy may be lifted for:1. Consent of the interested party - i.e. - Insurance2. For the common good: i. e.

reporting communicable diseases to proper authorities – Privileged Communication

3.unusual cases seen in emergency room, like accidents, medico-legal cases 4. impediments to marriage - sterility problems, impotence, venereal diseases


Four Paradigms of Confidentiality:1. As a religious duty]2. As a part of professionalism3. As an example of respect for patient autonomy4. As an aspect of friendship or community


1. As A Religious Duty:Has its origin in religious tradition.Hippocratic Oath . . . offers a simple but profound and perennial

code of medical ethics, constituted of various promises both of care for the patient and respect for the art of healing itself. . . includes the promise to keep confidential and hold as unutterable any private thing seen or heard in the course of treatment.

Even during the time of Christ, religious persons hearing the sick man’s confession and tending to his physical ailments . . . akin to health care also. As the law grew to recognize the privileged status of confessional communications with the clergy it also developed parallel doctrines of privilege for doctors and lawyers in their communications with their clients. And the three professions undoubtedly influenced each other’s attitude towards confidence-keeping.

•CONFIDENTIALITY and PRIVACY

2. Confidentiality As A Part of Professionalism

Hippocratic Oath -- ‘Into whatever houses I may enter, I shall come only for the benefit of the sick, avoiding all injustice and other mischief, and all sexual deeds upon the bodies of women and men, free or slave. I shall keep confidential any private thing I see or hear in the course of treatment, holding such things to be unutterable. .’


BASIC ETHICAL ARGUMENTS IN MAINTAINING CONFIDENTIALITY 1.Right to privacy: -

* individual’s right to control personal infor-mation and protect privacy flows from autonomy and respect for person’s personal information will not be shared unneces- sarily among health care providers;* keep in mind the number of people who have legitimate access to patient’s records.* Care must be observe in choosing information to be recorded in the patient’s chart.* Health care workers must be aware of the many threats to patient’s confidentiality.

• Important in revealing intimate and sensitive information potential to harm the patient, such as harassment, ridicule, discrimination, etc.

•

CONFIDENTIALITY and PRIVACY2. Utility:

if patient suspect that the health care provider reveal sensitive/personal information indiscriminately, patient has the right to seek for care.Ex. - Family planning, drug addiction, alcoholism, AIDS, mental illness, etc. which may lead to public scorn, if revealed.

3. Foreseeability: health care professionals should be able to reasonably

foresee harm or injury to an innocent person in order not to violate the principle of confidentiality in favor of a duty to warn.

Privacy is not absolute.

PRINCIPLES OF CHRISTIAN LOVE

HUMAN DIGNITY The maximum, integrated satisfaction of the innate and cultural

needs of every person, including his or her biological, psychological, social, and spiritual needs as a member of the world community and national communities. This principle sums up the :* true goal of human life:* Self-actualization in relation to God and neighbor. This is the first principle that must be considered in

Bioethics because without this, Bioethics is empty of meaning and direction.

CHRISTIAN LOVE: HUMAN DIGNITY

HUMAN DIGNITY relates to man’s being created in the image of his Creator, manifested in

PERSONHOOD thru his

intellectual control of his functions & will Re-visit Maslow’s hierarchy of needs.


TRENDS WHICH CONTRADICT HUMAN DIGNITY

1. Persons are swallowed up in totalitarian, bureau-

cratic institutions;

2. Persons who are not needed for the efficient operations of

these institutions and are treated as nonpersons:

women, the very young,

the very old, the uneducated,

the defective

3. Even successful persons find their happiness not in

sharing their lives with others but in private, individua-

listic satisfaction.

CHRISTIAN LOVE: HUMAN DIGNITYWOMEN TREATED AS NONPERSONS * Artificial insemination: - Desacralization of natural processes.

There should be an absolute respect for the dignity of the person and

the right understanding of the nature of the person in his capacity to reciprocate love; the loftiness of the parental vocation as an essential part of marriage.

* Abortion: - In utero, life is believed to be a truly human life.

The embryo or fetus could be considered a human person, a human being with an immortal soul. The following fundamental values must be considered:

1. The recognition of the right of each human being o the most basic conditions of life and to life itself.

2. The protection of this right to live, especially by those who have cooperated with the creative love of God.

3. The presentation of the right understanding of motherhood. 4. The ethical standard of the physician as one who protects and cares for

human life and never becomes an agent of its destruction.

CHRISTIAN LOVE: HUMAN DIGNITYTHE VERY YOUNG

* Infants with poor eugenic heritage or those afflicted by marked deformity should not be condemned to death.

* Only thru faith in the dignity of each person will the medical profession and mature parents find the golden mean.

No man has a right to declare another human life meaningless,worthless, and therefore condemned to death, since man’s dignitydoes not depend on his efficiency or his capacity to contribute tothe economy. Questions: 1. Can a totally deformed fetus that is lacking even the biological substra-

tum for any expression of truly human life still to be considered a person?

2. Can pregnancy be interrupted in this particular case? •

CHRISTIAN LOVE: HUMAN DIGNITY•

The VERY OLD, the UNEDUCATED, the DEFECTIVE

* Inhuman treatment of these people. * Medical Experimentation: A physician who manipulates others by making them instru

ments for the attainment of his own goal . Informed consent

is needed. The physician must not be abusive of his pa-tients, serving only his scientific ambitions.

* Manipulation of the human body for scientific progress is against human dignity. Cloning?

Desacralization of the human body is detrimental to man’s over-all well-being and human dignity.

CHRISTIAN LOVE: HUMAN DIGNITYMechanical Support for Transferrable Organs:

Is it not against the dignity of the human person to maintainorgans and tissues artificially after brain death in order to havethem available for transplant later?

The moral point of view is: If our earthly life has rightfully come to its end, some normal organs of our body can be saved for life-saving use of some persons. It is in keeping with the dialogical nature of man to have one’s organs, even after death, continue a lifededicated to the service of others in the form of atransplanted organ.


Dying:

Must the physician tell his patient the truth, that he is dying? The wisest course of action for the physician is to allow

thepatient an opportunity to exercise his choice about learning thereality of his condition. A patient has the right to make a choice forhimself about his destiny to give honor and dignity in his dying –thebeing to die in dignity.


The PRINCIPLE OF HUMAN DIGNITY requires that various levels of responsibilities be established within the community.

Pope Pius XII approved to remove respirators so as to allow

the patient already virtually dead, to depart in peace. Medical

progress must not deny a person his ethical right to die in

HUMAN DIGNITY.

COMMON GOOD, SUBSIDIARITY, FUNCTIONALISM

Human communities exist only to promote and share the commongood among all members: 1. From each according to his ability. 2. To each according to his needs in such a way that:

a) Decision-making rests vertically first with the person, then, with the lower social levels and horizontally with

functional social units. b) The higher social units intervene only to supply the lower

units what they cannot achieve to make it easier in the future for lower units and individuals to satisfy these needs by their own efforts.

COMMON GOOD

The Common Good requires: 1. Love and Mercy, and the2. Distribution of good according to need

Most social evils and injustices are the result of exclusionof some persons from the common good in which they have a rightto share. Ancient slavery -- slaves contributed to the common good; yet

were not permitted to fully share in it: - economic goods & Spiritual goods, like:* education* political participation* respect* right to worship the Gods

COMMON GOOD

* The present society - common good - equally distributed? Christian ethics of Health Care Distribution is based:

* not on merit; * nor the ability to pay; * but on the need –

Because the NEEDY are the most neglected; andSOCIAL OPPRESSION is the chief cause of their illness – an oppression from which the MORE AFFLUENT MEMBERS OF SOCIETY profit;

Hence, those who are helpless by reason of poverty, defect, or disease, age, should be the first consideration of any health plan.

COMMON GOOD

All persons should contribute to the health plan according to their ability. Thus social responsibility for health care falls:

First – on those who have the ability to heal: the health care professionals. Second – on those who have the ability to pay – those who

have financially profited the most from society.

Logically, from the notion of COMMON GOOD, the notion of SUBSIDIARITY follows.

PRINCIPLE of SUBSDIDIARITY or SOLIDARITYComes from French term “subsidie”- “to gift by way of financial aid.”

refers to the “poorest of the poor” but in Health care it refers to “the sick who are poor”.

Social institutions have an auxiliary and complementary functionconcerning the tasks and needs of the smaller groupings andindividuals. It implies that the first responsibility in meeting humanneed rests with: * the free and competent individual,

* then with the local group.

Higher and higher levels of the community must assume thisresponsibility.* Leave to the smaller groupings or individuals what they can do by their

own power;* When the lower unit cannot assume it or when the lower unit neglects

to assume it because of incapability or disregard, competent societies have the obligation to “subsidize” and to assist these smaller groupings or individuals.

SUBSDIDIARITY or SOLIDARITY

SUBSIDIARITY requires us to: Share decision-making power not only at * various levels of local, provincial, and national

government, * but also among horizontal sectors representing various

functional bodies. The role of Government is to:

COORDINATE and ENCOURAGE the full development of these different organs of society, not to deprive them of their decision-making capacity.


Principle of subsidiarity concretized in health care, considering thefollowing aspects:1. Sense aspect. – they must be accorded comfort and

consolation.2. Emotional Care. - words of comfort may be

offered.3. Spiritual Care. - encouragement that lifts the

human spirit.


The power to make social decisions ought to be kept asclose as possible to those who experience those problems andare most strongly affected by the decisions concerning them. A paternalism that decides everything for those it claims toserve is really nothing but a form of domination and tends toBecome self-serving.

The application of SUBSIDIARITY to the organization ofsociety on the basis of Social Functions, rather than on thebasis of a struggle between isolated individuals defending theirrights and a centralized government having all the powers ofsocial decisions is called FUNCTIONALISM.

FUNCTIONALISM

FUNCTIONLISM - to keep decision-making spread in the horizontal organization of society.

Functionalism is opposed to:Communism and National Socialism because they are

totalitarian, concentrating all decision-making power in the hands of the state and the military.

Competitive Individualism of Unregulated Capitalism or Free

enterprise, because of its hidden tendency to monopoly resulting in concentration of decision-making power in the hands of an interlocking power elite.

FUNCTIONALISM

As applied to health, a functional health plan must have the following features:

1.Comprehensive health care should aim primarily at the promo-tion of positive health not merely at the cure of acute disease or the prolongation of life through sophisticated techniques, hence, it should work for:a)removal of the environmental and social causes of ill health,

including the commercial exploitation of unhealthy patterns of living, and

b)provision of preventive health education, which will give persons control over their own health.

FUNCTIONALISM

2. Priority should be given to the most powerless, poorly informed, and least able to pay. These persons should not be cared for paternalistically, but should be admitted at once to participate in the power of decision about their own health needs.

3. Decision-making power should not be confined to a government bureaucracy nor to autonomous professionals, but should be shared by all concerned in mutual interdependence.

4. Planning should proceed in such a way as to avoid tendencies to increase dependence on higher levels and to promote a gradually increasing decentralization both in control and funding. This decentralization, however, should not be used as an excuse for the government to neglect the monitoring of health care and the supplementation and correction of defects at lower levels of organization.

FUNCTIONALISM

5. Planning must be a continuous process of decision-making that adapts to experience and new needs, rather than a fixed plan based on projections that may be mistaken.

The higher level should never be content merely to take over responsibility, but it must work to return responsibility to a lower level

The Principle of Subsidiarity protects the particular rights andcompetence of individuals against excessive domination bysocieties, as well as the competence of minor associations againstoppressive and totalitarian claims of the larger society.

Based on the Principle of Subsidiarity the kind of program that Christians can consistently support, must aim at:

PREVENTIVE MEDICINE

TOTALITY OF THE HUMAN PERSON

CAN MUTILATION BE DONE?Yes, by virtue of the PRINCIPLE OF TOTALITY.

Biologically speaking, life is the result of the harmonious functioning of aseries of organs. However, it can happen that at a certain moment a diseasedorgan may threaten the entire human body. The extirpation or elimination of an organ from a human body istermed “MUTILATION” The Principle of Totality states that the “whole is more importantthan the parts and the parts exist and function for the good of thewhole.

When a condition of the parts threatens the whole, then the part can be sacrificed.”


To promote human dignity in community, every person must“develop, use, care for, and preserve” all of his or her natural

physical and psychic functions in such a way that:

A. Lower functions are never sacrificed except for the better functioning of the whole person and even then with an effort to compensate for this sacrifice.

B. The basic capacities that define human personhood are never sacrificed unless this is necessary to preserve life.


This principle requires: * self-respect, as well as respect for others.

Unless a person respects his or her own integrity, which includes ones natural bodily and psychic integrity, and seeks to preserve and perfect one’s own gifts, that person cannot expect the community’s respect

* Human wholeness - consists in the interdependence of higher and lower spiritual and bodily functions. Thus, the lower functions cannot without qualifications be sacrificed even if it is to the advantage of the higher functions because the good of the whole person cannot be reduced or limited to the good of one part.


* To be a complete human being is not merely to have the higher level of functions but to have all the basic human functions in harmonious order which not only requires the subordination of the lower functions but also forbids their total sacrifice.


Norms pertaining to human integrity: 1. PRIMARILY, human health is not merely a matter of organs but

of capacities to function humanly.2. GENERALLY SPEAKING, any particular human functional

capacity can be diminished when neces-sary for the good of the whole person, so that the person can better exercise all other human functions.

3. SECONDARY FUNCTIONS can always be sacrificed for more basic ones.

4. PRIMARY or BASIC FUNCTIONAL CAPACITIES, however, cannot be destroyed to promote even more important capacities except when it is the only way to preserve the life of the whole person.


Examples:

Amputation of the gangrenous leg of a diabetic person in order to stop the spread of the disease.

Surgical removal of a vital organ (kidney) and replacing it with a normal one. (kidney transplantation)

Question:- Can liposuction be justified?

TOTALITY OF THE HUMAN PERSONCONTROVERSIAL CASES which involve the Principle of Totality:1. Plastic surgery2. Organ Transplants and Donation3. Sterilization Plastic Surgery - “Unnecessary Surgery”“Unnecessary Surgery” is one in which there is no real medical

indication. Justification for Plastic surgery:* That the intention is good;* That the patient is not exposed to grave medical risks;* That the motives are reasonably proportionate to the extraordinary

means employed.


AESTHETIC SURGERY Is definitely licit under the following conditions:To improve bodily appearance following injury caused by

accidents, congenital deformities, etc.When the external features could be a psycholo-gical, social or

economic handicap with repercus-sions in the individual’s adaptation to society.

Natural law ethicists go with Pope John Paul II’s pronouncement that:“ a strictly therapeutic intervention whose explicit objective is the healing ofvarious maladies such as those stemming from chromosomal defects will, inprinciple, be considered desirable, provided it is directed to the true promotionof the personal well-being of the individual without doing harm to his integrityor worsening his conditions of life.”•

STEWARDSHIP and CREATIVITY

The gifts of multidimentional hurespect for their intrinsic teleology, andespecially the gift of human creativity should be used to cultivate nature andenvironment with a care set by the limits man nature and its naturalenvironment should be used with profound of actual knowledge and the riskof destroying these gifts. Because man’s life is a gift of the Creator , man is only a steward, accoun-table for what he is, what he is capable of, and what he makes of himself.Although humans are “masters” over lesser creatures, dominion over themand over themselves is only a stewardship for which human beings remainresponsible to the one Lord.

In creativity, people have to respect their own limits and thelimits of the materials with which they must work.


Human beings are far more limited by the fact that their share inGod’s knowledge and love is finite. No matter how they mayprogress in science, freedom, and power, they dare not contradicttheir own human nature without destroying themselves.

This principle requires us to appreciate the two great gifts of a wise and loving God:

1. The earth with all its natural resources.


Our earthly environment is a marvelously balanced ecological system. Although we have a need and a right to cultivate and perfect it, to till and irrigate its soil, to build cities, and to use its raw materials for the wonderful devices of modern technology, we should not do this ruthlessly but must take the utmost care to conserve our ecological system unpolluted and unravished, and to cycle its raw materials and its energy supplies.

2. Our own human nature (“embodied intelligent freedom”), with its biological, psychological, ethical, and spiritual capacities.


Our own human nature, our bodies, and our minds are wonderfully constructed. We have the need and right to improve our bodies and to develop medical technologies that prevent and remedy the defects to which they are liable. But we must do so with the greatest respect for what we already are as human beings


The God-given gifts of our environment and our humanity are ours in stewardship, but because the greatest of our natural gifts are our intelligence and freedom, the stewardship should be creative. Our creativity should be used as a co-creativity with the Creator, not a reckless wasting of His gifts.

The principle is rooted in the basic human need for truth, since it is God-given intelligence, the capacity for truth, which makes a person co-creators with God.


Violations of the Principle:The New Reproductive Technologies:* Contraception* Sterilization

Artificial Insemination, etc.Genetic Selection - production of superior human beings – we

can share in the creativity of God, but usurp his power of creativity.

3. Suicide - Plato - ‘Suicide is a rejection of duty to one’s body, to the community of which the person is a part, and to God who gave the person life.’


Kant -Suicide is the greatest of crimes because it is man’s rejec-tion of morality, since man must be his own moral lawgiver. To kill oneself is to treat oneself as a thing (a means) rather than a person.Human beings are historically oriented to the future. As long as

there is hope for the future, suicide is clearly unreasonable. Hope

in God grounds the future. By God’s providence even the mostpainful situations not only can be endured but also may beextremely important events in the completion of earthly life.

Christians should wait on the God who gave them life, becausehe knows best how to prepare them for the mystery of eternal lifewith him.

4. Euthanasia - “mercy killing”


• When sufferers freely choose to die and ask to be killed, they are not only committing the crime of suicide but are also compounding it by making another a partner in the crime.

• On the other hand, if the sufferer is no longer really free to make a truly human decision, but is pleading to be put out of the pain or depression that has taken away the sufferer’s capacity to think straight, then the mercy killer (the physician) is simply a murderer putting to death someone no longer able to protect himself or herself.

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