ETHICAL

PRINCIPLE

Autonomy

GENERAL
RULE/DEFINITI
ON

EXEMPTIONS FOR DISCLOSURE

Autonomy is
the personal rule
of the self that is
free from both
controlling
interferences by
others and from
personal limitations
that prevent
meaningful choice.
Autonomous
individuals act
intentionally, with
understanding, and
without controlling
influences.

THE RIGHT TO CONSENT

Informed consent is required for all medical investigations
and procedures and is considered a cornerstone of modern
medicine. However, there are several legal exceptions to the right
of consent concerning minors, incapacitated patients, with mental
illness and patients suffering from communicable diseases.
The amount of information required to make consent
informed may vary depending on complexity and risks of
treatment as well as the patients wishes. Furthermore, individual
patients will have different intellectual capabilities and
understanding of their illness. It isa therefore mandatory to tailor
information provided to the individual patient and the current
situation. An emergency like acute myocardial infarction for
example will allow less time to discuss diagnosis and treatment
than an elective endoscopy.
To judge whether a patient has really understood the
information provided can be difficult and often little of the
information is retained. This leaves physician in doubt whether
their patients consent is truly informed. Consent based on partial
information may be invalid but this may go unnoticed by patient
and treating physician.
The principal of an absolute right to consent could be easily
undermined by partial information. It is highly dependent on the
willingness to provide full information and the patients capability
to understand and weigh up the options.

In summary the patients right to autonomy should always be

respected and step shall be taken to make consent truly
informed. On the basis of philosophical, ethical, legal and
practical considerations, however, there is no absolute right to
consent.
Examples:
a. In a prima facie sense, we ought always to respect the
autonomy of the patient. Such respect is not simply a
matter of attitude, but a way of acting so as to recognize
and even promote the autonomous actions of the patient.
The autonomous person may freely choose values,
loyalties or systems of religious belief that limit other
freedoms of that person. For example, Jehovah's
Witnesses have a belief that it is wrong to accept a blood
transfusion. Therefore, in a life-threatening situation
where a blood transfusion is required to save the life of
the patient, the patient must be so informed. The
consequences of refusing a blood transfusion must be
made clear to the patient at risk of dying from blood loss.
A desiring to "benefit" the patient, the physician may
strongly want to provide a blood transfusion, believing it
to be a clear "medical benefit." When properly and
compassionately informed, the particular patient is then
free to choose whether to accept the blood transfusion in
keeping with a strong desire to live, or whether to refuse
the blood transfusion in giving a greater priority to his or
her religious convictions about the wrongness of blood
transfusions, even to the point of accepting death as a

predictable outcome. This communication process must

be compassionate and respectful of the patients unique
values, even if they differ from the standard goals of
biomedicine.
In analyzing the above case, the physician had a prima
facie duty to respect the autonomous choice of the patient, as
well as a prima facie duty to avoid harm and to provide a medical
benefit. In this case, informed by community practice and the
provisions of the law for the free exercise of one's religion, the
physician gave greater priority to the respect for patient
autonomy than to other duties.
b. One clear example exists in health care where the

principle of beneficence is given priority over the principle

of respect for patient autonomy. This example comes from
Emergency Medicine. When the patient is incapacitated
by the grave nature of accident or illness, we presume
that the reasonable person would want to be treated
aggressively, and we rush to provide beneficent
intervention by stemming the bleeding, mending the
broken or suturing the wounded.
In this culture, when the physician acts from a benevolent
spirit in providing beneficent treatment that in the physician's
opinion is in the best interests of the patient, without consulting
the patient, or by overriding the patient's wishes, it is considered
to be "paternalistic." The most clear cut case of justified
paternalism is seen in the treatment of suicidal patients who are
a clear and present danger to themselves. Here, the duty of
beneficence requires that the physician intervene on behalf of

saving the patient's life or placing the patient in a protective

environment, in the belief that the patient is compromised and
cannot act in his own best interest at the moment. As always, the
facts of the case are extremely important in order to make a
judgment that the autonomy of the patient is compromised.

Beneficence

Inscribed in the
natural law, the
principle of
beneficence
provides that good
must be done
either to oneself or
to others. This
fundamental
principle binds and
urges everyone to
do what is good
and perform for
good as moral
obligation. It
mandates the right
of every human
person to the
preservation of life,
promotion of
quality life, physical
integrity and
health.

One instance of an exemption would be a case of bone

marrow transplant, which has the possibility of risks of the donor
becoming a cripple or even dying, to be undertaken from a
societal member to benefit a democratic president of a Republic
who is suffering from an end-stage organ failure. This example
makes it clear that an unconstrained principle of utility carries
danger (especially to the minority, unpopular or disadvantaged)
with it since it implies that dangerous and sometimes immoral
researches on human subjects ought to be undertaken. This is
echoed by Gallap Survey who argues that the general principle of
beneficence especially that with a version of the principle of
utility implies that premature or hastened death of individual
donors of cadaver organs done in order to benefit patients is
justified. Thus for Survey, the principle of utility shows that the
principle would justify hastening death of one patient in order to
benefit say five others who would procure a heart, a kidney, a
liver, an eye and bone marrow each. This situation that
beneficence implies is very problematic. It shows that the
principle is prone to abuse. As a matter of consequence,
unconstrained principle of beneficence generates a sense of
distrust and fear for abuse in donors of cadaver organs as they
would always worry that physicians might declare them dead
prematurely in order to benefit other patients.

Nonmaleficence

Engraved in
the natural law, the
principle of nonmaleficence
provides that evil or
harm should not be
inflicted either on
oneself or on
others. This
fundamental moral
principle binds and
urges everyone to
avoid inflicting
harm as a moral
obligation. It
mandates the right
not to be killed,
right not to have a
bodily injury, or
pain inflicted (on)
oneself, and right
not to have ones
confidence
revealed to others.

In the course of caring for patients, there are situations in

which some type of harm seems inevitable, and we are usually
morally bound to choose the lesser of the two evils, although the
lesser of evils may be determined by the circumstances. For
example, most would be willing to experience some pain if the
procedure in question would prolong life. However, in other cases,
such as the case of a patient dying of painful intestinal
carcinoma, the patient might choose to forego CPR in the event of
a cardiac or respiratory arrest, or the patient might choose to
forego life-sustaining technology such as dialysis or a respirator.
The reason for such a choice is based on the belief of the patient
that prolonged living with a painful and debilitating condition is
worse than death, a greater harm. It is also important to note in
this case that this determination was made by the patient, who
alone is the authority on the interpretation of the "greater" or
"lesser" harm for the self.
There is another category of cases that is confusing since a
single action may have two effects, one that is considered a good
effect, the other a bad effect. How does our duty to the principle
of nonmaleficence direct us in such cases? The formal name for
the principle governing this category of cases is usually called
the principle of double effect. A typical example might be the
question as to how to best treat a pregnant woman newly
diagnosed with cancer of the uterus. The usual treatment,
removal of the uterus is considered a life saving treatment.
However, this procedure would result in the death of the fetus.
What action is morally allowable, or, what is our duty? It is argued
in this case that the woman has the right to self-defense, and the

action of the hysterectomy is aimed at defending and preserving

her life. The foreseeable unintended consequence (though
undesired) is the death of the fetus. There are four conditions that
usually apply to the principle of double effect:
1. The nature of the act. The action itself must not be
intrinsically wrong; it must be a good or at least morally
neutral act.
2. The agents intention. The agent intends only the good
effect, not the bad effect, even though it is foreseen.
3. The distinction between means and effects. The bad effect
must not be the means of the good effect,
4. Proportionality between the good effect and the bad
effect. The good effect must outweigh the evil that is
permitted, in other words, the bad effect.
The reader may apply these four criteria to the case above,
and find that the principle of double effect applies and the four
conditions are not violated by the prescribed treatment plan.
KIDNEY TRANSPLANT: Gillons analysis of this case
demonstrates the flexibility in applying the four principles.
Despite the centrality of respect for persons, and the (mistaken)
view of some critics that adherents of the four principles always
place the so called American principle of autonomy at the head
of the list, Gillon demonstrates how considerations related to

beneficence may justifiably override the autonomy of individuals

who would seek to participate in a free exchange. Gillon argues
persuasively that there is no good reason to doubt whether poor
people who seek to sell their organs are, in general, able to make
adequately autonomous decisions. But that does not constitute
sufficient reason to endorse the practice. If the overall harms are
likely to exceed the expected benefitsfor the sellers, possibly
for the society as a whole, and maybe even for the recipients of
organsit would be justifiable to ban the sale of organs from live
donors. However, the conclusion relies on a set of empirical
assumptions and predictions of what is likely to occur.

Justice

Justice simple
means the
rendering of what is
ones due. A person
who is justly doing
an act to another
person gives the
latter what is his
due.
Principle of
justice refers to a
moral principle by
which certain
actions are
determined and
deemed as just or

One of the most controversial issues in modern health care

is the question pertaining to "who has the right to health care?"
Or, stated another way, perhaps as a society we want to be
beneficent and fair and provide some decent minimum level of
health care for all citizens, regardless of ability to pay. Medicaid is
also a program that is designed to help fund health care for those
at the poverty level. Yet, in times of recession, thousands of
families below the poverty level have been purged from the
Medicaid rolls as a cost saving maneuver. The principle of justice
is a strong motivation toward the reform of our health care
system so that the needs of the entire population are taken into
account. The demands of the principle of justice must apply at
the bedside of individual patients but also systemically in the
laws and policies of society that govern the access of a
population to health care.
If selection is to be made, what kind of recipients should be

unjust, as due or
undue.

Confidentiali Confidentiality is
commonly applied
ty

to conversations
between doctors
and patients. Legal
protections prevent
physicians from
revealing certain
discussions with
patients, even
under oath in court.
This physicianpatient
privilege only
applies to secrets
shared between
physician and
patient during the
course of providing
medical care.

selected? How should they be selected? Does it not constitute

injustice against those who will not be selected? What constitutes
just distribution of health resources? And what about burdens
health benefits bring about? Addressing said questions is the
concern of the so-called distributive justice. And much work
remains to be done in this arena.

WHEN TO BREAK CONFIDENTIALITY WITH MINORS:

Ronnie was a 16-year-old high school student who was
struggling academically. He had always been a strong student,
but his grades had recently begun to decline. Ronnie told his
guidance counselor that he was distracted by his parents recent
separation and pending divorce. With the guidance counselors
encouragement, Ronnie began therapy with a social worker,
Martha, who was employed by a nearby family service agency
that has a counseling program for adolescents. Ronnie and
Martha spent considerable time talking about how distressed
Ronnie was about his parents marital conflict and separation.
Ronnie also focused on his longstanding conflicts with his father
and his concern about his mothers psychiatric problems.
Almost two months after they started working together, Ronnie
told Martha that he had something important to tell her. He said
that he was concerned he had developed a drug problem. Ive
been doing a fair amount of ecstasy and amphetamines with my
friends on weekends, he said. I didnt think Id have a problem,
but now Im really worried that I might have an addiction. Ronnie

asked Martha to help him with his substance abuse, but he

insisted that she not tell his parents about his drug use. Youve
met my dad, and you know how afraid I am of him, and I cant
bear the thought of adding to my moms worries. I just dont want
you to say anything to them. All I want is some help, he pleaded.
Martha faced a common ethical challenge encountered by social
workers who provide services to minors: whether or not to
disclose confidential information to the minors parents (or
guardians), particularly when the minor client has explicitly asked
the social worker not to share the information. Nearly every social
worker who serves minors can think of times when he or she had
to decide whether or not to share sensitive information with a
clients parents over the clients objections. Usually, these
situations involve confidential information that minors have
shared with their social workers about drug and alcohol use,
sexual activity, contraception, pregnancy, abortion decisions, and
mental health treatment.
There is no simple answer to questions about social workers
ethical obligations in these circumstances. On one hand, minors
typically have a right (somewhat limited) to confidentiality. Social
workers understand that minor clients need to be able to trust
their therapists and counselors; otherwise, minors may be
reluctant to share clinically relevant information. Social workers
understand that many parents believe they have a right to know
about the risks their children face and believe that their childrens
clinicians have a duty to share critical information involving their

childrens safety.

Fidelity

Fidelity is a virtue
that refers to
integrity, which is
achieved by the
embodiment of
loyalty, fairness,
truthfulness,
advocacy, and
dedication that is
motivated by an
underlying principle
of care. Nurses
must encompass
integrity in all that
they do .The nurse
practices fidelity by
remaining
committed and
keeping promises.

A. Lichter (1989) believes it is vital to tell the truth to a patient

because they have a right to know. He therefore advocates
overriding the principles of non-maleficence (whether the
"full" truth may in some ways be detrimental to a patient)
and beneficence (whether it is to the patients advantage
not to know the full truth) in favour of autonomy (the right
to choose who we wish to be, to make our own decisions
and to be in control of what is being done to us). Kendall
(1995) argues that "an action can be harmful at the same
time as being beneficial" and draws an analogy between
truth
telling and chemotherapy
treatment.
While
chemotherapy introduces toxins that can cause extreme
harm, the outcome of this treatment may well be beneficial
for the patient. Likewise, telling the painful truth can be
beneficial by allowing patients and families to facilitate
planning and decision-making in regard to their lives and
future care.
The views of Lichter and Kendall are representative of many
others and lead us to conclude that the debate about truth telling
in the area of healthcare is no longer around 'to tell' or 'not to
tell', but rather about who should tell, when to tell and how to tell.
B. Case Scenario : Merry was a 40-year-old mother of two with
a history of tumor and hospital visits; however, her last

doctors visit in October left her and her family with

shattering news. Doctors diagnosed Merry with metastatic
inoperable tumor. Since Merry last visit, her conditions
worsened due to malignancy and she became a victim of
nausea, vomiting, intestinal obstruction and slothfulness.
When Merry came to know of her medical conditions, she
became stubborn and denied treatments the hospital
offered her: exploratory laparotomy, insertion of a urinary
catheter, and insertion of nasogastric tube. The matter of
refusal of treatment between the medical staff and Merry
put her family in a hard situation. They encouraged Merry to
agree to take the hospitals treatments; on the other hand,
they also wanted to respect and honour her autonomous
wishes. In due course, the medical team established a
terminal diagnosis for Merry and informed this to her family.
Afterwards, the family asked the consultant to keep this
information from Merry. The consultant agreed and Merry
sustained her stay in the hospital with the trust that she
was suffering from tumor which can be cured. A week later,
the holidays approached Merry and her family conversed
plans for Christmas as well as her discharge from the
hospital. Though Merrys family and doctors were well
aware of her prognosis, both groups willingly concealed the
truth and let Merry believe her health condition was not
terminal. This created an uncomfortable situation for the
involved health care professionals involved in this tough

conflict of interest. Eventually, Merrys disease took control

of her life and she unknowingly passed away one week
before her expected Christmas holiday. Truth telling to
terminally ill patients is a common ethical dilemma in
health care ethics: to inform or not to inform, is the main
question. Nurses work closely with patients and thus are the
ones put in this difficulty between their patient and their
patients family. Who should they listen to? Should they
leave their patient in the dark by not telling them truth?
The Ethical Dilemma: This case scenario presents a dilemma
when the nurse has to select between the mutually exclusive
events. The definite issue is whether a nurse by respecting the
familys wish should keep the truth from her terminally ill patient,
or by abiding the Code of Ethics for Nurses, should disclose the
truth to the patient. The Nurses Code of Ethics articulates the
ethics and values of the nursing profession by affirming that
nursing care is directed toward meeting the comprehensive
needs of patients and their families across the continuum of
care, in addition, promoting, advocating for, and striving to
protect the health, safety, and the rights of the patient .
Although the restriction of keeping truth from patient was posed
by family, but nurses the primary person who deals with such
dilemmas. However, nurses responsibility is to be professional,
stay true to the lawfulness of their practice, and follow the
Nursing Code of Ethics as well as hospitals policy in truth telling.

Veracity

Veracity is a dual
concept that refers
to both the duty to
disclose pertinent
information and the
obligation to
respect
confidentiality.
It refers to
a facet of moral
character and
connotes positive
and virtuous attribu
tes such
as integrity, truthful
ness, and
straightforwardness
, including
straightforwardness
of conduct, along
with the absence of
lying, cheating,
theft, etc.
Furthermore,
honesty means
being
trustworthy, loyal,
fair, and sincere.

A. Case Scenario: Merry was a 40-year-old mother of two with

a history of tumor and hospital visits; however, her last
doctors visit in October left her and her family with
shattering news. Doctors diagnosed Merry with metastatic
inoperable tumor. Since Merry last visit, her conditions
worsened due to malignancy and she became a victim of
nausea, vomiting, intestinal obstruction and slothfulness.
When Merry came to know of her medical conditions, she
became stubborn and denied treatments the hospital
offered her: exploratory laparotomy, insertion of a urinary
catheter, and insertion of nasogastric tube. The matter of
refusal of treatment between the medical staff and Merry
put her family in a hard situation. They encouraged Merry to
agree to take the hospitals treatments; on the other hand,
they also wanted to respect and honour her autonomous
wishes. In due course, the medical team established a
terminal diagnosis for Merry and informed this to her family.
Afterwards, the family asked the consultant to keep this
information from Merry. The consultant agreed and Merry
sustained her stay in the hospital with the trust that she
was suffering from tumor which can be cured. A week later,
the holidays approached Merry and her family conversed
plans for Christmas as well as her discharge from the
hospital. Though Merrys family and doctors were well
aware of her prognosis, both groups willingly concealed the
truth and let Merry believe her health condition was not

terminal. This created an uncomfortable situation for the

involved health care professionals involved in this tough
conflict of interest. Eventually, Merrys disease took control
of her life and she unknowingly passed away one week
before her expected Christmas holiday. Truth telling to
terminally ill patients is a common ethical dilemma in
health care ethics: to inform or not to inform, is the main
question. Nurses work closely with patients and thus are the
ones put in this difficulty between their patient and their
patients family. Who should they listen to? Should they
leave their patient in the dark by not telling them truth?
The Ethical Dilemma: This case scenario presents a dilemma
when the nurse has to select between the mutually exclusive
events. The definite issue is whether a nurse by respecting the
familys wish should keep the truth from her terminally ill patient,
or by abiding the Code of Ethics for Nurses, should disclose the
truth to the patient. The Nurses Code of Ethics articulates the
ethics and values of the nursing profession by affirming that
nursing care is directed toward meeting the comprehensive
needs of patients and their families across the continuum of
care, in addition, promoting, advocating for, and striving to
protect the health, safety, and the rights of the patient .
Although the restriction of keeping truth from patient was posed
by family, but nurses the primary person who deals with such
dilemmas. However, nurses responsibility is to be professional,
stay true to the lawfulness of their practice, and follow the

Nursing Code of Ethics as well as hospitals policy in truth telling.