PRINCIPLES AND RULES

Dr. E. T. Acevedo, MD, MPA, MPA

 PRINCIPLES AND RULES
INTRODUCTION
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 FOUNDATION
ETHICS (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 RULES
More 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 AND RULES: INTRODUCTION
PRINCIPLES

RULES

PARTICULAR JUDGMENTS

  MORAL JUSTIFICATION
 
Some dilemmas may result from the different viewpoints
about 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.
 
PRINCIPLES AND RULES: INTRODUCTION

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 ?

 
PRINCIPLES AND RULES: INTRODUCTION

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 of
ethical 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 different
standpoints -
Re – aspects of human act.
 
Page 3
 
PRINCIPLES AND RULES:
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.
PRINCIPLES AND RULES:

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.
PRINCIPLES AND RULES:
 * 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.
PRINCIPLES AND RULES:

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
 
 
 
PRINCIPLES AND RULES:
 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:
PRINCIPLES AND RULES:

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
 
PRINCIPLES AND RULES:
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
PRINCIPLES AND RULES:
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
PRINCIPLES AND RULES:
A. PRINCIPLES OF CHRISTIAN FAITH:
These principles instruct us how to form a prudent conscience thru
a process of knowing, strengthening and deepening of human
insight and reason. We are guided in making prudent decisions
by 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.
 
PRINCIPLES AND RULES:
B. PRINCIPLES OF CHRISTIAN LOVE:
The fundamental motivation of these principles is the drive to
self fulfillment through relationships with other human
beings, and above all with the three divine persons, Father,
Son and Holy Spirit. Three particular norms to define the
content 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.
PRINCIPLES AND RULES:
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 person
2. the whole human race
3. 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.
PRINCIPLES AND RULES:
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 because
They 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 in
nature 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 such
discernment 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 other
forms 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)
FAITH: MORAL DISCERNMENT
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 pa-
tient’s non- negotiable right to life or other such basic
needs.
FAITH: MORAL DISCERNMENT
 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 inten- tion, 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.
 
FAITH: DOUBLE-EFFECT
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.

 
FAITH: DOUBLE-EFFECT
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”.
FAITH: DOUBLE-EFFECT
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
FAITH: DOUBLE-EFFECT
 
ACTIONS
 
DESIRE WE DO NOT DESIRE
(wish, intend, want,) BUT MERELY ALLOW
will) (permit, tolerate)
 SIN
  
ACT OF THE WILL
 
 Willed or Tolerated or
Intended merely permitted
 
MORAL JUDGMENT
 Performing a good act Performing an evil
Which has both good VS. act in order that
and evil effects good may result.
 
FAITH: DOUBLE-EFFECT
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.
FAITH: DOUBLE-EFFECT
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 judge
it unethical to cooperate formally with an immoral act but one
may sometimes judge it an ethical duty to cooperate materially
with an immoral act when only in this way can a greater harm be
prevented, 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 Cpmpromise

One 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).
 
FAITH: LEGITIMATE COOPERATION

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 was
St. Thomas Aquinas, when he observed that the actions we
perform 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.
FAITH: LEGITIMATE COOPERATION
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.
FAITH: LEGITIMATE COOPERATION
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.
FAITH: LEGITIMATE COOPERATION
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 patient
demands. (formal cooperation).
FAITH: LEGITIMATE 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.
 
FAITH: LEGITIMATE COOPERATION
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.
 
FAITH: LEGITIMATE COOPERATION
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)
FAITH: LEGITIMATE COOPERATION
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.
 
FAITH: LEGITIMATE COOPERATION
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.
FAITH: LEGITIMATE COOPERATION
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. Trust
2. Contact among people who have the needed information
3. Clear formulation and expression of this information
4. Continuous feedback by which failures in communication can be
corrected.
5. Courtesy
6. 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-centered
2. Problem-centered
PRINCIPLE OF VERACITY
Person-centered:
 
It lends importance to the patient as a person. It considers the
patient as a person with a problem, but not as a problem himself.
The patient is a person with feelings of hope and despair, with
purpose and defeat. As such, one has the right to know the
nature of one’s disease, and the physician is morally obligated to
respect that right. The physician owes the patient the truth, just as
the patient owes the physician’s skill and technical powers.
Moreover, caring for a person is a moral relationship in which the
physician’s attitude should be an utmost concern for the patient.
PRINCIPLE OF VERACITY
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.
 
PRINCIPLE OF VERACITY
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.
 
PRINCIPLE OF VERACITY
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.
 
PRINCIPLE OF VERACITY

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. prognosis
2. complications
3. 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 assurances
about confidentiality patients may be reluctant to give doctors the
information 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;
CONFIDENTIALITY and PRIVACY
• 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.
 
CONFIDENTIALITY and PRIVACY
Medical Secrecy may be lifted for:
1. Consent of the interested party - i.e. - Insurance
2. 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
 
CONFIDENTIALITY and PRIVACY
Four Paradigms of Confidentiality:
1. As a religious duty]
2. As a part of professionalism
3. As an example of respect for patient autonomy
4. As an aspect of friendship or community
 
CONFIDENTIALITY and PRIVACY
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. .’
 
CONFIDENTIALITY and PRIVACY
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 PRIVACY
2. 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, psycholo
gical, social, and spiritual needs as a member of the world com
munity 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.
CHRISTIAN LOVE: HUMAN DIGNITY
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 DIGNITY
WOMEN 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 DIGNITY
THE 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 dignity
does not depend on his efficiency or his capacity to contribute to
the 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 DIGNITY
Mechanical Support for Transferrable Organs:
Is it not against the dignity of the human person to maintain
organs and tissues artificially after brain death in order to have
them 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 life
dedicated to the service of others in the form of a
transplanted organ.
 
 
 
CHRISTIAN LOVE: HUMAN DIGNITY
Dying:
Must the physician tell his patient the truth, that he is dying?
The wisest course of action for the physician is to allow the
patient an opportunity to exercise his choice about learning the
reality of his condition. A patient has the right to make a choice for
himself about his destiny to give honor and dignity in his dying –the
being to die in dignity.
CHRISTIAN LOVE: HUMAN 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 common

good 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 the
2. Distribution of good according to need
Most social evils and injustices are the result of exclusion
of some persons from the common good in which they have a right
to 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; and
SOCIAL 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 SOLIDARITY
Comes 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 function
concerning the tasks and needs of the smaller groupings and
individuals. It implies that the first responsibility in meeting human
need rests with: * the free and competent individual, *
then with the local group.

Higher and higher levels of the community must assume this

responsibility.
* 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.
 
SUBSDIDIARITY or SOLIDARITY
Principle of subsidiarity concretized in health care, considering the
following 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.
SUBSDIDIARITY or SOLIDARITY

The power to make social decisions ought to be kept as

close as possible to those who experience those problems and
are most strongly affected by the decisions concerning them.
  A paternalism that decides everything for those it claims to
serve is really nothing but a form of domination and tends to
Become self-serving.
The application of SUBSIDIARITY to the organization of
society on the basis of Social Functions, rather than on the
basis of a struggle between isolated individuals defending their
rights and a centralized government having all the powers of
social 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 and

competence of individuals against excessive domination by
societies, as well as the competence of minor associations against
oppressive 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 a
series of organs. However, it can happen that at a certain moment a diseased
organ may threaten the entire human body.
 
The extirpation or elimination of an organ from a human body is
termed “MUTILATION”
 
The Principle of Totality states that the “whole is more important
than the parts and the parts exist and function for the good of the
whole.
When a condition of the parts threatens the whole, then the part can
be sacrificed.”
 
TOTALITY OF THE HUMAN PERSON
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.
 
TOTALITY OF THE HUMAN PERSON
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.
 
TOTALITY OF THE HUMAN PERSON

* 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.
TOTALITY OF THE HUMAN PERSON
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.
 
TOTALITY OF THE HUMAN 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 PERSON
CONTROVERSIAL CASES which involve the Principle of Totality:
1. Plastic surgery
2. Organ Transplants and Donation
3. 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.
 
TOTALITY OF THE HUMAN PERSON
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 of
various maladies such as those stemming from chromosomal defects will, in
principle, be considered desirable, provided it is directed to the true promotion
of the personal well-being of the individual without doing harm to his integrity
or worsening his conditions of life.”
•  
 STEWARDSHIP and CREATIVITY
The gifts of multidimentional hurespect for their intrinsic teleology, and
especially the gift of human creativity should be used to cultivate nature and
environment with a care set by the limits man nature and its natural
environment should be used with profound of actual knowledge and the risk
of 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 them
and over themselves is only a stewardship for which human beings remain
responsible to the one Lord.
In creativity, people have to respect their own limits and the
limits of the materials with which they must work.
STEWARDSHIP and CREATIVITY
Human beings are far more limited by the fact that their share in
God’s knowledge and love is finite. No matter how they may
progress in science, freedom, and power, they dare not contradict
their 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.

 
STEWARDSHIP and CREATIVITY
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.
STEWARDSHIP and CREATIVITY
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
STEWARDSHIP and CREATIVITY
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.
 
STEWARDSHIP and CREATIVITY
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.’
 
STEWARDSHIP and CREATIVITY
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 most
painful situations not only can be endured but also may be
extremely important events in the completion of earthly life.
Christians should wait on the God who gave them life, because
he knows best how to prepare them for the mystery of eternal life
with him.
4. Euthanasia - “mercy killing”
STEWARDSHIP and CREATIVITY
• 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.