Nursing Leadership and Management

STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR

Session # 7

LESSON TITLE: NURSING ETHICS Materials:

LEARNING OUTCOMES: Book, pen and notebook, index card/class list
Upon completion of this lesson, the nursing student can: References:
1. Define ethics; Lydia M. Venzon RN, MAN, FPCHA Ronald M.
2. Enumerate the Ethical Principles and Universal Principles; Venzon RN, MAN (2010), Professional Nursing In
and, The Phillippines 11th Edition: C & E Publishing, Inc.
3. Recognize patients’ and nurses’ responsibilities. 839 EDSA, South Triangle, Quezon City

LESSON PREVIEW/REVIEW
Based on the previous lesson, give a kind of contract and give an example situation:

MAIN LESSON

ETHICS came from the Greek word ethos which means moral duty. Ethics refers to a standard to examine and
understand moral life. Ethical theories, principles and codes of conduct serve as guides of human conduct provided by
ethical systems. Ethics studies how people make judgment in regard to right or wrong.
Morals, on the other hand, are specific ways of behavior or of accomplishing ethical practices. Morality is derived from
the 1 Greek word moralis which refers to social consensus about moral conduct for human beings and society. Human
decency, right or wrong, good or evil, proper or improper, cruel or benevolent acts are explained in terms of morality.'
Ethics is about making choices that are best for the individual or society at certain times and in particular situations and
then evaluating such choices and outcomes. Ethicist Joseph Fletcher differentiates morality from ethics. He states that
morality is what you believe is right and good while ethics is the critical reflection about morality and rational analysis about
it.
Professional ethics is a branch of moral science concerned with the obligations that a member of the profession owes to
the public. Health care ethics, on the other hand, is the division of ethics that relates to human health. It resides in the realm
of human values, morals, customs, personal beliefs, and faith.
Bio-ethics is a specific domain of ethics that focuses on moral issues in the field of health care. It evolved into a discipline
all on its own as a result of life and death dilemmas faced by health care practitioners. It is a systematic study of human
behavior in the field of life science and health care in the light of moral values and principles. While originally, bio-ethics was
concerned with ethical issues described with medical practice, it has expanded to issues surrounding health and biological
sciences and social issues including environmental concerns.
As members of the health team, nurses have to make independent decisions in the performance of their daily duties.
Within the health team, however, many decisions are also made interdependently. Also, nurses are expected to exhibit
bio-ethical behavior in their professional duties. Knowledge of ethical challenges enable them to hone their skills in decision
making regarding their patients' life-and-death issues and integrate ethical principles and theories into their practice thereby
helping them resolve moral conflicts.
Nursing ethics is related to all the principles of right conduct as they apply to the profession. Nursing ethics reinforces
the nurses' ideals and motives in order to maximize the effectivity of their service.
Oftentimes, nurses find it difficult to resolve ethical issues partly because they do not have the sensitivity to recognize
ethical problems and conflicts or to display the needed knowledge and experience in every situation that they face.
Johnstone defines nursing ethics as the "examination of all ethical and bio-ethical issues from the perspective of nursing
theory and nursing ethics." Vercoe, et.al., emphasize that "the field of nursing ethics be focused on the needs and
experiences of practicing nurses, the exploration of its meaning and that of ethical practice in terms of the perception of
these nurses.

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ETHICAL PRINCIPLES AND OTHER APPROACHES

Teleological Approach
Teleology comes from the Greek word telos or "goal or end." This is expressed in the maxim, "the right thing to do is the
good thing to do." The teleological approach is also termed as act utilitarianism where the good resides in the promotion of
happiness or the greatest net increase of pleasure over pain.
In recent formulation of act utilitarianism, Joseph Fletcher, a situation ethicist, holds that good is agape, the general
goodwill or love for humanity. In the final analysis human need determines what is or what is not ethical. If the act helps
people, then it is a good act, and if it hurts people, then it is a bad one.
In his writings, Fletcher provides the guidelines for making ethical decisions: These are:
1. consideration for people as human beings;
2. consideration of consequences;
3. proportionate good to come from the choices;
4. propriety of actual needs over ideal or potential needs;
5. a desire to enlarge choices and reduce chance; and
6. a courageous acceptance of the consequence of the decision.

An example may be given of a City Health Department planning for their annual budget. To which program should they
allot a bigger budget—the modernization of the city hospital or the nutrition and immunization programs of the
poverty-stricken families of the city? Will promotion of health and prevention of illness have priority over treatment of illness
and rehabilitation?

Deontological Approach or Duty-Oriented Theory

The word deontology came from the Greek word deon which means duty. In this theory, the ethicist feels that the basic
rightness or wrongness of an act depends on the intrinsic nature rather than upon the situation or its consequences.
Immanuel Kant, a German philosopher and ethicist in the 18th century, defines a person as a "rational human being with
freedom and social worth." A person is morally good and admirable if his actions are done from a sense of duty and reason.
He states that it is only through dutiful actions that people have moral worth. Even when individuals do not want to fulfill their
duty, Kant believes that they are required to do so.7
Suppose a nurse is assigned to care for a patient with AIDS. Could she reasonably refuse to care for the patient on the
ground that the patient's condition may threaten her health? As practitioners of the art of healing, nurses are to take care of
the sick even if patients have conditions that threaten their personal health. Nurses, however, must observe the necessary
precautions to protect their health.

Virtue Ethics Approach

Virtue ethics, known as aretaic ethics (from the Greek word arete), is focused primarily on the heart of the person
performing the act. It focuses on the traits and virtues of a good person such as courage, temperance, wisdom, and justice.
However, doing the right thing is not all that is needed. One must have the right motivation, disposition and traits for
being good and doing right such as courage, magnanimity, honesty, justice, and beneficence.
Intellectual virtue is the power to deliberate about things good for oneself. Moral virtues, on the other hand, must be lived
over time in order to be learned. Nurses, when faced with a particular situation must be able to know what to do. They must
be able to integrate virtue ethics with duty.
Suppose a student is requested by her classmate, who is also her best friend, to let her copy in their examination so that
she will pass. The student should not allow this to happen as formal cooperation in an evil act is never allowed. She will be
as equally guilty as the one who will cheat as she will be serving as an accomplice to the evil act.

DIVINE COMMAND ETHICS

Divine command ethics is based on the theory that there is a Supreme or Divine being that sets down the rules to
provide guidance to moral decisions. For Christians, these rules are found in the Ten Commandments. Differences in
religion, however, pose problems such as what to do when the decision would conflict with one's religious beliefs. For
example, members of the Jehovah's Witnesses will not receive blood transfusion even if their lives will be put in danger.
Suppose a nurse is approached by a friend who quests for re an abortion. The nurse refuses but refers the friend to a
doctor who can perform it. This is a violation of the divine command, "Thou shall not kill." It violates the principle relating to
the origin and destruction of life which states, "The owner of life is man, but it is God who gave him that life, therefore no one
has a right to take life except God."
The divine command is also applicable to cases of euthanasia, which is the direct killing of people who may not have
committed any crime deserving of death, but because of mental, or physical conditions are considered worthless to society.
Examples of these are patients in persistent vegetative state whose relatives request that the respiratory ventilators be
turned off or the feeding tubes be removed to put an end to both the patients' and the relatives' suffering.

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UNIVERSAL PRINCIPLES OF BIOMEDICAL ETHICS
In health care delivery, basic ethical principles assist the health professionals to determine right or wrong in regard to
value issues involving the pursuit of health, alleviation of suffering, and assisting patients towards peaceful death. These are
autonomy, veracity, beneficence, nonmaleficence, and justice.

Autonomy — Autonomy comes from the Greek word autos meaning self and nomos meaning governance. It involves
self-determination and freedom to choose and implement one's decision, free from deceit, duress, constraint or coercion.
This is called informed consent. The kind of information provided the patient and his family is within their level of
understanding that they may evaluate the risks and the other options open to them. This includes allowing the patient to
refuse treatment if he so decides; disclosure of his ailment, prognosis, mode of treatment; and maintaining confidentiality.
Restrictions on autonomy may occur when there is potential harm to others such as communicable diseases or acts of
violence.
The person making the decision must be deemed competent. He must have the intellectual capacity to make a rational
decision and he must be of legal age. The decision should be of his own free will and he should not be coerced or put under
duress to do so. Every adult of sound mind must have the right to determine what should be done to his body. Therapeutic
privilege is the legal exception of the rule of informed consent, which allows the caregiver to proceed with the care in case of
emergency, incompetence, waiver or implied consent.

Veracity-To maximize the efficiency of healthcare, the patient and the healthcare providers are bound to tell the truth.
The patient has the responsibility to provide, to the best of his knowledge, accurate and complete information about his
complaints, past illness, previous hospitalizations, medications being taken, allergies, religious restrictions, and other
matters relevant to his health. If the patient cannot provide the information, his family or significant others should do so in
order that accurate diagnosis could be arrived at and immediate treatment provided.
The physician should tell the patient and his family his diagnosis, plan of care, treatment and possible risks involved,
length of treatment, possible expenses, and other options they make take if there be any.
There are times, however, that the physician or health practitioner is requested not to tell the relative the exact nature of
the patient's illness. Sometimes, the relative requests the physician not to tell the patient his true diagnosis or condition. At
times the practitioner himself intentionally withholds information according to his sound judgment when such revelation
would do more harm to an emotionally unstable or depressed person. This is called a benevolent deception.
Several cases are therein cited:
1. A young, married male who was diagnosed to have AIDS, requests the doctor not to tell his diagnosis to his wife.
2. The children of an aged grandmother suffering from metastatic cancer request the doctor not to tell their mother
her diagnosis and instead to proceed with the chemotherapy.
In the case cited above of the young, married man who has AIDS, telling the wife would be far more advantageous so
that she can be examined, protected or treated as the case may be. She would be able to use proper precautionary
measures for herself, understand the husband's illness, and participate in his care.
In the case of the grandmother, gently telling her the truth would help convince her to participate in the treatment plan
including spiritual preparation towards peaceful death.
It is very important that health care workers be very discreet in providing information. While telling the truth increases
their credibility, it is oftentimes how they say this information that makes them acceptable or not.

Beneficence — The principle of beneficence refers to acts of kindness and mercy that directly benefit the patient. These
acts promote the health of the patient, prevent illness or complications, alleviate suffering, and assist towards peaceful
death if the inevitable comes.
The Patient's Bill of Rights helps the health practitioners provide more effective patient care. The patient has the right to
1. considerate and respectful care;
2. relevant, current and understandable information concerning diagnosis, treatment prognosis, specific procedures,
treatment, risks involved, medically reasonable alternative benefits needed to make informed consent;
3. make decisions regarding his plan of care; in case of refusal, he is entitled to other appropriate care and service or
be transferred to another hospital;
4. have advance directive (such as a living will) concerning treatment or designating a surrogate decision maker;
5. every consideration of his privacy such as in case discussion, consultation and treatment;
6. confidentiality of communications and records;
7. review his records concerning his medical care and have these explained to him except when restricted by law;
8. be informed of business relationship among the hospital, educational institution, health care providers that may
influence the patient's treatment and care;
9. consent or decline to participate in experimental research affecting his care;
10. reasonable continuity of care when appropriate and be informed of other care options when hospital care is no
longer appropriate; and
11. be informed of hospital policies and practices that relate to patient care.

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 All activities provided to patients must be conducted with deep considerations of their values and dignity.

Nonmaleficence —In some way the principle of nonmaleficence is similar to the principle of beneficence. The
distinction lies in the fact that the principle of beneficence is stated in a positive form while nonmaleficence is stated as an
admonition in the negative form to remind health practitioners to do no harm.
Examples of nonmaleficence is not assisting in or performing abortion, not assisting persons to commit suicide, not
performing euthanasia or mercy killing, or not willfully subjecting patients to experimental drugs whose potential harm may
be greater than the expected benefit, and not harming a person's reputation by revealing confidential information.
What benefit does it give a patient who is in persistent vegetative state to be attached to a respirator, or for a dying
person to be given cardiopulmonary resuscitation? Should a dying person in pain be given a sedative, when the health
practitioner knows it would cause respiratory depression or arrest?
Nurses should remember that human life is inviolable. They should do what is best for the patient. When biological death
is imminent, they should not abandon the patient. Treating them with respect, providing nursing measures safely, gently and
with kindness, and providing psychological and spiritual support allow the patient to die with dignity and peace.. Nurses
should not participate in treatments or procedures that will harm the patient. They should make their stand known and
should withdraw from the team if what is to be done is against their conscience.

Justice— In healthcare, refers to the right to demand to be treated justly, fairly and equally.
Article XIII of the Philippine Constitution guarantees that the state shall adopt an integrated and comprehensive
approach to health development and shall endeavor to make essential goods, health and social services available to all
people at affordable cost. There shall be priority for the needs of the underprivileged, the sick, the elderly and the disabled,
the women and children. The state shall endeavor to provide free medical care to paupers, establish and maintain an
effective food and drug regulatory system, and undertake appropriate health manpower development and research
responsive to the country's health needs and problems. It shall establish a special agency for disabled persons for their
rehabilitation.
To this end, the Department of Health affirms that health is a basic human right. To make this right a reality, the DOH
shall work to make quality health services available and affordable by mobilizing resources, providing means to better
health, and arousing community participation.
The National Health Insurance Act of 1995 provides for a universal compulsory health insurance program in the country.
Employees from private and public sectors are covered with Medicare privileges. Even the self-employed such as drivers,
vendors, beauticians, may become members of the Social Security System and will be entitled to insurance benefits,
hospitalization, and discounted out-patient services.
Republic Act 7432 called the Senior Citizens Act, gives honor and justice to the elderly by giving 20 percent discount in
public establishments such as restaurants, and pharmacies; public utility vehicles; and hospitals including free medical and
dental check-up and free hospitalization in all government hospitals.
In allocating budget for the promotion of health, prevention of illness, and for health education and immunization, more
benefits can be expected in terms of lessened morbidity and mortality rates.
Common methods for distribution of goods and resources are based on fair opportunity rule where every person is given
an equal share according to need, merit, contribution, effort and social worth.
The fair opportunity rule is based on the egalitarian theory that emphasizes equal access to goods and services. The
"the greatest good for utilitarian theory employs the maxim, the greatest number." Thus government authorities should
carefully think about the dilemma of whether the government should spend more for the care of one child with congenital
defect over the need to protect the lives of thousands of children who would benefit from mass immunization against
communicable diseases.
Hospitals put up triage schemes to determine who should be served first. One criterion often put up is that of medical
prognosis or medical utility or who among the patients is most likely to survive. The next criterion is social utility or social
value or worth, the ability to pay, or first-come-first-served basis.
To be ethically sound, the criteria selected must favor more the socially disadvantaged, and those incapacitated by
illness. Nurses should utilize their critical thinking ability and skills, listen carefully and objectively and analyze facts. Ethical
principles and values should be used in making moral decisions. Open communication between patients, their families, and
the health team results in acceptance of decisions and congenial relationships.

ETHICS COMMITTEES IN HOSPITALS AND THE ROLE OF MEDICAL ETHICISTS

There is a growing trend for hospitals to have formal ethics committees. These may be composed of philosophers,
doctors, nurses, lawyers, clergy or social workers. They discuss sensitive issues such as when to withdraw or withhold
treatment for an adult and the treatment of a severely handicapped newborn. Some may include topics such as the right to
die, informal consent, right to choose or refuse treatment, right to know who is treating the patient.
Discussion usually begins with a description of the patient's condition and medical history. Most often, conflicts involve
families and doctors; and where doctors want to treat or continue to treat a patient and the family wants to do nothing.
Research proposals involving human subjects are also reviewed.

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 Some cases that have reached worldwide attention are:
1. the removal of Terri Schiavo's stomach feeding tube upon his husband's request to the Court as she was in a
persistent vegetative state for 15 years;
2. the Nancy Beth Cruzan case in Missouri, United States where the Supreme Court denied her parents' request to
remove her feeding tube. She was in vegetative state for seven years;
3. the California couple who conceived a child in the hope that the baby would be a bone marrow donor for its
seventeen year-old sister who is acutely ill of leukemia;
4. the couple convicted of manslaughter for the death of their 2-1/2 year-old son because they failed to seek medical
attention and the baby died of intestinal obstruction; and
5. the doctor who assisted a woman sick of Alzheimer's disease to commit suicide.

RESPONSIBILITIES OF NURSES TO THE PATIENTS

The primary responsibility of nurses to the patients is to give them the kind of care their condition needs regardless of
their race, creed, color, nationality or status. In so doing, the patients' care shall be based on needs, the physician's orders,
and the ailment; and shall involve the patients and their families so that they or any number of the family can participate in
their care.
Nurses are advised to become familiar with the patient's Bill of Rights and observe its provisions14.
Because nurses are given compensation for their services, they should not accept tips or expensive gifts that may
induce them to give more care to favored patients and neglect those who cannot give. It is advocated that they treat patients
in a manner that will show concern whether the patient is rich or poor.
When nurses are engaged by patients or any agency, they shall complete said service on the length of time stipulated in
the contract. They may not leave their patients or any agency without proper permission or resignation or without relief.
Nurses can be sued for breach of contract or abandonment of duty if they do.
Nurses should commit themselves to the welfare of those entrusted to their care. They should be loyal to their sworn
duty This is termed role fidelity.

CONFIDENTIALITY OF INFORMATION
Confidential information is also termed as privileged communication because it is given based on trust. Patients and/or
their relatives are expected to give the necessary information so that proper diagnosis and treatment could be made.
Patients and their families are entitled to know information or facts within the limits determined by the physician. If the
patients insist on knowing their diagnosis, nurses may only repeat what doctors wish to disclose.
Any information gathered by nurses during the course of caring for their patients should always be treated confidential.
This duty extends even after the patients' death. Confidential information may be revealed only when:
1. patients themselves permit such revelation as in the case 00 of claim for hospitalization, insurance benefits,
among others;
2. the case is medico-legal such as attempted suicide, gunshot wounds which have to be reported to the local police
or NBI or constabulary;
3. the patients are ill of communicable disease and public safety may be jeopardized; and
4. given to members of the health team if information is relevant to his care.
Confidential information may also be revealed as provided for by law in Article IV, Section 4(1) of the New Constitution,
which states that: "The privacy of communication and correspondence shall be inviolable except upon lawful order of the
court or when and order require otherwise."

PATIENTS' RESPONSIBILITIES
Just as the agency and the staff are expected to inform the patients of their rights, they are also expected to inform these
patients of their responsibilities which include the following:
1. Providing information. A patient has the responsibility to provide—to the best of his/her knowledge—accurate
and complete information about his/her complaints, past illnesses, hospitalization, medications, and other matters
relating to his/her health. Changes in status and level of understanding must also be communicated. If the patient
cannot provide said information, the family is responsible for doing so in his/her behalf.
2. Complying with instructions. A patient is responsible for complying with the treatment plan recommended by
the attending physician or health team that is primarily responsible for his/her health care. He/She is expected to
keep his/her appointments, abide by the hospital rules, and inform those concerned if he/she cannot keep them.
3. Informing the physician of refusal to treatment. A patient who refuses treatment or to be compliant with the
treatment regimen must inform the physician of his decision.
4. Paying hospital charges. If the patient is in the Pay Service, he/she is responsible for ensuring that financial
obligations of his/her health care are fullfilled as promptly as possible.
5. Following hospital rules and regulations. The patient is responsible for following the hospital's rules and
regulations and shall advise his/her family to do so, too.

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 6. Showing respect and consideration. The patient must be considerate of the rights of other patients and hospital
personnel and shall assist in the control of noise, smoking, and/or playing of loud music on radio. The patient must
respect the property of other persons and that of the hospital. Since the nurses are the closest caregivers, they are
the most logical guardians of the patient's rights. It shall also be part of their duties to inform the patients and their
relatives, upon admission, of the responsibilities expected of them.

Bill of Rights for Registered Nurses

Registered nurses promote and restore health, prevent illness, and protect the people entrusted to their care. They work
to alleviate the suffering experienced by individuals, families, groups, and communities. In so doing, nurses provide services
that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health
problems, without restriction in regard to social or economic status. To maximize the contributions nurses make to society, it
is necessary to protect the dignity and autonomy of nurses in the workplace. To that end, the following rights must be
afforded.
1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive
nursing care.
2. Nurses have the right to practice in environments that allow them to act in accordance with professional standards
and legally authorized scopes of practice.
3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the
Code of Ethics for Nurses and its interpretive statements.
4. Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience, and
professional responsibilities.
6. Nurses have the right to a work environment that is safe for themselves and their patients.
7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all
practice settings.

NURSES' RESPONSIBILITIES IN RESEARCH ON HUMAN SUBJECTS

The Helsinki Declaration of 1964 issued guidelines on medical research. In 1975 it differentiated two major types of
research: that which is essentially therapeutic and that which is directed toward developing scientific knowledge and has no
therapeutic value for the subjects. The declaration emphasizes that the research subjects must be informed when a clinical
or non-clinical study will be of no personal benefit to them to avoid any suspicion to the contrary.
The American Nurses Association's Human Rights Guidelines for Nurses in Clinical and Other Research specified
several important entities:
1. Employment in Settings Where Research is Conducted. Employees in work settings that carry potential risks
shall be informed about these, how to recognize these risks and how to take the proper precautions to counteract
harmful effects and unnecessary danger.
2. Vigilant Protection of Human Subject's Rights. Prior to participation in any activities that go beyond established
and accepted procedures, the prospective subjects must be informed. Special mechanisms shall be devised to
safeguard the confidentiality of information and protection of human dignity.
3. Scope of Application. These guidelines apply to all individuals involved in research activities, including patients,
organ donors, informants, normal volunteers, students and vulnerable populations, such as the mentally retarded
and prisoners.
4. Supporting Accrual of Knowledge. Nurses have an obligation to support the accrual of knowledge that
broadens scientific underpinnings of nursing practice and delivery of nursing services.
5. Informed Consent. Consent to participate in researches safeguards the basic rights to self-determination. There
shall be no direct nor indirect coercion. He should be given in detail the full benefits or possible harm that may
happen to him. If possible, the investigator shall secure the consent himself so that any questions or clarifications
can be made immediately.
6. Representation on Human Rights Committee. A Human Rights Committee is formulated to ensure that the
individual rights of patients are not denied. The nursing profession has an obligation to publicly support the
inclusion of nurses to these committees.

BASIC HUMAN RIGHTS OF RESEARCH SUBJECTS

Adequate protection of human subjects includes their legal as well as moral rights. They must be given the right to
informed consent, the right to refuse or withdraw from participation, privacy, confidentiality or anonymity of data and
protection from harm.
1. Right to Informed Consent. Recognition of self-determination and thorough comprehension of the proposed
participation are the two components of self-determination. Self-determination means free consent is pre-requisite
to any human involvement. The subjects must also understand the risks involved, the benefits anticipated, time

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 and energy requirements and any anticipated loss of dignity or autonomy; any anticipated pain or discomfort,
psychological stress or embarrassment; and the way the data will be handled and reported.
2. The Right to Refuse and/or Withdraw from Participation. The person has the right to refuse to participate.
There shall be neither recrimination for refusal nor for withdrawing from participation. Nurses shall explore the
subject's reason for refusing. Refusal to participate can be minimized, if at the onset the subject has been given
careful and honest opinion on what is to be done.
3. Right to Privacy. This right includes privacy of one's thoughts, opinions and physical presence and privacyof
one's records. The subject has the freedom to decide the time, the extent and circumstances he/she will
willingly share his/her presence, thoughts, beliefs, attitudes and behavior with others.
4. Right to Confidentiality or Anonymity of Data. Data about the research subjects shall be handled confidentially.
Data shall be available only to the research staff and shall be reported anonymously. Data shall not be used other
than for the specific purpose for which the subject gave consent and shall not be made public or available to
others. The identity of the agency shall be protected. This shall be done unless knowledge about the setting is
necessary in the interpretation of the data. After the report is written, all data by which individuals can be identified
shall be destroyed. They shall be burned or shredded and not dropped into the wastebasket as someone may find
and use them for other purposes.
5. Right to be Protected from Harm. There shall be appropriate balance between potential benefits of the research
and the risks assumed by the subjects. This is called the risk-benefit ratio in which the benefits outweigh the harm.
Minimal risk is defined as exposure to the possibility of injury going beyond everyday situations. These include
physical, legal, emotional, financial, and social harm.
Sometimes, the subject may experience undue anxiety if the instrument evokes disturbing feelings.
Debriefing is a process of disclosing to the subject all information that was previously withheld. Referral to counselling
shall be included in the study protocol if necessary.

VULNERABLE SUBJECTS
Subjects who are mentally ill or legally incompetent such as the unconscious, or are in unique situations, like fetuses,
require special attention. Those who are mentally ill, mentally retarded, unconscious and minors are incapable of evaluating
the risks involved and cannot be given consent in their own behalf. Consent of parents or guardians are required.
Investigative studies regarding fetuses shall have the consent in the presence of a third person because of the possible
danger or injury to it. The Philippine Constitution guarantees the protection of the life of the mother and the life of the unborn.
Students are vulnerable as their participation or non-participation may affect their grades. Employees may participate
because of the influence it may bring to their promotion, salary increases or bonuses. It must be explained to them that this
is not so.

INVESTIGATIVE STUDIES AND MEDICAL REGIMEN

When the medical regimen of a research subject will be affected, it is best that there be proper coordination with the
physician in charge. The investigative study shall not, in any way, be in conflict with the medical regimen. Drugs to be used
by the investigators must have a medical prescription.
An example of this was an experiment done in a government hospital where banana leaves were used to promote
healing of decubitus ulcers of bedridden patients. This study was coordinated with the physicians in the unit. Even though
the treatment method which consisted of cleaning, massaging the area around the wound, relief of pressure, and putting
banana leaves beneath the area with ulcer were all within the scope of nursing practice, the success of the study was further
enhanced since the doctors refrained from ordering topically-applied medications.

EXPERIMENTAL SUBJECT'S BILL OF RIGHTS

Below are the rights of every person who is asked to participate in a research study. An experimental subject has the
right to:
1. be told what that study is trying to find out;
2. be told what will happen to himself/herself and whether the procedure, drugs, or devices are different from what
are used in standard practice;
3. be told of the frequent or important risks, side effects or discomforts of the things that will happen to himself/ herself
for research purposes;
4. be told if he/she can expect any benefit from participating, and if so, what the benefits may be;
5. be told the other choices he/she has and how he/she may become better or worse than being in the study;
6. be allowed to ask y any question concerning the stud both before agreeing to be involved and durin course of the
study; g the
7. be told what sort of treatment is available if any complications arise;
8. refuse to participate at all or to change his/her mind about participation after the study is started. This decision will
not affect his/her right to receive the care he/she would receive if he/she were not in the study;
9. receive a copy of the signed and dated consent form; and

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 10. be free from pressure when considering whether he/she wishes to agree to be in the study.

SAMPLE FORM: Consent Letter

Name of Agency
Address
Consent to be a Research Subject

TO WHOM IT MAY CONCERN:

I have been informed by my doctor that I have not been responding well to the chemotherapy I have
received unlike other patients who have the same condition. He has advised cobalt therapy.
The amount of radiation I will be exposed to is relatively small. However, small doses may also cause
potential harm and these risks were already explained to me. I may have other examinations during the
treatment. I may call him at his clinic as stated below, if I have further questions about the treatment.
I have received a copy of this form and the Experimental Subject's Bill of Rights to keep. I have the right to
refuse to participate or to withdraw any time without any prejudice to my care in this agency.

Date:
Subject's Signature

Date:
Investigator's Signature

Clinic Address
Telephone Number

If the subject has other questions, he/she may ask the research, or his assistant, if he/she may contact the agency's
review board concerned with the protection of volunteers in research projects.
Participation in research is voluntary. One has the right to refuse to participate, and the right to withdraw without any
jeopardy to his/her care.

RESPONSIBILITIES OF THE NURSE TO THE PHYSICIAN

Section 28 (a) of R.A. 9173 states that:
It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to,
traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures,
comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral, topical and
parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of
suturing of perineal laceration, special training shall be provided according to protocol established.

It is therefore expected that nurses will not only carry out doctor's orders but help plan and implement patient care as
well. Patient's condition should be reported including results of therapies so that management of care can be properly
monitored and modified as necessary.
If any of the medical orders were not carried out for some reason (e.g., medications are unavailable, or a patient refuses
to accept them), such shall not only be brought to the attention of the physician but also noted properly in the patient's chart.
Explore patient's reason for refusal. Clarify misconceptions as needed.
Nurses shall familiarize themselves with the various routines, methods or idiosyncrasies of physicians, so that smooth
relationships can be maintained. In case the patient has a complaint against the physician, this shall be tactfully brought to
the latter's attention.
Any case of illegal, incompetent or unethical practice by any member of the health team shall be brought to the attention
of the appropriate authority through channels within the institutional or agency setting.
Nurses shall remember that any medical act relegated to them is illegal because it is specified in the Medical Law that
any licensed nurse who does this, even if supervised, can be held for illegal practice of medicine.

RESPONSIBILITIES OF NURSES TO THEIR COLLEAGUES

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Education (Department of Nursing) 8 of 13
 Nurses are expected to be able to get along smoothly with their colleagues. There may be instances where a nurse may
have a different opinion, or may not like certain people. This shall be the exception rather than the rule.A mature person
easily blends in any situation. Nurses shall adjust themselves to the organization and know its policies and procedures.
They shall establish good working relationships with co-workers. If one has a grievance he/she should bring it to the
attention of the proper authority rather than talk about it with others who may not be able to help. Most agencies have
grievance procedures to be followed.
It is important that nurses know their place in the total organization so that they may cooperate, coordinate and
maximize their work. Loyalty and consideration of others while at work will foster these relationships further.
Nurses who are cranky, too sensitive, who "backbite," who do not see any good in their colleagues, are the type of
nurses who will not be happy in their work.
Situations, such as when nurses see their colleagues neglect their duties or are incompetent shall be brought to the
attention of the immediate supervisor or appropriate authority within the agency setting before any life could be endangered.
Constructive criticism is always welcome but not fault-finding. Fault-finders, gossipers, and those who are fond of intrigues
will surely resent it too if they become the target of their own practices.

RESPONSIBILITIES OF NURSES TO THEMSELVES

Since nurses carry personal responsibility for nursing practice and for maintaining competence by continuous learning,
it is expected that every possible means shall be utilized by them to develop their skills. Their conduct must bring credit to
the profession. Just like any other professional, nurses are looked upon with respect in the community. They shall therefore
endeavor to live a life that will uphold their self respect.
Especially when nurses are on duty, they shall try to look neat and attractive. Female nurses are advised to use
moderate make-up and have a neat hair style. They shall wear uniforms that are neither too short nor tight-fitting that will
tend to restrict movement, nor expose unnecessarily any part of the body while giving care to the patients. Clean uniforms
and clean bodies tend to enhance the image of nurses. Use of anti-perspirant is advised most especially during hot summer
months. Male nurses are likewise advised to be clean-shaven, with hair clipped close to the nape instead of flowing to the
shoulders.
The use of the uniform shall be specified in the policy of the hospital/agency. It shall be worn only when on duty. Dining
in public, shopping or going to the market while in uniform is discouraged. Nurses' caps are worn only while on duty. These
are either carried in bags or are left in their places of assignment. Jewelry such as earrings, necklaces or bracelets are not
worn while on duty. However, wedding rings, school rings or school pins may be worn.
Nurses are looked upon by nursing students as their role models. Therefore, especially while they are on duty, they must
act in a manner that is worth emulating. Sincere and compassionate attitudes towards patients are caught by those around
them. Soon their working environment becomes permeated with a good working relationship that is so vital in dealing with
patients.

LIVING WILLS OR ADVANCE DIRECTIVES

There is a trend in the use of living Wills or advance directives. While this is not yet widely used in the Philippines, it is
used extensively in the United States. Hospitals are required to provide health-care proxy forms to patients being
admitted. These are called living wills and advance directives. The patient designates a health care representative,
usually a member of the family, a friend, or a family physician to make decisions for him/her when he/she is unable,
due to physical or mental incapacity, to make his/her own health care decision. This includes decisions to accept or
refuse any treatment, service or procedure used to diagnose or treat his/her physical or mental condition and decisions to
provide, withhold or withdraw life-sustaining measures.
Circumstances are stated in which various forms of medical treatment including life-sustaining measures shall be
provided, withheld or discontinued. The desire to make anatomical gifts after death are also indicated in the will, if
the patient desires to do so.
This living will is signed by the patient. It is witnessed by two other persons who declare that the patient signed
the will, that the latter appears to be of sound mind, free of duress or undue influence. The witnesses must be 18 years
of age or older, and are not designated as the person's health care representative or alternate as such. This living will is
attached to the patient's chart. This directive has a force of law.

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Education (Department of Nursing) 9 of 13
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed. You
are given 20 minutes for this activity:

Multiple Choice

1. Ethics came from this word which means moral duty:

a. Eros
b. Etos
c. Ethos
d. Ehos
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. What ethical approach focuses primarily on the heart of the person performing the act?
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. During the pandemic, nurses caring for Covid-19 patients despite the risks is an example based on what ethical
approach?
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. This approach is expressed in the maxim, “the right thing to do is the good thing to do”:
a. Teleological approach
b. Deontological approach
c. Virtue Ethics approach
d. Divine Command Ethics
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. In healthcare, this refers to the right to demand, to be treated justly, fairly and equally:
a. Autonomy
b. Veracity
c. Beneficence
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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Education (Department of Nursing) 10 of 13
6. This is stated as an admonition in the negative form to remind health practitioners to do no harm:
a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. This refers to acts of kindness and mercy that directly benefit the patient:
a. Beneficence
b. Nonmaleficence
c. Autonomy
d. Justice
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. When the patient and the healthcare providers are bound to tell the truth to maximize the efficiency of healthcare, this
principle is:
a. Autonomy
b. Veracity
c. Justice
d. Beneficence
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. This principle involves self-determination and freedom to choose and implement one's decision, free from deceit,
duress, constraint or coercion:
a. Autonomy
b. Veracity
c. Justice
d. Beneficence
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

10. The Senior Citizens Act is known as:

a. RA 7423
b. RA 3274
c. RA 7432
d. RA 4732
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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Education (Department of Nursing) 11 of 13
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

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Education (Department of Nursing) 12 of 13
LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

This closure activity is to evaluate AL Strategy:what you learned after the discussion and the activity.
Three things you learned:

1) _______________________________________________________________________________________________

2) _______________________________________________________________________________________________

3) _______________________________________________________________________________________________

Two things that you’d like to learn more about:

1) _______________________________________________________________________________________________

2) _______________________________________________________________________________________________

One question you still have:

1) _______________________________________________________________________________________________

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Education (Department of Nursing) 13 of 13