MODULE 3 REVIEWER

Medical Infertility. The failure to become pregnant after twelve months of unprotected (no
contraceptive use) sexual intercourse.

Causes: Age and STD (e.g. Chlamydia)

Assisted Reproductive Technologies (ART). Involve extracting and combining eggs and sperm to create
embryos outside a woman’s body, which are then placed in her uterus or fallopian tubes, in an attempt
to achieve pregnancy.

Artificial Insemination (AI). Involves implanting male sperm (from the husband or from a donor) into
the woman’s vagina to aid in conception.

In vitro Fertilization (IVF). Literally means “fertilization in glass.” A fertilization that is artificially
performed outside the woman’s body—in a test tube.

Surrogate Motherhood. A woman agrees to have a child for another married heterosexual couple or for
a homosexual couple using the in vitro method. In cases in which the female is unable to produce ova so
the surrogate’s ovum or another donor’s ovum is used. The sperm may or may not be obtained from the
couple.

o Limitations on how many children a sperm donor may give rise to in order to prevent the risk of
accidental consanguinity or inbreeding between donor offspring.

o Prohibitions on the use of donor semen after the donor has died

o Payment to sperm donors

o Banned or restricted use of donor sperm for IVF treatment to married heterosexual couples,
single women or lesbian couples. As a consequence, women travels to a country which does not
impose restrictions in a practice called fertility tourism.

HISTORY OF AI

1455 ~ Unofficial history claims that the first attempts to artificially inseminate a woman, were done
by Henry IV (1425-1474), King of Castile, nicknamed the Impotent.

1678 ~ Spermatozoa were first seen and described by Antoni van Leeuwenhoek and his
assistant Johannes Hamin in the Netherlands. In a letter to William Bounker of the Royal Society of
London he showed a picture of sperm cells of the human and the dog. van Leeuwenhoek described the
spermatozoa as “living animalcules in human semen

1784 ~ More than 100 years later, the first artificial insemination in a dog was reported by the
scientist Lazzaro Spallanzani (Italian physiologist, 1729-1799). This insemination resulted in the birth of
three puppy’s

1770s ~ The first documented application of artificial insemination in human was done in London
by John Hunter, which has been called in medical history the “the founder of scientific surgery”.
1800s ~ J Marion Sims reported his findings of postcoital tests and 55 inseminations. Only one
pregnancy occurred but this could be explained by the fact that he believed that ovulation occurred
during menstruation

1897 ~ Heape, an outstanding reproductive biologist from Cambridge, reported the use of AI in rabbits,
dogs and horses

1899 ~ The first attempts to develop practical methods for artificial insemination were described by Ilya
Ivanovich Ivanoff (Russia, 1870-1932). Although Ivanoff studied artificial insemination in domestic farm
animals, dogs, rabbits and poultry, he was the first to develop methods as we know today in human
medicine.

Milovanov, another Russian scientist. He published his paper on “Artificial insemination in Russia” in
the Journal of Heredity in 1938

The introduction of the first AI cooperative in the US in 1938 by EJ Perry, a dairyman from New Jersey. In
the US and other Western countries the number of AI cooperatives increased rapidly. Nowadays more
than 90 % of dairy cows are artificially inseminated in the Netherlands, Denmark and the United
Kingdom.

November 1, 1939, the first animal, a rabbit, conceived by artificial insemination was exhibited in the
United States at the 12th Annual Graduate Fortnight at the New York Academy of Medicine. Gregory
Pincus, an American biologist, removed an egg from the ovary of a female rabbit and fertilized it with a
salt solution. The egg was then transferred to the uterus of a second rabbit,

Phillips and Lardy (1939) were the first to use egg yolk to protect bull sperm cells from temperature
shock upon cooling. This protection was explained by the effect of phospholipids and lipoproteins in the
egg yolk

Polge and co-workers (1949) were the first to freeze fowl and bull spermatozoa by using glycerol in the
extender media. In 1950 Cornell University scientists (New York)

In 1953 Dr. Jerome K. Sherman, an American pioneer in sperm freezing, introduced a simple method of
preserving human sperm using glycerol.

the first successful human pregnancy with frozen spermatozoa was reported in 1953

o ARTIFICIAL INSEMINATION - Involves implanting male sperm (from the husband or from a
donor) into the woman’s vagina to aid in conception.

REASONS FOR AI

A. Male:

1. Azoospermia (male semen contains no sperm) or Oligospermia/Oligozoospermia (low sperm

count)

2. Asthenozoospermia (poor sperm motility)

3. Neurological condition that makes ejaculation impossible or from a disease (e.g. diabetes) that
renders the man impotent
 B. Female:

1. The vaginal environment is biochemically inhospitable to sperm.

2. The female has a small cervix or if her uterus is in an abnormal position.

3. The couple may be carriers of a recessive gene for a genetic disorder (e.g. Tay-Sachs disease),
or the male may be the carrier of a dominant gene for a genetic disorder (e.g. Huntington’s
disease).

RECIPIENT OF AI

1. Traditionally, a married woman in consultation with her husband to have a child.

2. Single women

3. Lesbian couples

IN- VITRO FERTILIZATION - A method of assisted reproduction in which a man's sperm and a woman's
eggs are combined outside of the body in a laboratory dish.

The main reason for the renewed interest in AI in human was undoubtedly the introduction of IVF in
1978 by Steptoe and Edwards.

In the early days the ejaculate of the husband was inseminated intrauterine without preparation
resulting in uterine cramps and increasing the probability of tubal infections.

With the arrival of IVF, semen preparation techniques were developed and IUI regained its popularity,
being more safe and painless.

Louise Joy Brown (25 July 1978) & Family

An English woman known for being the first human
to have been born after conception by in-vitro fertilization, or IVF.

INDICATION OF IVF FOR INFERTILE COUPLE

IVF was initially used to treat women with blocked, damaged, or absent fallopian tubes.

Today, IVF is used to treat many causes of infertility,

such as endometriosis and male factor,

when a couple's infertility is unexplained or

in women with advanced maternal age where her chances for pregnancy are rapidly declining and IVF
remains as the best possible option
DURATION

The average time that is required to complete one IVF cycle (from start of ovarian stimulation to testing
for pregnancy) is about four to six weeks, depending on the chosen ovarian stimulation protocol
appropriate for your case.

Intracytoplasmic Sperm Injection (ICSI)? ICSI - the step in the IVF process which aims to
achieve fertilization for the collected eggs.

- a single sperm is directly injected into each mature egg. It is usually performed when there is a
likelihood of reduced fertilization, i.e., poor semen quality, history of failed fertilization in a prior IVF
cycle, etc.

SUCCESS OF IVF

1.women’s age,

2.presence of co-morbidities (endometriosis, previous ovarian surgery),

3.and quality of husband’s sperm).

-success rates vary from center to center and between practicing clinicians.

SURROGACY MOTHERHOOD

HISTORY

Biblical Times.

The first mention of surrogacy can be found in “The Book of Genesis” in the story of Sarah and

Abraham. Hegar was the surrogate mother. This is a case of traditional surrogacy, where the surrogate
uses her own egg in the child she’s carrying for intended parents.

1884. The first successful AI of a woman was completed, although in an ethically questionable way. This
paved the way for future AIs used in the surrogacy process.

1975. The first ethically completed IVF embryo transfer was successful.

1976. The first legal surrogacy agreement in the history of surrogacy was brokered by lawyer Noel
Keane.

This was a traditional surrogacy, and the surrogate did not receive any compensation for the pregnancy

1984–1986. Perhaps the most famous case in surrogacy history is the “Baby M.” case, involving a
traditional surrogacy. Bill and Betsy Stern hired Mary Beth Whitehead to be their surrogate in 1984,
agreeing to pay her $10,000. Whitehead’s eggs were used in the AI process, making her the biological

mother of the child. Custody was granted to Bill Stern, with Whitehead receiving visitation rights.
Reasons for taking surrogacy
o Either male or female or both are found to be infertile;

o sperm count is less,

o female uterus is weak,

o or congenital abnormality such as small uterus or bicornate uterus because of which the female
cannot bear the child normally.

Ethical Principles involved in Surrogate Mother and Fetus

1. The surrogate mother has the right to own the child since she gives life to the fetus.
- She may decide to withdraw the agreement anytime and to own the pregnancy and
fetus for herself.
- She should not be forced emotionally or tortured physically to handover the baby to the
couple.
2. A surrogate mother has the right to get bonded with her child since she has given birth to the
child.
-Their relationship starts at the time of conception and gradually increases during the antenatal
period.
-A surrogate mother should handover the child wholeheartedly to the concerned couple as per
the agreement, and separating the child from her against her wish is against the law.
Ethical Principles involved in Surrogate Mother and Fetus
1. The surrogate mother has the right to own the child since she gives life to the fetus.
2. . A surrogate mother has the right to get bonded with her child since she has given birth
to the child
3. Every newborn child has the right to be with the mother and get breastfed.
4. If it is revealed to the child in the future that he/she was born to a surrogate mother, it
might result in an emotional disturbance throughout the child’s life, which might affect
his/her growth and development.

Nurse’s Role in Handling Surrogate Mother

1. A nurse should neither support nor go against the surrogate mother.
- He/she should ensure that there is no confusion once the informed consent is signed
and legal agreement is made between the two parties.
- However, if the nurse is still in a dilemma regarding whether to support or go against
for it, he/she should do the following:
a. Get the informed consent signed from both surrogate mother and the couple.
b. Ensure that the surrogate mother has agreed by self and not by force and support the
mother at any cost. Check for any conflict between two parties
c. Never reveal the details regarding the surrogate mother or the couple to any third
party.
d. Never neglect or degrade the surrogate mother or gossip about her or the couple.
2. It is the duty of a nurse as a care provider to respect the right of the concerned parties to
get information, orientation, privacy, and take decision.
3. The nurse should be supportive and give psychological care and act as a guide,
counsellor, advocate, and change agent.

Ethical Issues in ART

1. the nature of parenthood and families (emergence of nontraditional families);
2. the commodification of children, women’s bodies, and gametes;
3. the health and safety of the participating individuals including harm to future children;
4. the rights of individuals to use and access the technologies;
 5. commercialization (exploitation, potentiality, pay for a service, reward, risk for
distinctions in genetic pedigree)
6. alternative sources (eggs and ovaries from aborted female fetuses; donation of eggs
and ovaries after a woman’s death)
7. donor anonymity (the right of autonomy and privacy of the parents; the right of privacy
of the donor; the right of the child to know his/her origins)
8. Pre-implantation Genetic Diagnosis (PGD)
9. screening of cells from preimplantation embryos for the detection of genetic and or
chromosomal disorders before embryo transfer
10. Status of the embryo (discrimination; “designer” babies; sex selection; destruction of
unwanted embryos)

Emergence of Nontraditional Families due to ART

1. Single women can choose a sperm donor from profiles listed on sperm bank websites.
2. Gay and lesbian couples can use ART to conceive children who are genetically related to
or at least one of the individuals in the couple.
3. Women who are past the age of menopause may be able to use ART to successfully
conceive a biologically related child.

4. Children can even be conceived after their father’s death, by using stored frozen sperm
or sperm retrieved immediately postmortem.

Catholic Church Teaching on ART

In view of the genetic experiments that have been performed in recent years, test-tube
fertilization must be declared ethically unlawful because:
o it implies a high risk of abortion;

o the practice of freezing and storing an embryo as if it were an object, interrupting the
natural development of life, violates the dignity that is enjoyed by a human being from
the very moment of conception;
o in all cases, it dissociates the two aspects of the human act, union and procreation, since
procreation is sought separately from the conjugal relation.
 - Heterologous artificial fertilization is contrary to the unity of marriage, to the dignity
of the spouses, to the vocation proper to parents, and to the child's right to be conceived
and brought into the world in marriage and from marriage.
- Fertilization of a married woman with the sperm of a donor different from her husband
and fertilization with the husband's sperm of an ovum not coming from his wife are
morally illicit.
- Artificial fertilization of a woman who is unmarried or a widow, whoever the donor may
be, cannot be morally justified
- The Church remain opposed from the moral point of view to homologous 'in vitro'
fertilization. Such fertilization is in itself illicit and in opposition to the dignity of
procreation and of the conjugal union, even when everything is done to avoid the death
of the human embryo.
- SURROGATE MOTHERHOOD is not morally LECIT because it is contrary to the unity
of marriage and to the dignity of the procreation of the human person.
- Surrogate motherhood represents an objective failure to meet the obligations of maternal
love, of conjugal fidelity and of responsible motherhood

Morality of
Abortion, Rape, and other problems related to the Destruction of Life
ABORTION - The deliberate removal (or deliberate action to cause the expulsion) of a fetus from the
womb of a human female, at the request of or through the agency of the mother, so as in fact to result
in the death of the fetus.

It can occur spontaneously (usually termed miscarriages) due to complications during pregnancy or can
be induced

Constitution of the Republic of the Philippines (1987), Article II, Section 12 The Revised Penal
Code of the Philippines,
Act No. 3815 of December 8, 1930, Articles 256-259
Art. 256. Intentional abortion. – Any person who shall intentionally cause an abortion shall
suffer:
1. The penalty of reclusion temporal, if he shall use any violence upon the person of the
pregnant woman.
2. The penalty of prision mayor if, without using violence, he shall act without the consent
of the woman.
3. The penalty of prision correccional in its medium and maximum periods, if the woman
shall have consented.
Art. 257. Unintentional abortion. – The penalty of prision correccional in its minimum and medium
period shall be imposed upon any person who shall cause an abortion by violence, but
unintentionally.

Art. 258. Abortion practiced by the woman herself of by her parents. – The penalty of prision
correccional in its medium and maximum periods shall be imposed upon a woman who shall
practice abortion upon herself or shall consent that any other person should do so.

Any woman who shall commit this offense to conceal her dishonor, shall suffer the penalty of
prision correccional in its minimum and medium periods.

If this crime be committed by the parents of the pregnant woman or either of them, and they act
with the consent of said woman for the purpose of concealing her dishonor, the offenders shall
suffer the penalty of prision correccional in its medium and maximum periods.

Art. 259. Abortion practiced by a physician or midwife and dispensing of abortives. – The penalties
provided in Article 256 shall be imposed in its maximum period, respectively, upon any physician or
midwife who, taking advantage of their scientific knowledge or skill, shall cause an abortion or assist
in causing the same.

Any pharmacist who, without the proper prescription from a physician, shall dispense any abortive
shall suffer arresto mayor and a fine not exceeding 1,000 pesos.

TYPES OF ABORTION

1. Miscarriage, or spontaneous abortion, is due to causes that are beyond human control. It has
no moral qualification.

2. Induced abortion is due to voluntary and effective human intervention.

- The right to life does not come from the parents, society, nor any human authority; it
comes directly from
God. Therefore, nobody may dispose of another’s life, neither as an end nor as a means.
induced abortion is thus intrinsically evil, and must be qualified as homicide.

All the participants, including the mother, automatically incur

excommunication.
The Magisterium of the Church has consistently condemned
abortion throughout history, even when the exact moment of the
fetus’s animation was being disputed (Cf. CIC, can. 1398).
An entirely different thing is indirect abortion, or indirectly provoked abortion. This is
an unwanted and unavoidable consequence of a good action. It is foreseen, but not wanted—
just tolerated. The good action must be necessary for reasons that are serious enough to
balance the evil effect of abortion. The latter, we must insist, is never wanted and would be
avoided if it were possible. Indirect abortion is another case of double effect, or indirectly
voluntary, actions. It is lawful when all the conditions required in these cases are fulfilled.

Ethical Dilemmas AGAINST Abortion

1. Killing an innocent life is wrong. As human life begins at conception, the fetus is a living
being, which is very innocent. Therefore, doing abortion is wrong and is a merciless act.
2. Fetus is a person. People consider the fetus as a unique genetic code and a unique
individual, and therefore, it should not be destroyed.
3. If not killed, the fetus would also grow into a human being and have a future similar to
others, therefore, it is wrong to kill the fetus and destroy its future.
4. It is wrong to cause pain and discomfort to the fetus. Since the fetus can feel pain by 18
weeks, carrying out abortion after 18 weeks of pregnancy will cause pain to the fetus.
5. Legalized killing of fetus is wrong as legal killing reduces or decreases the respect for
life. It is bad for the society and contributes to mercy killing called euthanasia and
genocide, and increases the mortality rate of children. Therefore, abortion is always
considered to be wrong.

Ethical Delimitation FAVOUR of Abortion

Though there are arguments against abortion, there are certain cases where
abortion is done with scientific rationale.
1. A pregnant woman has the right to survive. In certain cases, if abortion is not done,
the fetus will harm the life of the mother.
2. Fetus is only a potential human being and hence does not have the rights similar to
human beings.
3. Fetus is not necessarily considered as a ‘person’ with the right to live. If the growth
of the fetus is harmful to the mother, the doctor will advice abortion. A fetus never attains
the stage of development that makes a person a moral human being and hence can be
aborted.
4. It is not always wrong to end the life of an innocent person. In the case of conjoint
twins, that is, thoracopagus, where two fetuses are joined together, effort is made to
separate the twins.
5. There are cases where abortion is done since there is a serious medical problem to
mother or the fetus: eclampsia, uncontrolled convulsion, untreatable hyperemesis,
 multiple pregnancies, defective fetus that will die if pregnancy is continued, defective
fetus such that the baby will not be able to survive after birth.
6. Abortion is done because the child will not be normal and healthy to be able to
survive (e.g. down syndrome or mental retardation).
7. There are cases where abortion is done since the pregnancy was totally
unintentional (e.g. rape, failure of contraception, unsuccessful vasectomy, mentally
incapable woman).
8. Abortion is also done in cases where the pregnancy was unintentional, but the risk
was taken by the parent (e.g. usage of failed contraceptives even after knowing all the
advantages and disadvantages of the contraceptive before using it; careless use of
contraceptive; not using contraception).
9. Abortion is done because the pregnancy affects the lifestyle of the mother (e.g.
coping up with a disabled child is difficult for the a pregnant mother; difficulty in
bringing up the child because of poverty).

DUTIES TOWARD ABORTED FETUS

Health care workers have particular obligations toward aborted fetuses. An aborted fetus, if still alive,
must be baptized (“Emergency Baptism”).
An aborted fetus that is already dead deserves the respect owed to a human corpse, and if possible it
should be given a suitable burial.

TYPES OF BAPTISM

Proximate Matter: the application of water to the body of the candidate by way of a triple immersion in
water,or by a triple effusion of it.

Remote Matter: true and natural water. In case of necessity,what is still commonly called and
considered water may be used,even if it is mixed with other substances.

Form:“(Name),I baptize you in the name of the Father and of the Son and of the Holy Spirit.”

RAPE
An unlawful sexual activity and usually sexual intercourse carried out forcibly or under threat of
injury against a person's will or with a person who is beneath a certain age or incapable of valid
consent because of mental illness, mental deficiency, intoxication, unconsciousness, or
deception.
TYPES OF RAPE
1. Date Rape. A non-domestic rape committed by someone who knows the
victim, and drug facilitated sexual assault (DFSA), where the rapist intentionally drugs
the victim with a date rape drug so that they are incapacitated.
2. Gang Rape. Occurs when a group of people participate in the rape of a single victim.
 3. Spousal Rape. also known as marital rape, wife rape, husband rape, partner rape
or intimate partner sexual assault (IPSA), is rape between a married or de facto couple
without one spouse's consent. Spousal rape is considered a form of domestic
violence and sexual abuse.
4. Rape of Children. Rape of a child is a form of child sexual abuse.
When committed by another child (usually older or stronger) or adolescent, it is called child-
on-child sexual abuse.
- Committed by parents, close relative- called INCEST
- Not by family members but by caregiver, teacher, religious authorities, on whom a child
is dependent is called INCESTUAL RAPE.

5. Statutory Rape. Sexual activity that violates age-of-consent law, but is neither violent
nor physically coerced. MINOR child 12 years and below.
6. Prison Rape.
7. War Rapes. Are rapes committed by soldiers, other combatants or civilians during armed
conflict or war
8. Serial Rape. Is rape committed by a person over a relatively long period of time and
committed on a number of victims
9. Rape by Deception. Occurs when the perpetrator gains the victim's agreement
through fraud. In one case, a man pretended to be an official for a government who had
power to cause negative impacts on a woman to pressure a woman into sexual activities.
10. Corrective Rape. Is targeted rape against non-heterosexuals as a punishment for
violating gender roles. It is a form of hate crime against LGBT individuals, mainly
lesbians, in which the rapist justifies the act as an acceptable response to the victim's
perceived sexual or gender orientation and a form of punishment for being gay.
11. Custodial Rape. Is rape perpetrated by a person employed by the state in a supervisory
or custodial position, such as a police officer, public servant or jail or hospital employee

Child Sexual Abuse does not need to include physical contact

between a perpetrator and a child.
Forms of child sexual abuse:
1. Obscene phone calls, text messages, or digital interaction
2. Fondling- To grab and touch and feel oneself or others in a sexual manner
3. Exhibitionism, or exposing oneself to a minor
4. Masturbation in the presence of a minor or forcing the minor to masturbate;
5. Intercourse; Sex of any kind with a minor, including vaginal, oral, or anal;
6.Producing, owning, or sharing pornographic images or movies of children
7.Sex trafficking -human trafficking for the purpose of sexual exploitation, including sexual slavery

8.Any other sexual conduct that is harmful to a child's mental, emotional, or physical welfare

WHAT THE NURSE DO IF A RAPED PATIENT COMES TO YOU

FOUR ASPECT OF CARE

(Ethical and Religious Directives for Catholic Health Care Services )

1. She must receive spiritual and psychological support and counseling to help her deal with the
trauma of the attack.

2. Health care providers need to cooperate with law enforcement officials, gathering evidence that
can be used in the prosecution of the rapist.

3. The victim needs treatment for bruises, cuts, or other injuries.

4. Contraction of venereal disease and pregnancy.

DEATH DIGNITY AND DYING

 John Keown - distinguishes three different approaches to the value of human beings:
1. Quality of Life view - some human lives are not worth living.
2. The Inviolability of Life view - that intentional killing is not ethical and should not
be legally permissible, yet that it is often acceptable to withdraw life support.
3. The Vitalistic view, every effort must be made to extend the duration of human
life. In this view, the cancer patient must employ all possible medical options in
order to remain alive, even if such options are psychologically repugnant,
physically painful, or experimentally untried.

EUTHANASIA
• ITS TYPES, CATEGORIES & OTHER CLASSIFICATION
 Commission (Active); Omission (Passive)
 Voluntary, Non-voluntary & Involuntary
 Suicidal, Homicidal, Ortothanasia, Dysthanasia
  From the Greek word “Eu” (good) and “Thanatos” (death), signifies good death,
a pleasant, gentle death, without awful suffering.
 The act of practice of permitting the death of hopelessly sick or injured
individuals in relatively painless way for reasons of mercy. It is commonly called
merciful killing to relieve suffering.
 (Sacred Congregation for the Doctrine of the Faith) is understood an action of
omission which, of itself or by intention causes death, or in order that all
suffering may in this way be eliminated.
 TYPES OF EUTHANASIA:
 Euthanasia by Commission (Active Euthanasia) – refers to the positive act of
causing death that is geared towards termination of pain & suffering. By positive
act is meant a measure necessary to end the life of a suffering person in directly
use. E.g. a lethal dose is injected into the terminally ill patient to cause
immediate death.
 Euthanasia by Omission (Passive Euthanasia) – the negative act of causing death
that is geared towards termination of pain & suffering. By negative act is meant a
measure necessary to sustain the life of a suffering person is omitted, withheld
or withdrawn. E.g. food & water are withdrawn to bring about the earlier death
of a terminally ill patient.
• TYPES OF EUTHANASIA
 Voluntary Euthanasia – indicates the measure of causing the death of the patient
at his willful consent or request. It could be expressed, written in the patient’s
advance directive as in a living will or durable power of attorney or given by
mere gesture in case of inability to speak & manage oneself. This is currently
legal in Belgium, Luxembourg, The Netherlands, Switzerland, and the states of
Oregon and Washington in the U.S.
 Non-voluntary Euthanasia – indicates the measure of causing death of the
patient who is unable to express his will & make his intentions known as in
unconscious or comatose state. The decision to end the patient’s life is made
either by the watchers of the patient, health care team or the society.
 Involuntary Euthanasia – indicates the measure of causing the death of the
patient in defiance of his expressed will and/or against his consent.
OTHER CLASSIFICATION OF EUTHANASIA
• Suicidal Euthanasia – subject himself (alone or with help of other people) resorts to
lethal means to interrupt or suppress his life. Done with the subject’s consent.
• Homicidal Euthanasia – Euthanasia for piety or pious homicide, performed to liberate a
person from a terrible disease. It prescribes “death without suffering” for hopeless
patients, saving them from further “useless”, “unnecessary” suffering.
• Ortothanasia – etymologically, means passive death. Subject is left to die by omitting
any medical assistance. Some authors defines it as “just death” or death in its due time,
which is considered ethical. The mere allowing & acceptance of natural death in its
definitely inescapable occurrence in due time as the final moment of one’s earthly life. A
normal or natural manner of death and dying. Sometimes used to denote the deliberate
stopping of artificial or heroic means of maintaining life.
• Dysthanasia – the undue prolongation of life & delay of the occurrence of natural death
which in effect lengthens the suffering of the person. It is a term generally used when a
person is seen to be kept alive artificially in a condition where, otherwise, they cannot
survive; sometimes for some sort of ulterior (intentionally hidden/future) motive.

• Below are the major arguments invoked by pro-euthanasia

activists in the pursuit of their cause:
 An act of mercy
 Prolonging the suffering of a dying patient is an act of cruelty
 A dignified death
 It serves the best interest of the patient, the relatives & the health care
professional
 It is in accordance with the Golden Rule
• IS EUTHANASIA MORAL
• The question as to the moral inadmissibility of euthanasia is still relevantly in place. It is
evil on the following basis:
 Violation of the natural moral law & the Decalogue.
 Contrary to the ultimate Author of Life.
 SUICIDE
• Intentional self-inflicted death.
• People usually suffer from extreme emotional pain & distress & feels
unable to cope with their problems.
• They are likely to suffer from mental illness particularly, severe
depression & feels hopelessness about the future.
 ADMINISTRATION OF DRUGS TO THE DYING

• In medicine, specifically in end-of-life care, palliative sedation is the practice of relieving

distress in a terminally ill person in the last hours or days of a dying patient's life, usually
by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or
by means of a specialized catheter designed to provide comfortable and discreet
administration of ongoing medications via the rectal route.
• Palliative sedation is an option of last resort for patients whose symptoms cannot be
controlled by any other means.
• It is not a form of euthanasia, as the goal of palliative sedation is to control symptoms,
rather than to shorten the patient's life.

ADVANCE DIRECTIVES
• Are legal documents that allow you to spell out your decisions about end- of-life care
ahead of time. They give you a way to tell your wishes to family, friends, and health care
professionals and to avoid confusion later on.
• Forms of Advance Directives:
1) The living will is a legal document used to state certain future health care
decisions only when a person becomes unable to make the decisions and choices
on their own.
2) Durable power of attorney for health care/Medical power of attorney is a legal
document in which you name a person to be a proxy (agent) to make all your
health care decisions if you become unable to do so.
DNR OR END OF LIFE CARE
• Do Not Resuscitate (DNR), also known as no code or allow natural death, is a legal
order, written or oral depending on country, indicating that a person does not want to
receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating.
Sometimes it also prevents other medical interventions. The legal status and processes
surrounding DNR orders vary from country to country. Most commonly, the order is
placed by a physician based on a combination of medical judgement and patient wishes
and values.
• Palliative Care & Hospice Care
 • End of life care includes palliative care. If you have an illness that can't be cured, based
on the understanding that death is inevitable. palliative care makes you as comfortable
as possible, by managing your pain and other distressing symptoms. It also involves
psychological, social and spiritual support for you and your family or careers.
• WHEN DOES END OF LIFE CARE BEGIN? Have an advanced incurable illness, such as
cancer, dementia or motor neuron disease are generally frail and have co-existing
conditions that mean they are expected to die within 12 months •have existing
conditions if they are at risk of dying from a sudden crisis in their condition •have a life-
threatening acute condition caused by a sudden catastrophic event, such as an accident
or stroke.
ACUTE CARE PLANNING

 A key component of holistic care is making assessment that include planning for the
future.

 It anticipates deterioration and explores what the patient & family want to do when the
time comes.

 The process involves & allows open discussion between the patient, family members &
the multidisciplinary team.
NURSES ROLE AND REPONSIBILITIES IN END OF LIFE CARE
1) Treat people compassionately.
2) Listen to people
3) Communicate clearly and sensitively .
4) Identify and meet the communication needs of each individual.
5) Acknowledge pain and distress and take action.
6) Recognize when someone may be entering the last few days and hours of life.
7) Involve people in decisions about their care and respect their wishes.
8) Keep the person who is reaching the end of their life and those important to them up to
date with any changes in condition.
9) Document a summary of conversations and decisions.
10) Seek further advice if needed.
11) Look after yourself and your colleagues and seek support if you need it.
12) Learning from complaints.
 13) Care of the person.
CRUCIAL ROLE OF A NURSE IN PALLIATIVE CARE
1) Teacher / Health Educator
2) Counselor
3) Caregiver
4) Advocate
5) Messenger - help patients in establishing advance care planning decisions by asking,
listening & guiding.
ETHICAL DECISION MAKING
 Choosing among alternatives in a manner consistent with ethical principles. In making
ethical decisions, it is necessary to perceive and eliminate unethical options and select
the best ethical alternative.
 The process of making ethical decisions requires:
1) Commitment: The desire to do the right thing regardless of the cost
2) Consciousness: The awareness to act consistently and apply moral convictions to
daily behavior
3) Competency: The ability to collect and evaluate information, develop
alternatives, and foresee potential consequences and risks
 Good decisions are both ethical and effective:
1) Ethical decisions generate and sustain trust; demonstrate respect, responsibility,
fairness and caring; and are consistent with good citizenship. These behaviors
provide a foundation for making better decisions by setting the ground rules for
our behavior.
2) Effective decisions are effective if they accomplish what we want accomplished
and if they advance our purposes. A choice that produces unintended and
undesirable results is ineffective. The key to making effective decisions is to think
about choices in terms of their ability to accomplish our most important goals.
This means we have to understand the difference between immediate and short-
term goals and longer-range goals.
Making Ethical Decisions: Model

 ETHICAL DECISION MAKING PROCESS

 The "Character-Based Decision-Making Model" model, developed by the Josephson

Institute of Ethics, can be applied to many common problems and can also be used by
most individuals facing ethical dilemmas. three steps:
1) All decisions must take into account and reflect a concern for the interests and
well being of all affected individuals ("stakeholders").The underlying principle
here is the Golden Rule — help when you can, avoid harm when you can.
2) Ethical values and principles always take precedence over nonethical ones.- are
morally superior to nonethical ones. When faced with a clear choice between
such values, the ethical person should always choose to follow ethical principles.
3) It is ethically proper to violate an ethical principle only when it is clearly
necessary to advance another true ethical principle, which, according to the
decision-maker's conscience, will produce the greatest balance of good in the
long run. Some decisions will require you to prioritize and to choose between
competing ethical values and principles when it is clearly necessary to do so
because the only viable options require the sacrifice of one ethical value over
another ethical value. When this is the case, the decision-maker should act in a
way that will create the greatest amount of good and the least amount of harm
to the greatest number of people.