“ In some
embedded in the
of the nursing
The Management Challenge
there is great potential
for managers to
The systematic study of what a
person’s conduct and actions
ought to be with regard to him-
or herself, other human beings,
and the environment; it is the
justification of what is right or
good and the study of what a
person’s life and relationships
ought to be, not necessarily what
In general terms is
sciences that deal
with human acts.
A study of
morality’s effect on
conduct; the study
of moral standards
and how they
Is a practical and normative science, based
on reason, which studies human acts and
provides norms for their goodness or
The way managers
approach and solve
ethical dilemmas is
influenced by their
values and basic
beliefs about the
rights, duties, and
goals of all human
making a choice
between two or
The individual who
must solve an
ethical dilemma is
the only person
who can ascertain
if actions taken
Leah Curtin (1982) maintained that in order
for a problem to be an ethical dilemma, it
needed to have three characteristics:
1. The problem cannot be solved
using only empirical data.
2. The problem must be so
perplexing that it is difficult to
decide what facts and data
need to be used in making the
3. The results of the problem
should have far-reaching
Three Approaches to
Ethical Decision Making
1. Deontological— duty-
focused normative approach
centered on rules from which
all action is derived.
2. Teleological— outcome-
focused approach that places
emphasis on results and
protects the interest of the
3. Situational— no prescribed
rules, norms, or majority-
focused results that must be
Frameworks for Ethical
Principles of Ethical
6. Truth telling (veracity)
Self governance, ability to choose
and carry out one’s decision
without undue pressure or coercion
The actions one
takes should be
done in an effort
Refers to action that benefits
others based on the Hippocratic
Oath to “apply measures that
will benefit the sick”
Is the practice of doing acts of goodness,
kindness, and charity. The beneficence
principle may thus be stated: “DO NO
HARM AND PRODUCE THE GOOD” or
“DO GOOD AND DO NO HARM”
This principle imposes the duty to
avoid harming the patient based on
the Hippocratic Oath of “do no
Refers to prevention of harm and the
removal of harmful conditions.
right to make
From the Latin word pater “father” or
paternus “fatherly”- paternalism means the
act of being fatherly to someone, as if the
latter were one’s own offspring. Strictly
speaking, it consist in acting like a father to
a person for the latter's own good and
Treats “equals” equally.
Treats “unequals” according to
JUSTICE- it signifies fairness which also
to give to each one what he deserves.
In general, justice refers to what is
owed or due to the individual
members of society.
When considering the concept of
JUSTICE, it is important to distinguish
between four different types of justice:
– 1. COMMUTATIVE JUSTICE
– 2. CONTRIBUTIVE JUSTICE
– 3. LEGAL JUSTICE
– 4. DISTRIBUTIVE JUSTICE
1. COMMUTATIVE JUSTICE
Refers to that which is owed between
individuals, e.g. in conducting business
2. CONTRIBUTIVE JUSTICE
Refers to what individuals owe to society
for the common good
3. LEGAL JUSTICE
Refers to rights and responsibilities of
citizens to obey and respect the rights of all
and the laws devised to protect peace and
4. DISTRIBUTIVE JUSTICE
Refers to what society owes to its
– i.e. the just allocation of resources
SOME INFLUENCIAL THEORIES
THAT GO WITH THE PRINCIPLE OF
Emphasizes a mixture of criteria for the
purpose of maximizing public utility.
Emphasizes rights to social and economic
liberty, invoking fair procedures rather
than substantive outcome.
Stresses the principles and practices of
justice that evolve through traditions in a
Emphasizes equal access to goods in life
that every rational person values.
Refers to prevention of harm and the
removal of harmful conditions.
Is the practice of doing acts of goodness,
kindness, and charity. The beneficence
principle may thus be stated: “DO NO
HARM AND PRODUCE THE GOOD” or
“DO GOOD AND DO NO HARM”
By fidelity, we mean the obligation to act
in good faith and to keep vows and
promises, fulfill agreements, maintain
relationships and fiduciary responsibilities.
THE MODEL FOR FIDELITY:
Keeping one’s word of honor
Loyalty to commitments and oaths
Fiduciary responsibilities refers to the
contract of relationship we enter into with
Fiduciary relationship bank on trust and
confidence. This means that once the
physician or nurse enters into a relationship
with the patient, these professionals
become the trustees of the patient’s health
The good of
PRINCIPLE OF DOUBLE
An action that is good in itself that has two
effects- an intended and otherwise not reasonably
attainable good effect, and an unintended yet
foreseen evil effect– is licit, provided there is a
due proportion between the intended good and
the permitted evil.
To make appropriate
The manager must
use a professional
eliminates trial and
error and focuses on
making models or
The MORAL Decision Making Model
M—Massage the dilemma.
R—Review criteria and resolve.
A—Affirm position and act.
L—Look back. Evaluate the
Murphy and Murphy (1976) Approach
to Ethical Problem Solving
1. Identify the problem.
2. Identify why the problem is an ethical problem.
3. Identify the people involved in the ultimate decision.
4. Identify the role of the decision maker.
5. Consider the short- and long-term consequences of
6. Make the decision.
7. Compare the decision with the decision maker’s
philosophy of ethics.
8. Follow up on the results of the decision to establish a
baseline for future decision making.
Another error made by
managers in ethical
problem solving is
using the outcome of
the decision as the sole
basis for determining
the quality of the
Ethics in Action
In an era of markedly
human, and fiscal
resources, nearly all
decision making by
involves some ethical
“If a structured approach to
problem solving is used, data
gathering is adequate, and
multiple alternatives are
analyzed, even with a poor
outcome, the manager should
accept that the best possible
decision was made at that
time with the information and
The following forces ensure that ethics will
become an even greater dimension in
management decision making in the future:
increasing technology, regulatory pressures, and
competitiveness among healthcare providers;
national nursing shortages;
reduced fiscal resources;
spiraling costs of supplies and
and the public’s increasing distrust
of the healthcare delivery system and
Health care profession
Is defined as a profession in which a
person exercises skill and judgment or
provides a service related to:
– A. the preservation or improvement of the
health of an individual
– B. the treatment or care of individuals who are
sick, injured, harmed, disabled or infirmed.
Health care professionalism
Profession and professional come from the
Latin word “profession” which means a
public declaration with the force of a
Professionalism in health care requires that
one strives for excellence in the following
areas which becomes part of the attitudes,
behaviors and skills integral to patient care:
A health care professional is obligated to
attend to the best interest of patients rather
than self interest.
A health care professional is accountable to
their patients, to society on issues of public
health and to their profession.
Health care professionals are obligated to
make a commitment to life-long learning.
A health care professional should be
available and responsive, accepting a
commitment to service within the
profession and the community.
E. HONOR AND INTEGRITY
Health care professionals should be
committed to being fair, truthful and
straightforward in their interactions with
patients and the profession.
F. RESPECT FOR OTHERS
A health care professionals should
demonstrate respect for patients and their
families and to the other members of the
Stewardship requires us to appreciate the two great
gifts that a wise and loving God has given: the
earth, with all its natural resources and our own
human nature, with its biological, psychological,
social, and spiritual capacities. This principle is
grounded in the presupposition that God has
absolute Dominion over creation, and that, in so far
as human beings are made in God’s image and
likeness (Imago Dei), we have been given a limited
Dominion over creation and are responsible for its
The principle of stewardship includes but is not
reducible to concern for scarce resources, rather,
it also implies a responsibility to see that the
mission of Catholic health care is carried out as
ministry with its particular commitment to human
dignity and the common good.
Principles of integrity and
These principles dictates that the well-being of
the whole person must be taken into account in
deciding about any therapeutic intervention or
use of technology. Therapeutic procedures that
are likely to cause harm or undesirable side
effects can be justified only by a proportionate
benefit to the patient.
INTEGRITY refers to each individuals
duty to “preserve a view of the whole
human person in which the values of the
intellect, will, conscience and fraternity are
TOTALITY refers to the duty to preserve intact
the physical component of the integrated bodily
and spiritual nature of human life, whereby every
part of the human body “exists for the sake of the
whole as the imperfect for the sake of the
Moral and spiritual
responsibilities of nurses
Principles or rules
1. THE GOLDEN RULE
• God said “do unto others
what you would like others
do unto you.”
2. The two-fold effects
When a nurse is faced with a situation which
may have both good and bad effects, how
should she choose which one to follow? The
basis of action may be the following:
– That the action must be morally good
– That the good effect must be willed and the bad effect
– That the good effect must not come from evil action but
from the initial action itself directly; and
– That the good effect must be greater than the bad effect.
It is not morally good if a boy steals in order to
alleviate his hunger because the action itself is
already bad. On the other hand, if a patient who
has cancer of the uterus submits to hysterectomy
she will not be able to bear a child. If she does
not have the operation, she will die. It is the
gynecologist’s intention to help the mother and
no to harm the her. The surgeon’s action is
morally good since saving the mother’s life is of
primary importance. Also the doctor himself did
not will that the patient lose her child-bearing
3. The principle of totality
The whole is greater than any of its parts.
Suppose a man’s foot is gangrenous, should he
consent to an amputation? Since the amputation
will save the patient’s life and he can still walk
through the aid of crutches or artificial limbs, he
can consent to an operation.
“exception to the general rule”
It is a reasonable presumption that the authority
making the law will not wish to bind a person in
some particular case, even though the case is
covered by the letter of the law.
if a mental patient went berserk and the doctor
could not be contacted, the patient may be
restrained by the virtue of epikia. Another example
is allowing a relative to see a seriously ill patient
who expresses the desire to see the former although
it is not yet visiting hours.
5. One who acts through an agent is
For example, a patient wants to have an
abortion and asks a nurse if she can do it.
The nurse refuses, but then recommends a
doctor who is capable of performing an
abortion. The nurse becomes liable to such
crime, since he/she is an accomplice of the
6. No one is obliged to betray
In testifying before a court, no one can force any
person to answer a question if such will
7. The end does not justify the
Giving a sleeping tablet to a chronically ill
person so he/she can die in peace is morally
wrong. A physician in the US assisted a woman,
diagnosed as having Alzheimer’s disease, in
committing suicide. This is both legally and
8. Defects of nature may be
Patients with a cleft palate may have their
defects corrected by plastic surgery. What shall
be the role of the nurse in a case in which
parents of a severely deformed newborn child
(Down’s Syndrome with intestinal atresia)
refuse to feed and allow their child to starve to
Withholding nutrition can constitute nursing
neglect and expose the nurse to criminal charges
of negligence or conspiracy to commit suicide.
9. If one is wiling to cooperate in
the act, no injustice is done to
Suppose a patient subjects
himself/herself willingly to an
experimental drug and he/she has
been told of the possible effects of
the same, is of right age, and is sane,
there is no violation of human rights.
10. A little more or less does not
change the substance of an act
If a nurse gets a medicine from a hospital
stock without permission or without
prescription, he/she will be guilty of theft
even if he/she got only one tablet of the
11. No one is held to the
To promise that a patient with heart transplant
will live may be an impossibility. Yet, such
procedures are done in the hope of saving or
prolonging a patient’s life. The doctor or the
nurse cannot be held to the impossible if they
have done their best to take care of the patient
and the latter dies.
12. The morality of cooperation
Formal cooperation in an evil act is never
allowed. Immoral operations such as
abortion shall not be participated upon by a
nurse even if the doctor commands
13. Principle relating to the origin
and destruction of life
“thou shall not kill”
If God has given man a life, will it mean
that God has already ceded his right to
Assuming that God gave life to man, who
will know that God does abhor a man who
takes his own life?
Basic moral criteria
1. the object of the act must not be intrinsically
contradictory to one’s fundamental
commitment to God and neighbor, that is, it
must be a good action judged by its moral
object (in other words, the action must not be
2. the direct intention of the agent must be to
achieve the beneficial effects and to avoid the
foreseen harmful effects as far as possible, that
is, one must only indirectly intend the harm.
3. the foreseen beneficial effects must not
be achieved by the means of the foreseen
harmful effects, and no other means of
achieving those effects are available.
4. the foreseen beneficial effects must be
equal to or greater than the foreseen
harmful effects (the proportionate
5. The beneficial effects must follow
from the action at least as immediately
as do the harmful effects.
Principle of subsidiarity
Often considered a corollary of the principle of
the common good, subsidiarity requires those in
positions of authority to recognize that
individuals have a right to participate in decisions
that directly affect them, in accord with their
dignity and with their responsibility to the
Decisions should be made at the most
appropriate level in a society or
organization, that is, one should not
withdraw those decisions or choices that
rightly belong to the individuals or smaller
groups and assign them to a higher
The principle of beneficence
Principle of beneficence provides that good
must be done either to oneself or to others.
The principle of non-
Provides that evil or harm should not be
inflicted either on oneself or on others.
This fundamental moral principle binds and
urges everyone to avoid inflicting harm as a
It mandates the right not to be killed, right not
to have bodily injury, or pain inflicted (on)
oneself, and right not to have one’s
confidence revealed to others.
Some violations of the principle of
Physically harming a person as in suicide,
abortion, infanticide, mutilation, torture,
Exposing a person to physical harm as in
subjecting a person to unnecessary
treatment or to a dangerous procedure
without a commensurate important goal;
Harming a person’s reputation, honor,
property or interests as by revealing
The principle of double-effect
A good act may have several good effects
and is worthy of being performed thereby
increasing its goodness or even adding new
goodness. An evil act may also have
several evil effects and is unworthy of
The four conditions:
1. The act must be good in itself, or at least,
Being the primary moral determinant, the act
by it very nature must be good. Its goodness
proceeds from within itself. If it not possible
to be good, the act must not be evil in itself.
At least, it is morally indifferent.
2. The good effect must directly proceed from the act
itself and not from the evil effect. At the very least,
both effects must occur simultaneously.
it indicates the fact that the good effect is the
one that is being directly willed and not the evil
effect in the performance of an act. The good
effect is the very purpose for which the act is done,
and as such, it is produced not by the evil effect but
by the act itself. In fact, it comes ahead of the evil
3. There must be sufficient reason for the
performance of an act in its attainment of the
As determined by the nature of the act and its
circumstances, sufficiency of reason exists
when there is no other means by which the
desired good effect is as equally important as
to permit the occurrence of the evil effect.
4. The motive of the agent must be holy and
how can the agent be honest in his
By directly willing to obtain the good
effect and not the evil effect of the act.
This can be proven when the evil effect
just follows after the good effect is
When can the principle of double
effect not be invoked?
1. When the act by its nature is evil.
2. When the good effect directly proceeds
from the evil effect and not from the act
3. When there is no sufficient reason for the
performance of an act with two effects,
one-good, the other-evil.
4. When the motive of the agent is not
The principle of indirect voluntary
Aside from an act with two-effects-one,
good as directly intended and the other,
evil as unintended-there is also an act that
is directly intended with an evil effect that
is not directly intended though foreseen or
Sometimes, in the performance of human act which
is of course a willed act as freely determined by the
will, an evil effect sprouts which is not directly
willed. That is why, oftentimes, remarks like:
“sorry, I did not truly mean it,” or “sorry, it was not
really intended” are at once addressed by the one
who performs the act, with an evil effect which
does not directly intend, to the other who suffers
from the said effect. This is what INDIRECT
VOLUNTARINESS of an act is all about.
The three conditions:
1. The evil effect must be foreseen or
foreseeable in the performance of the act
at least in a general way.
Common sense gives anyone the capacity to
foresee that an evil effect, though indirectly
willed, may happen as it proceeds from a
human act that is to be performed.
2. There must be freedom to choose not to do
the act which is the cause of the evil act.
A free act is elicited by the will having the
power to choose to do or not to do it.
However, freedom cannot be exercised if
there is no light of knowledge in the
3. Refraining from doing the act which is the
cause of the evil effect holds the agent
Reason dictates that when the evil effect is
foreseen or foreseeable and that the agent
is free, he is morally obliged not to pursue
the performance of an act which serves as
the cause of the evil effect.
The principle of stewardship
STEWARDSHIP refers to the expression
of one’s responsibility to take care of,
nurture and cultivate what has been
entrusted to him.
In health care practice, STEWARDSHIP
refers to the execution of responsibility of
the health care practitioners to look after,
provide necessary health care services, and
promote the health and life of those
entrusted to their care.
The principle of justice
JUSTICE- simply means the rendering of
what is one’s due. A person who is justly
doing an act to another person gives the
latter what is his due.
Principle of justice refers to a moral
principle by which certain actions are
determined and deemed as just or unjust, as
due or undue.
RIGHT – is a moral power of performing,
of possessing, or of requiring something
which is due.
DUTY – is defined as a moral obligation
incumbent upon a person of doing or
omitting (avoiding) something.
Main duties and obligations of
health care practitioners:
1. Preservation of life and health
2. Protection of bodily integrity from harm.
3. Respect for human dignity.
Pertains to a fair scheme of distributing
society’s benefits and burdens to its
In health care milieu, benefits refers to
various health care services, while burdens
include the necessary payment for the
delivery of health care and participation in
medical experimental research.
1. THE UTILITARIAN ALTERNATIVES
These represents maximizing strategies to
achieve the greatest amount of good or
minimizing strategies to reduce the amount of
a. The medical success principle
Gives priority to those for whom treatment
has the highest probability of medical
success. If the condition of the patient
shows favorable prognosis and that he has
the utmost possibility of being cured, his
right to medical treatment prevails over the
b. The principle of immediate
Gives priority to the candidate who is of
greatest immediate service to the larger
group under the circumstances. In case of
typhoon-related health problems in the
community, the social worker or the
community leader has the greater right to
medical assistance than the community
c. The principle of conservation
Gives priority to those candidates who require
proportionally smaller amount of resources
and therefore more lives would be saved. If a
group of patients needs smaller quantity of
health benefits proportionate to each of them,
all members in that group are entitled to
medical interventions. Minimizing health care
resources is equivalent to maximizing the
number of health care recipients. Hence, more
patients are treated.
d. The parental role principle
Gives priority to those who have the
largest responsibility to dependents. The
father with dependent children would be
given priority over a bachelor with no
e. The principle of general social
Gives priority to those believed to have the
greatest general social worth thus leading
to the good of society. The municipal or
city mayor has a right to medical treatment
deemed greater than an ordinary citizen.
2. The egalitarian alternatives:
These represent maintaining or restoring
the equality of the person in need.
a. The principle of saving no
Gives priority to no one because not all can
be saved. If there are no enough resources
for all who need them, then no one should
b. The principle of medical
Gives priority to the candidates with the
most pressing medical needs. Patients who
are the most seriously ill are the one who
benefit from the limited health care
c. The principle of general
Gives priority to the most helpless or
generally neediest in an attempt to bring
them as nearly as possible to the level of
well-being equal to that enjoyed by others.
The poorest candidate would receive the
d. The principle of first come, first
Gives priority to those who arrive first.
This principle is practical. It may
apparently convey a message of giving one
what is his due as determined by the time
he arrives. It also helps establish order in
the distribution of health care goods.
e. The principle of random
Gives priority to those selected by chance
or random. The candidate chosen in a
lottery receives the resources.
Health care burdens
Burden may involve the necessary payment
for the health benefits patients receive, their
being subjected, from time to time, to medical
and experimental research, their donation of
organs, and risks involved in a recommended
treatment. It is in accordance with the
principle of justice to let patients know both
the due and undue burdens hat they are to
undergo as they accept and submit for health
DUE BURDEN- refers to a certain sense
of pain or discomfort necessarily
associated with one’s submission for health
Ex: buying medicines at the pharmacy as
prescribed, the pain brought about by
intravenous insertion and injections, and
UNDUE BURDEN- refers to a certain sense
of pain or discomfort brought about by a
certain medical, experimental or surgical
proceeding which is of no direct benefit to the
subject. It may be deemed unnecessary as far
as the subject is concerned.
Ex: donation of one’s organ, paying for
somebody else’s hospital bill, and others.
The principle of cooperation
Cooperation comes from the Latin word
cum which means “with” and operari
which means “to work”.
COOPERATION is working with another
in the performance of an action.
Various degrees of cooperation
The degrees of cooperation may vary
according to the gravity or essentiality of
the shared act in the performance of an evil
1. Formal and material
FORMAL COOPERATION- consists of an
explicit intention and willingness for the evil
act. The one formally cooperating
categorically wills and intends the evil action.
Ex: a medical director who wills and intends
the evil act of contraception by means of
hysterectomy at the request of an interested
party, by arranging with the members of the
O.R. team as to the operation and its schedule.
MATERIAL COOPERATION- consists of
an act other than the evil act itself but
facilitates and contributes to its
achievement. The one materially
cooperating may provide means apart from
the evil act itself which is used to carry out
the performance of an evil act.
2. Direct and indirect
DIRECT COOPERATION- consists of
direct participation in the performance of
an evil act. The one directly cooperating
gets involved by openly and
straightforwardly taking part in the practice
of an evil action.
INDIRECT COOPERATION- consists of
an act that is not intimately connected with
the performance of an evil act as in formal
and direct cooperation but whose effect
may have an indirect bearing upon it.
3. Proximate and remote
PROXIMATE COOPERATION- consists
of an act that is intimately linked with the
performance of an evil action due to its
REMOTE COOPERATION- consists of an
act with a distant bearing upon or
connection with the execution of an evil
Moral rules governing cooperation
a. No one should formally and directly
cooperate in the performance of an evil
b. If a reason sufficiently grave exists, material
cooperation in the performance of an evil
action may be morally excused.
c. If the material cooperation is proximate, a
reason sufficiently graver should exist so as
to be morally excused without which evil is
The principle of totality
The whole implies the existence of its
parts. The existence of its parts indicates
the existence of the whole.
Parts as such should continuously be
connected with the whole of which they
are parts without which they cease to be.
However, if its state of condition and
continuous existence as part pose a threat
to do more harm than good leading to the
destruction of the whole and that there is
no other means by which the problem can
be addressed, the principle of totality
provides that it be removed and sacrificed
for the sake of the whole.
Ex: a patient is admitted with a gangrenous
leg. The attending doctor reasons out,
based on scientific medical basis, that there
is no other way which the patient can be
saved but to amputate the gangrenous part
of the patient’s body.
It is morally permissible for the doctor to
do the amputation?
Principle of subsidiarity
The principle of subsidiarity is a kind of
sociological discipline adhered to and
advocated by the church. Its moral
implication is embedded in its meaning.
PRINCIPLE OF SUBSIDIARITY- means
that what an individual, lower or smaller
group can achieve within his/her or its
capacity should not be taken away and
transmitted to the custody and performance
of a higher or bigger group.
Ex: in an effort to control the apparent rapid
population growth in the country, the State
formulates program on responsible parenthood
which rebounds to the enactment of a law
mandating every family to just limit the
number of its offspring only to one or two
under pain of penalty. And so, the State
through the Department of Health conducts
contraceptive programs and distributes various
forms of contraceptive methods to ensure the
State-directed number of children every
family ought to raise.