Students and many educators have difficulty in differentiating among Legal, Ethical and Moral viewpoints. After explaining these terms, the concept of biomedical ethics, a brief history of its origin in the post-War period and the components of ethics are explained. The final part is on Nursing ethics, attributes of an ethical nurse and ethical challenges faced by the nursing profession.

1. Concepts and Principles of
Bioethics for the Students of
Health Professions
Prof. KR Sethuraman. MD, PGDHE.
VC – Sri Balaji Vidyapeeth (deemed varsity) &
Professor of Medicine, MGMCRI,
Puducherry 607402

2. NURSING Practice

3. Legal – Ethical - Moral Overlap?
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MORAL

4. Legal – Ethical – Moral
• Legal: What the Society
accepts as Good or Bad
• Moral: What an Individual decides
for oneself based on personal value
system
• Ethical: What a body of
Professionals accept as
Desirable Acts

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6. Nurses Dismissed Over Cell Phone
Photos of Patient on FaceBook
• In February 2009, two Wisconsin nurses were
dismissed for posting pictures of a patient on
Facebook taken on a cell phone.
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7. Historical Development
• Bioethics and human rights: conceived in the
aftermath of the Nazi Atrocities, when moral
outrage reenergized “bioethics,” and “human
rights”
• 1948 Universal Declaration of Human Rights:
prompted by Nuremberg trials of ‘47, at which
doctors, lawyers, scientists, and soldiers were
indicted for “crimes against humanity.”
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8. How Nazi Doctrine was Justified
• The inherent dignity and special value of humans
was rejected which permitted widespread
destruction of human life during the Nazi era.
• It was influenced by 5 tenets of social Darwinism:
– morality is relativistic, and not constant,
– humans do not have a unique status,
– human dignity is relative,
– some lives are not worth living, and
– survival of the fittest is an ethical principle
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9. What is Bioethics?
• Ethics refers to standards of conduct,
derived from principles of right and wrong
• We must be able to distinguish right from
wrong, good from evil, and propriety from
impropriety – at times difficult
• We must commit ourselves to do what is
right, good and proper
• Ethics is therefore an action concept &
NOT simply an idea to argue about

10. Ethical Principles are Aspirational Goals
• Universal principles :
– Patient Autonomy – freedom of choice
– Non-maleficence – do not cause harm
– Beneficence – do good
– Justice – fairness & equality
Principles can overlap as well as compete
with each other for priority

11. 1. Patient Autonomy -"self-governance"
• treating a patient according to the patient's
desires, within the bounds of accepted
treatment
• involving patients in treatment decisions
• considering the patient's needs, desires and
abilities
• safeguarding the patient's privacy

12. 2. Nonmaleficence "do no harm"
• duty to protect the patient from harm
• keeping knowledge and skills current
• knowing one's own limitations and when to
refer to other specialists
• knowing when delegation of patient care to
assistants or trainees is appropriate

13. 3. Beneficence "do good”
• primary obligation is service to the patient
and the public-at-large
• duty to promote the patient's welfare
• competent and timely delivery of health care
• obliged to become familiar with the signs of
abuse and neglect and to report suspected
cases

14. 4. Justice "fairness"
• duty to be fair in their dealings with patients,
colleagues and society
• delivering health care without prejudice
– shall not deny service to patients because of the
patient's race, creed, color, sex or nationality
– not to provide treatment to an individual infected
with HIV, HBV, HCV solely on that fact is unethical

15. Ethical Dilemmas
• Occur when the core principles compete or are
point to different decisions
• Some examples –
– Beneficence versus Non-maleficence
• Risky surgery
– Autonomy versus Beneficence
• Treating one who has attempted suicide
– Justice versus Autonomy
• Fetal sex determination by USG

16. Biomedical ethics:
Practical classification
• Ethics in biomedical research
• Ethics in clinical practice
• Ethics in public health, medical law, and
health policy
• Methodology in bioethics
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Bærøe et al. BMC Medical Ethics (2017) 18:30 DOI 10.1186/s12910-017-0193-x

17. Nurse Refuses To Give CPR; Senior Dies:
Ethical Problem or Legal Issue?
• A licensed nurse refuses to give CPR to an
87 year old woman who collapsed in an
old-age home where the nurse worked
because of "company policy“ of not
resuscitating those older than 85 years of
age...
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18. Assessing Behaviour:
Four Perspectives
Societal outlook - LEGAL
Professional Outlook
Ethical
Institution NORM
Individual
Outlook -
Moral

19. Sound ethical decision-making
incorporates 6 abilities
1. to sort ethically relevant issues from those
irrelevant.
2. to analyse elements of ethically relevant
information.
3. willingness to research issues and reflect upon
them.
4. willingness to seek advice.
5. to form a well-reasoned, unbiased, and
ethically defensible conclusion in any given
situation.
6. to justify this position and act upon it.

20. A Scenario:
A Homeless Man with
Drug Resistant TB
• 52 year old homeless individual
• Sleeps in a shelter with 35 others
• Diagnosed as ‘open drug resistant TB’
• After a week in hospital, feels better, requests
discharge & promises follow-up
• Should he be detained against his will?

21. Core Issues in Analyzing Ethical Dilemmas
Medical Indications Patient Preferences
Quality of Life Contextual Features

22. Wrong
Acceptable
Exemplar
No Single “Correct” Answer

23. Traditional Ethical Theory
Rule of reciprocity:
Do unto others as you
would have them do
unto you
Reflects “concern for
others”
Ethical sensitivity leads to professional commitment

24. Types of Ethical Theories
• Moral Obligation Theories
– What is the Right Thing to Do – DUTY
– Focus on Action Itself – UTILITY & OUTCOME
• Virtue Theories
– What Kind on Person You Ought to Be
– Focus on Agent and Motivations

25. Virtues of a Nursing Professional
• Duty
• Accountability
• Integrity
• Altruism
• Excellence
• Respect for Others
Project Professionalism, American Board of Internal Medicine

26. Ethical and
Patient Care
Issue
Frequency Degree of Stress
Frequently
or Daily (%)
Sometimes
(%)
Never or
Seldom (%)
High or
Very High
(%)
Moderate
(%)
None or
Low (%)
Protecting
patients' rights
63.9 21.5 14.5 12.3 28.7 58.9
Autonomy and
informed
consent to
treatment
61.3 21.1 17.7 6.3 20.3 73.4
Breaches of
patient
confidentiality
23.2 26.4 50.4 10.9 24.5 64.6
Unethical
practices of
health
professionals
6.8 21.3 72.0 18.7 22.1 59.2
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Ethical issues faced by Nurses (n = 415)
J Adv Nurs. 2010 Nov; 66(11): 10.1111/j.1365-2648.2010.05425.x.

27. Top 10 ethical challenges in health care-I …
1. Disagreement between patients/families and
health care professionals about treatment
decisions
2. Waiting lists
3. Access to needed health care resources for
the aged, chronically ill and mentally ill
4. Shortage of family physicians or primary care
teams in both rural and urban settings
5. Medical error
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BMC Medical Ethics 2005, 6:5 doi:10.1186/1472-6939-6-5

28. Top 10 ethical challenges in health care-II …
6. Withholding/withdrawing life sustaining treatment
in the context of terminal or serious illness
7. Achieving informed consent
8. Ethical issues related to subject participation in
research
9. Substitute decision-making
10.The ethics of surgical innovation and incorporating
new technologies for patient care
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BMC Medical Ethics 2005, 6:5 doi:10.1186/1472-6939-6-5

29. Evidence Informed Bioethics
• “conscientious and judicious use of the best
evidence relevant to the care and prognosis of
the condition/patient for better informed and
better justified ethical decision making.”
• Indian examples:
– Illegal abortion before the MTP act
– Female foeticide resulting in Control of USG scan
– Forced hysterectomy in Mentally challenged teens
– Organ donation act to curb unethical activities
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30. To conclude -
Let Us all strive to be
Ethical Professionals and
Role-Models for our own students –
Let us create ethical Nursing
Professionals that India can be
Justifiably Proud of…

31. Google “Trick or Treat – Sethuraman” to get the e-book for free