Healthcare Ethics© marekullaszShutterstockEthics is nothi

Healthcare Ethics
© marekullasz/Shutterstock
Ethics is nothing else than the reverence for life.
—Albert Schweitzer
Learning Objectives
The reader, upon completion of this chapter, will be able to:
• Describe the concepts of ethics and morality.
• Describe how an understanding of ethical theories, principles,
virtues, and values are helpful in resolving ethical dilemmas.
• Explain the relationship between spirituality and religion.
• Discuss situational ethics and how one’s moral character can
change as circumstances change.
• Explain how one’s reasoning skills influence the decision-
making process.
• Discuss the purpose of an ethics committee and its consultativ
e role in the delivery of patient care.
This chapter provides the reader with an overview of healthcare
ethics and moral principles. Ethics and morals are derivatives fr
om the Greek and Latin terms (roots) for custom. The intent her
e is not to burden the reader with the philosophical arguments s
urrounding ethical theories, moral principles, virtues, and value
s; however, as with the study of any new subject, “words are the
tools of thought.” Therefore, some new vocabulary is presented
to the reader in order to lay a foundation for applying the abstr
act theories and principles of ethics and making practical use of
them.
An ethical dilemma arises in situations where a choice must be
made among unpleasant alternatives. It can occur whenever a ch
oice involves giving up something good and suffering somethin
g bad, no matter what course of action is taken. Ethical dilemma
s often require caregivers to make decisions that may break som
e ethical norm or contradict some ethical value. For example, sh

ould I choose life knowing that an unborn child will be born wit
h severe disabilities, or should I choose abortion and thus preve
nt pain for both parent and child? Should I adhere to my spouse’
s wishes not to be placed on a respirator, or should I choose life
over death, disregarding her wishes and right to self-
determination? How should I allocate scarce financial resources
when there is such a wide range of demands for building projec
ts, expanded patient care programs, equipment, staff, and numer
ous other budget items in competition for limited dollars?
3.1 ETHICS
How we perceive right and wrong is influenced by what we feed
on.
—Author Unknown
Ethics is the branch of philosophy that seeks to understand the n
ature, purpose, justification, and the founding principles of mor
al rules and the systems they comprise. Ethics deals with values
relating to human conduct. It focuses on the rightness and wron
gness of actions, as well as the goodness and badness of motive
s and ends. Ethics seeks to understand and to determine how hu
man actions can be judged as right or wrong. Ethical judgments
can be made based on our own experiences or based on the natur
e of our principles of reason.
Ethics encompasses the decision-
making process of determining the ultimate actions: What shoul
d I do, and is it the right thing to do? It involves how individual
s decide to live, how they exist in harmony with the environmen
t, and how they live with each other when so few have so much
and so many have so little.
Ethics is also referred to as a moral philosophy, the discipline c
oncerned with what is morally good or bad, right or wrong. The
term is also applied to any theoretical system of moral values or
principles. Ethics is less concerned with factual knowledge tha
n with virtues and values—
namely, human conduct, as it ought to be, as opposed to what it

actually is.
Microethics involves an individual’s view of what is right and
wrong based on personal life experiences.
Macroethics involves a more global view of right and wrong.
Because no person lives in a vacuum, solving ethical dilemmas i
nvolves consideration of ethical issues from both a micro-
and macroethical perspective.
The term ethics is used in three different, but related, ways, sig
nifying (1) philosophical ethics, which involves inquiry about w
ays of life and rules of conduct; (2) a general pattern or “way of
life,” such as religious ethics (e.g., Judaeo-
Christian ethics); and (3) a set of rules of conduct or “moral cod
e,” which involves professional ethics and unethical behavior.
The scope of healthcare ethics encompasses numerous issues, in
cluding the right to choose or refuse treatment and the right to li
mit the suffering one will endure. Incredible advances in techno
logy and the resulting capability to extend life beyond the point
of what some may consider a reasonable quality of life have co
mplicated the process of healthcare decision making. The scope
of healthcare ethics is not limited to philosophical issues but em
braces economic, medical, political, and legal dilemmas.
Bioethics addresses such difficult issues as the nature of life, th
e nature of death, what sort of life is worth living, what constitu
tes murder, how we should treat people who are especially vuln
erable, and the responsibilities that we have to other human bein
gs. It is about making the right judgments in difficult situations.
We study ethics to assist us in making sound judgments, good d
ecisions, and right choices—
or if not right choices, at least better choices. To those in the he
althcare industry, ethics is about anticipating and recognizing h
ealthcare dilemmas and making good judgments and decisions b
ased on the patient’s needs and wishes and the universal values
that work in unison with the laws of the land, our Constitution;
where the Constitution remains silent, we rely on the ability of
caregivers to make the right choices using the wisdom of Solom
on to “do good.”

3.2 MORALITY
Aim above morality. Be not simply good; be good for something
.
—Henry David Thoreau
Morality is a code of conduct. It is a guide to behavior that all r
ational persons put forward for governing their behavior. Morali
ty describes a class of rules held by society to govern the condu
ct of its individual members. A moral dilemma occurs when mor
al ideas of right and wrong conflict.
Morals are ideas about what is right and what is wrong; for exa
mple, killing is wrong, whereas healing is right, and causing pai
n is wrong, whereas easing pain is right. Morals are deeply ingr
ained in culture and religion and are often part of their identitie
s. Morals should not be confused with cultural habits or customs
, such as wearing a certain style of clothing.
Moral judgments are those judgments concerned with what an in
dividual or group believes to be the right or proper behavior in
a given situation. They involve assessing another person’s mora
l character based on how he or she conforms to the moral convic
tions established by the individual and/or group. What is consid
ered right varies from nation to nation, culture to culture, religi
on to religion, and one person to the next. In other words, there
is no universal morality that is recognized by all people in all c
ultures at all times.
A code of conduct generally prescribes standards of conduct, sta
tes principles expressing responsibilities, and defines the rules e
xpressing duties of professionals to whom they apply. Most me
mbers of a profession subscribe to certain “values” and moral st
andards written into a formal document called a code of ethics.
Codes of conduct often require interpretation by caregivers as th
ey apply to the specific circumstances surrounding each dilemm
a.
Michael D. Bayles, a famous author and teacher, describes the d
istinction among standards, principles, and rules:
• Standards (e.g., honesty, respect for others, conscientiousness

) are used to guide human conduct by stating desirable traits to
be exhibited and undesirable ones (dishonesty, deceitfulness, sel
f-interest) to be avoided.
• Principles describe responsibilities that do not specify what t
he required conduct should be. Professionals need to make a jud
gment about what is desirable in a particular situation based on
accepted principles.
• Rules specify specific conduct; they do not allow for individu
al professional judgment.
Morality Legislated
When it is important that disagreements be settled, morality is o
ften legislated. Law is distinguished from morality by having ex
plicit rules and penalties and officials who interpret the laws an
d apply penalties when laws are broken. There is often consider
able overlap in the conduct governed by morality and that gover
ned by law. Laws are created to set boundaries for societal beha
vior. They are enforced to ensure that the expected behavior hap
pens.1
Moral Dilemmas
Moral dilemmas arise when values, rights, duties, and loyalties
conflict and, consequently, not everyone is satisfied with a parti
cular decision. An understanding of the concepts presented here
will help the caregiver in conflict resolution when addressing e
thical dilemmas. Caregivers often find that there seems to be no
right or wrong answer. The best answer when attempting to res
olve an ethical dilemma is based on the wishes known and the in
formation available at the time a decision must be made. The an
swer to a dilemma is often illusive.
3.3 ETHICAL THEORIES
Ethics, too, are nothing but reverence for life. This is what give
s me the fundamental principle of morality, namely, that good c
onsists in maintaining, promoting, and enhancing life, and that
destroying, injuring, and limiting life are evil.
—Albert Schweitzer
Theories and principles of ethics introduce order into the way p

eople think about life. They are the foundations of ethical analy
sis and provide guidance in the decision-
making process. The various theories present differing viewpoin
ts that assist caregivers in making difficult decisions that impac
t the lives of others. Ethical theories help caregivers to predict t
he outcome of alternative choices, when following their duties t
o others, in order to reach an ethically correct decision.
Normative Ethics
Normative ethics is the attempt to determine what moral standar
ds should be followed so that human behavior and conduct may
be morally right. Normative ethics is primarily concerned with e
stablishing standards or norms for conduct and is commonly ass
ociated with general theories about how one ought to live. One
of the central questions of modern normative ethics is whether h
uman actions are to be judged right or wrong solely according t
o their consequences.
The determination of a universal moral principle for all humanit
y is a formidable task and most likely not feasible due to the div
ersity of people and cultures. However, there is a need to have a
commonly held consensus as to right and wrong to avoid chaos.
Thus, there are generally accepted moral standards around whic
h laws are drafted.
General normative ethics is the critical study of major moral pre
cepts concerning such matters as what things are right, what thi
ngs are good, and what things are genuine. General normative et
hics is the determination of correct moral principles for all auto
nomous rational beings. Applied ethics is the application of nor
mative theories to practical moral problems. It attempts to expla
in and justify specific moral problems such as abortion, euthana
sia, and assisted suicide.
Descriptive ethics, also known as comparative ethics, deals with
what people believe to be right and wrong, whereas normative e
thics prescribes how people ought to act.
Meta-
ethics seeks to understand ethical terms and theories and their a
pplication.

Consequential and Teleological Ethics
The consequential theory of ethics emphasizes that the morally r
ight action is whatever action leads to the maximum balance of
good over evil. From a contemporary standpoint, theories that ju
dge actions by their consequences have been referred to as cons
equential ethics. Consequential ethical theories revolve around t
he premise that the rightness or wrongness of an action depends
on the consequences or effects of an action. The theory of conse
quential ethics is based on the view that the value of an action d
erives solely from the value of its consequences. The goal of a c
onsequentialist is to achieve the greatest good for the greatest n
umber. It involves asking the following questions:
• What will be the effects of each course of action?
• Will the effects be positive or negative?
• Who will benefit?
• What action will cause the least harm?
Situational Ethics
Situational ethics is concerned with the outcome or consequence
s of an action in which the ends can justify the means. Why do g
ood people behave differently in similar situations? Why do goo
d people sometimes do bad things? The answer is fairly simple:
One’s moral character can sometimes change as circumstances c
hange—thus the term situational ethics.
Why good people do bad things became a reality for Eddie Ada
ms. He was the photojournalist who had photographed the event
described in the news clipping below during the Vietnam War f
or which he received the Pulitzer Prize. Mr. Adams regrets takin
g the photo because he believed it sent the wrong message as to
what the picture alone depicts.
A person, therefore, may contradict what he believes is the right
thing to do and do what is wrong. The values held ever so stron
gly in one situation may conflict with the same values given a d
ifferent set of facts. For example, if your plane crashed high in t
he Andes mountains and the only source of food for survival wo
uld be the flesh of those who did not survive, you may, if you w
ish to survive, have to give up your belief that it is morally wro

ng to eat the flesh of another human being. Given a different set
of circumstances, given an abundance of food, you would most
likely find it reprehensible to eat human flesh. Thus, there are n
o effective hard and fast rules or guidelines to govern ethical be
havior.
Viet Cong Execution
“And out of nowhere came this guy who we didn’t know.” Gen.
Nguyen Ngoc Loan, chief of South Viet Nam’s national police,
walked up and shot the prisoner in the head. His reason: The pri
soner, a Viet Cong lieutenant, had just murdered a South Vietna
mese colonel, his wife, and their six children.
The peace movement adopted the photo as a symbol of the war’s
brutality. But Adams, who stayed in touch with Loan, said the
photo wrongly stereotyped the man. “If you’re this general and
you caught this guy after he killed some of your people … how
do you know you wouldn’t have pulled that trigger yourself? Yo
u have to put yourself in that situation…. It’s a war.”
—1969 Spot News, Newseum, Washington, DC
As applied to healthcare decision making, each situation may ha
ve a different fact pattern, thus resulting in moral decisions bein
g made on a case-by-
case basis. For example, a decision not to use extraordinary mea
ns to sustain the life of an unknown 84-year-
old may result in a different decision if the 84-year-
old is one’s mother. To better understand this concept, consider
the desire to live, and the extreme measures one will take in ord
er to do so. Remember that ethical decision making is the proce
ss of determining the right thing to do in the event of a moral di
lemma.
Utilitarian Ethics
Happiness often sneaks in a door you did not think was open.
—John Barrymore
The utilitarian ethics approach involves the concept that the mor
al worth of an action is solely determined by its contribution to

overall usefulness. It describes doing the greatest good for the
most people. It is thus a form of consequential ethics, meaning t
hat the moral worth of an action is determined by its outcome, a
nd thus, the ends justify the means. The utilitarian commonly ho
lds that the proper course of an action is one that maximizes util
ity, commonly defined as maximizing happiness and reducing su
ffering.
Deontologic Ethics
Act in such a way that you always treat humanity, whether in yo
ur own person or in the person of any other, never simply as a m
eans, but always at the same time as an end.
—Immanuel Kant
Deontologic ethics is commonly attributed to the German philos
opher Immanuel Kant (1724–
1804). Kant believed that although doing the right thing is good
, it might not always lead to or increase the good and right thing
sought after. It focuses on one’s duties to others and others’ rig
hts. It includes telling the truth and keeping your promises. Deo
ntologic ethics is often referred to as duty-
based ethics. It involves ethical analysis according to a moral co
de or rules, either religious or secular. Deontology is derived fr
om the Greek word meaning “duty.” Kant’s theory differs from
consequentialism in that consequences are not the determinant o
f what is right; therefore, doing the right thing may not always l
ead to an increase in what is good.
Duty-
based approaches are heavy on obligation, in the sense that a pe
rson who follows this ethical paradigm believes that the highest
virtue comes from doing what you are supposed to do—
either because you have to, e.g., following the law, or because y
ou agreed to, e.g., following an employer’s policies. It matters l
ittle whether the act leads to good consequences; what matters i
s “doing your duty.”2
Nonconsequential Ethics
The nonconsequential theory of ethics denies that the consequen

ces of an action or rule are the only criteria for determining the
morality of an action or rule. In this theory, the rightness or wro
ngness of an action is based on properties intrinsic to the action,
not on its consequences. In other words, the nonconsequentialis
t believes right or wrong depends on the intention, not the outco
me.
Ethical Relativism
“Ethical relativism is the theory that holds that morality is relati
ve to the norms of one’s culture. That is, whether an action is ri
ght or wrong depends on the moral norms of the society in whic
h it is practiced. The same action may be morally right in one so
ciety but be morally wrong in another.”3 What is acceptable in
one society may not be considered as acceptable in another soci
ety. Slavery may be considered an acceptable practice in one so
ciety and unacceptable and unconscionable in another. The admi
nistration of blood may be acceptable as to one’s religious belie
fs and not acceptable to another within the same society. The le
gal rights of patients vary from state to state, as is well borne o
ut, for example, by Oregon’s Death with Dignity Act. Caregiver
s must be aware of cultural, religious, and legal issues that can
affect the boundaries of what is acceptable and what is unaccept
able practice, especially when delivering health care to persons
with beliefs different from their own. As the various cultures m
erge together in common communities, the education and trainin
g of caregivers become more complex.
3.4 PRINCIPLES OF HEALTHCARE ETHICS
You cannot by tying an opinion to a man’s tongue, make him th
e representative of that opinion; and at the close of any battle fo
r principles, his name will be found neither among the dead, nor
the wounded, but the missing.
—E.P. Whipple4 (1819–1886)
Ethical principles are universal rules of conduct, derived from e
thical theories that provide a practical basis for identifying what
kinds of actions, intentions, and motives are valued. Ethical pri
nciples assist caregivers in making choices based on moral princ

iples that have been identified as standards considered importan
t when addressing ethical dilemmas. Ethical principles provide a
framework within which particular ethical dilemmas can be ana
lyzed and decisions made. As noted by the principles discussed
in the following sections, caregivers, in the study of ethics, will
find that difficult decisions often involve choices between conf
licting ethical principles.
Autonomy
No right is held more sacred, or is more carefully guarded, by th
e common law, than the right of every individual to the possessi
on and control of his own person, free from all restraint or inter
ference of others, unless by clear and unquestioned authority of
law.
—Union Pac. Ry. Co. v. Botsford, 141 U.S. 250, 251 (1891)
The principle of autonomy involves recognizing the right of a p
erson to make one’s own decisions. Auto comes from a Greek w
ord meaning “self” or the “individual.” In this context, autonom
y means recognizing an individual’s right to make his or her ow
n decisions about what is best for him or herself. Autonomy is n
ot an absolute principle, meaning that the autonomous actions o
f one person must not infringe upon the rights of another.
Respect for autonomy has been recognized in the Fourteenth A
mendment to the Constitution of the United States. The law uph
olds an individual’s right to make his or her own decisions abou
t health care. A patient has the right to refuse to receive health c
are even if it is beneficial to saving his or her life. Patients can
refuse treatment, refuse to take medications, refuse blood or blo
od by-
products, and refuse invasive procedures regardless of the benef
its that may be derived from them. They have a right to have the
ir decisions followed by family members who may disagree sim
ply because they are unable to “let go.”
Autonomous decision making can be affected by one’s disabiliti
es, mental status, maturity, or incapacity to make decisions. Alt
hough the principle of autonomy may be inapplicable in certain

cases, one’s autonomous wishes may be carried out through an a
dvance directive and/or an appointed healthcare agent in the eve
nt of one’s inability to make decisions.
Beneficence
Beneficence describes the principle of doing good, demonstratin
g kindness, showing compassion, and helping others. In the heal
thcare setting, caregivers demonstrate beneficence by balancing
benefits against risks. Doing good requires knowledge of the bel
iefs, culture, values, and preferences of the patient—
what one person may believe to be good for a patient may be ha
rmful. For example, a caregiver may decide that a patient shoul
d be told frankly, “There is nothing else that I can do for you.”
This could be injurious to the patient if the patient really wants
encouragement and information about care options from the care
giver. Compassion here requires the caregiver to explain to the
patient, “I am not aware of new treatments for your illness; how
ever, I have some ideas about how I can help treat your sympto
ms and make you more comfortable. In addition, I will keep you
informed as to any significant research that may be helpful in tr
eating your disease processes.”
Paternalism
Paternalism is a form of beneficence. People, believing that the
y know what is best for another, often make decisions that they
believe are in that person’s best interest. It may involve, for exa
mple, withholding information from someone, believing that the
person would be better off that way. Paternalism can occur as a
result of one’s age, cognitive ability, and level of dependency.
A patient’s right to self-
determination is compromised when a third party imposes their
wishes against those of the patient.
Paul Ramsey in The Patient as Person (1970) discusses the quest
ion of paternalism. As physicians are faced with many options f
or saving lives, transplanting organs, and furthering research, th
ey also must wrestle with new and troubling choices—
for example, who should receive scarce resources (e.g., organ tr
ansplants), determining when life ends, and what limits should b

e placed on care for the dying.
Medical Paternalism
Medical paternalism often involves making choices for patients
who are capable of making their own choices. Physicians by the
nature of their work are in situations where they can influence a
patient’s healthcare decision simply by selectively telling the p
atient what he or she prefers based on personal beliefs. This dir
ectly violates patient autonomy. The problem of paternalism inv
olves a conflict between principles of autonomy and beneficenc
e, each of which is conceived by different parties as the overridi
ng principle in cases of conflict.
Nonmaleficence
Nonmaleficence is an ethical principle that requires caregivers t
o avoid causing patients harm. It derives from the ancient maxi
m primum non nocere, translated from the Latin, “first, do no ha
rm.” Physicians today still swear by the code of Hippocrates, pl
edging to do no harm. Medical ethics require healthcare provide
rs to “first, do no harm.” A New Jersey court, in In re Conroy,5
found that “the physician’s primary obligation is … First do no
harm.” If there is no cure for a patient’s disease, the caregiver i
s often faced with a reoccurring dilemma. Do I tell the patient h
e is terminal and possibly cause serious psychological harm, or
do I do my best to give the patient hope?
The principle of nonmaleficence is shattered when a physician i
s placed in the position of ending life by removing respirators, g
iving lethal injections, or by writing prescriptions for lethal dos
es of medication. Helping patients die violates the physician’s d
uty to save lives. Allowing death to follow its natural course ca
n help solve the dilemma. In this instance, the patient’s caregive
rs can help ease the transition from life to death by providing co
mfort care and addressing the patient’s spiritual needs. For thos
e who believe in an afterlife of peace and happiness, the transiti
on will more likely be easier when one accepts that the patient i
s leaving one life to an even better life.
Tuskegee Syphilis Experiment
The Tuskegee syphilis experiment, conducted by the U.S. Public

Health Service between 1932 and 1972, was designed to analyz
e the natural progression of untreated syphilis in African Ameri
can men. The participants were not warned during the study that
penicillin was available for the cure for syphilis. They believed
that they were receiving adequate care and unknowingly suffere
d unnecessarily. The Tuskegee syphilis study used disadvantage
d, rural black men to investigate the untreated course of the dise
ase, one that is by no means confined to that population. The stu
dy should have been recognized from the beginning that selectio
n of research subjects, regardless of race, must be closely monit
ored to ensure that specific classes of individuals (e.g., terminal
ly ill patients, welfare patients, racial and ethnic minorities, or
persons confined to institutions) are not selected for research st
udies based on their availability, compromised position, or mani
pulability. Rather, they must be selected for reasons directly rel
ated to the research being conducted. The ethical principle of no
nmaleficence requires all people to avoid causing harm. In this
case the failure to alert those involved in the research study that
a cure was available was both ethically and legally wrong.
National Research Act of 1974
Because of publicity from the Tuskegee Syphilis Study, the Nati
onal Research Act (NRA) of 1974 was passed. The NRA created
the National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research.6 One of the commissio
n’s charges was to identify the basic ethical principles that shou
ld underlie the conduct of biomedical and behavioral research in
volving human subjects and to develop guidelines to ensure that
such research is conducted in accordance with those principles.
7 The commission was directed to consider the following:8
1. the boundaries between biomedical and behavioral research a
nd the accepted and routine practice of medicine,
2. the role of assessment of risk–
benefit criteria in the determination of the appropriateness of re
search involving human subjects,
3. appropriate guidelines for the selection of human subjects fo
r participation in such research, and

4. the nature and definition of informed consent in various rese
arch settings.
Justice
Justice is the obligation to be fair in the distribution of benefits
and risks. Justice demands that persons in similar circumstances
be treated similarly. A person is treated justly when he or she r
eceives what is due, is deserved, or can legitimately be claimed.
Justice involves how people are treated when their interests co
mpete with one another.
Distributive justice is a principle requiring that all persons be tr
eated equally and fairly. No one person, for example, should get
a disproportional share of society’s resources or benefits. There
are many ethical issues involved in the rationing of health care.
This is often a result of limited or scarce resources, limited acc
ess as a result of geographic remoteness, or a patient’s inability
to pay for services combined with many physicians who are unw
illing to accept patients who are perceived as “no pays” with hig
h risks for legal suits.
Senator Edward M. Kennedy, speaking on health care at the Joh
n F. Kennedy Presidential Library in Boston, Massachusetts, on
April 28, 2002, stated:
It will be no surprise to this audience that I believe securing qua
lity, affordable health insurance for every American is a matter
of simple justice. Health care is not just another commodity. Go
od health is not a gift to be rationed based on ability to pay. The
time is long overdue for America to join the rest of the industri
alized world in recognizing this fundamental need.
Senator Kennedy, speaking at the Democratic National Conventi
on on August 25, 2008, later said:
And this is the cause of my life—
new hope that we will break the old gridlock and guarantee that
every American North, South, East, West, young, old, will have
decent quality health care as a fundamental right and not a privi
lege.
Although Senator Edward Kennedy did not live to see the day hi
s dream would come true, President Barack Obama signed into l

aw the final piece of his administration’s historic highly contro
versial healthcare bill on March 23, 2010, a bill that continues t
o be challenged in various courts and plays a troublesome role b
etween political parties and their constituencies.
3.5 VIRTUE ETHICS AND VALUES
The most important human endeavor is the striving for morality
in our actions. Our inner balance, and even our very existence d
epends on it. Only morality in our actions can give beauty and d
ignity to our lives.
—Albert Einstein
Virtue ethics focuses on the inherent character of a person rathe
r than on the specific actions that he or she performs. A virtue i
s normally defined as some sort of moral excellence or benefici
al quality. In traditional ethics, virtues are those characteristics
that differentiate good people from bad people. Virtues, such as
honesty and justice, are abstract moral principles. A morally vir
tuous person is one who does the good and right thing by habit,
not by a set of rules of conduct. In other words, the character of
a virtuous person is naturally good, as exhibited by his or her u
nswerving good behavior and actions.
Virtue-
based ethical theories place much less emphasis on which rules
people should follow and instead focus on helping people devel
op good character traits, such as kindness and generosity. These
character traits will, in turn, allow a person to make the correct
decisions later on in life. Virtue theorists also emphasize the ne
ed for people to learn how to break bad habits of character, such
as greed or anger.9
Properly understood, virtues serve as indispensable guides to ou
r actions; however, they are not ends in themselves. Virtues are
merely abstract means to concrete ends. The ends are values—
the things in life that we aim to gain and keep. Many individual
s have a tendency to focus on values and not virtues. Simply sta
ted, most individuals find it difficult to make the connection bet
ween abstract principles (virtues) and what has value. The relati

onship between means and ends and principles (virtues) and pra
ctice (values) is often difficult to grasp.
A moral value is the relative worth placed on some virtuous beh
avior. What has value to one person may not have value to anot
her. A value is a standard of conduct. Values are used for judgin
g the goodness or badness actions. Ethical values imply standar
ds of worth. They are the standards by which we measure the go
odness in our lives. Intrinsic value is something that has value i
n and of itself (e.g., happiness). Instrumental value is something
that helps to give value to something else (e.g., money is valua
ble for what it can buy).
Values may change as needs change. If one’s basic needs for fo
od, water, clothing, and housing have not been met, one’s value
s may change such that a friendship, for example, might be sacri
ficed if one’s basic needs can be better met as a result of the sac
rifice. If mom’s estate is being squandered at the end of her life,
the financially well-
off family member may want to take more aggressive measures t
o keep mom alive despite the financial drain on her estate. Anot
her family member, who is struggling financially, may more rea
dily see the futility of expensive medical care and find it easier
to let go. Values give purpose to each life. They make up one’s
moral character.
All people make value judgments and make choices among alter
natives. Values are the motivating power of a person’s actions a
nd necessary to survival, both psychologically and physically.
We begin our discussion here with an overview of those virtues
commonly accepted as having value when addressing difficult h
ealthcare dilemmas. The reader should not get overly caught up
in the philosophical morass of how virtues and values differ, but
should be aware that virtues and values have been used intercha
ngeably.
Whether we call compassion, for example, a virtue or a value or
both, the importance for our purposes in this text is to understa
nd what compassion is and how it is applied in the healthcare se
tting.

Pillars of Moral Strength
I am part of all I have met.
—Alfred Tennyson
There is a deluge of ethical issues in every aspect of human exis
tence. Although cultural differences, politics, and religion influ
ence who we are, it is all of life’s experiences that affect who w
e become. If we have courage to do right, those who have influe
nced our lives were most likely courageous. If we are compassio
nate, it is most likely because we have been influenced by the c
ompassionate.
Figure 3-1 Pillars of moral strength.
The Pillars of Moral Strength illustrated in Figure 3-
1 describes a virtuous person. What is it that sets each person a
part? In the final analysis, it is one’s virtues and values that bui
ld moral character. Look beyond the words and ask, “Do I know
their meanings?” “Do I apply their concepts?” “Do I know their
value?” “Are they part of me?”
This book is not about memorizing words; it is about applying
what we learn for the good of all whose lives we touch. We begi
n our discussion here with an overview of those virtues common
ly accepted as having value when addressing difficult healthcare
dilemmas.
Courage as a Virtue
Courage is the greatest of all virtues, because if you haven’t cou
rage, you may not have an opportunity to use any of the others.
—Samuel Johnson
Courage is the mental or moral strength to persevere and withst
and danger. “Courage is the ladder on which all the other virtue
s mount.”10 It is the strength of character necessary to continue
in the face of fears and the challenges in life. It involves balanc
ing fear, self-
confidence, and values. Without courage, we are unable to take
the risks necessary to achieve the things most valued. A courage

ous person has good judgment and a clear sense of his or her str
engths, correctly evaluates danger, and perseveres until a decisi
on is made and the right goal that is being sought has been achie
ved.
Courage, in differing degrees, helps to define one’s character (t
he essence of one’s being) and offers the strength to stand up fo
r what is good and right. It crosses over and unites and affects a
ll other values. Courage must not be exercised to an extreme, ca
using a person to become so foolish that his or her actions are la
ter regretted.
When the passion to destroy another human being becomes such
an obsession that one is willing to sacrifice the lives of others,
that person has become a bully and a coward and not a person of
courage. History is filled with those men and women who have
hidden their fears by inciting others to do evil. Such people are
not the models of character that we wish to instill thoughts of in
the minds of our children.
Wisdom as a Virtue
You can’t inherit wisdom, You can’t be taught wisdom. You can
not learn wisdom. Wisdom is a God given gift that often comes
with age.
—Gp
My Journey–How Lucky Am I?
No words can be scripted to say what I have been through, so I
will just speak from my heart and off the cuff. From the day the
Dr. said to me, “Denise, you have a rare cancer and we are sorry
there is nothing we can do,” I did not waver in my faith in God.
He was in me, he was thru me and he was around me. I just ask
ed the Dr., “What Do I Do?” And yet, although he said a whole
bunch of words, I wasn’t focused so much on what was being sa
id. It’s like a calmness was over me, not much worry, just a feel
ing of I will never be ALONE on this new journey I’m about to
experience. I felt calm. Not until I looked at my loved ones’ FA
CES did I realize, oh my, this can be bad. But again, a feeling c

ame over me that I will not face this ALONE. God has plans for
me and I will surrender in his grace and as time passed, I realiz
ed how lucky and blessed I am, for most people who may feel th
at death may be close by, I didn’t feel that way. What I felt was
WOW!! Everyone gets to show me their love in the NOW and n
ot in the later when I am no longer HERE. How lucky am I.
—Denise
Wisdom is the judicious application of knowledge. Wisdom begi
ns first by learning from the failures and successes of those who
have preceded us. Marcus Tullius Cicero (106–
43 BC), a Roman philosopher and politician, is reported to have
said, “The function of wisdom is to discriminate between good
and evil.” In the healthcare setting, when the patient’s wishes a
nd end of life preferences are unknown, wisdom with good judg
ment without bias or prejudice springs forth more easily. As Ger
da Lerner, an American author, historian, and teacher, so profou
ndly said:
We can learn from history how past generations thought and act
ed, how they responded to the demands of their time and how th
ey solved their problems. We can learn by analogy, not by exam
ple, for our circumstances will always be different than theirs w
ere. The main thing history can teach us is that human actions h
ave consequences and that certain choices, once made, cannot b
e undone. They foreclose the possibility of making other choice
s and thus they determine future events.11
Wisdom often comes with age, therefore, “Count your age by fri
ends, count your life by smiles.”12
Temperance as a Virtue
Being forced to work, and forced to do your best, will breed in
your temperance and self-
control, diligence and strength of will, cheerfulness and content,
and a hundred virtues which the idle will never know.
—Charles Kingsley13
Temperance involves self-
control and restraint. It embraces moderation in thoughts and ac
tions. Temperance is evidenced by orderliness and moderation i

n everything one says and does. It involves the ability to control
one’s actions so as not to go to extremes. The question arises,
without the ability to control oneself from substance abuse, for
example, how can a person possibly live the life of a virtuous pe
rson? The old adage, “the proof is in the pudding,” lies in one’s
actions. A virtuous person stands out from the crowd by actions
and deeds.
Commitment
I know the price of success: dedication, hard work, and an unre
mitting devotion to the things you want to see happen.
—Frank Lloyd Wright
Commitment is the act of binding oneself (intellectually or emot
ionally) to a course of action. It is an agreement or pledge to do
something. It can be ongoing or a pledge to do something in the
future.
Compassion
Compassion is the basis of morality.
—Arnold Schopenhauer
Compassion is the deep awareness of and sympathy for another’
s suffering. The ability to show compassion is a true mark of mo
ral character. Compassion is a moral value expected of all careg
ivers. Those who lack compassion have a weakness in their mor
al character. Dr. Linda Peeno showed her compassion as she test
ified before the Committee on Commerce on May 30, 1996. She
stated that she had been hired as a claims reviewer for several h
ealth maintenance organizations (HMOs). Here is her story in pa
rt:
I wish to begin by making a public confession. In the spring of
1987, I caused the death of a man. Although this was known to
many people, I have not been taken before any court of law or c
alled to account for this in any professional or public forum. In
fact, just the opposite occurred. I was rewarded for this. It brou
ght me an improved reputation in my job and contributed to my
advancement afterwards. Not only did I demonstrate that I could

do what was asked, expected of me, I exemplified the good com
pany employee. I saved a half a million dollars.
Since that day, I have lived with this act and many others eating
into my heart and soul. The primary ethical norm is do no harm
. I did worse, I caused death. Instead of using a clumsy bloody
weapon, I used the simplest, cleanest of tools: my words. This
man died because I denied him a necessary operation to save his
heart. I felt little pain or remorse at the time. The man’s faceles
s distance soothed my conscience. Like a skilled soldier, I was t
rained for the moment. When any moral qualms arose, I was to r
emember, “I am not denying care; I am only denying payment.”
14
Duty-
based ethics required Dr. Peeno to follow the rules of her job. I
n so doing, a life was lost. Although Dr. Peeno came forward wi
th her story, the lack of compassion for others plagues the healt
hcare industry in a variety of settings.
Never apologize for showing feeling. When you do so, you apol
ogize for the truth.
—Benjamin Disraeli
Detachment
Detachment, or lack of concern for a patient’s needs, is what oft
en translates into mistakes that can result in patient injuries. Th
ose who have excessive emotional involvement in a patient’s ca
re may be best suited to work in those settings where patients ar
e most likely to recover and have positive outcomes (e.g., mater
nity wards). As with all things in life, there needs to be a comfo
rtable balance between compassion and detachment. Caregivers
need to show the same compassion for others as they would exp
ect for themselves or their loved ones.
What Went Wrong?
The son of a prominent Boston doctor … was on his way to bec
oming a leading surgeon in his own right when a bizarre blunder
interrupted his climb: he left his patient on the operating table

so he could cash his paycheck. A series of arrests followed expo
sing a life of arrogance, betrayal, and wasted promise.
—
Neil Swidey, “What Went Wrong,” The Boston Globe, March 21
, 2004
Conscientiousness
The most infectiously joyous men and women are those who for
get themselves in thinking about and serving others.
—Robert J. McCracken
Teaching Doctors to Care
At Harvard and other medical schools across the country, educat
ors are beginning to realize that empathy is as valuable to a doct
or as any clinical skill…. [D]octors who try to understand their
patients may be the best antidote for the wide-
spread dissatisfaction with today’s health care system.
—
Nathan Thornburgh, “Teaching Doctors to Care,” Time Magazin
e, March 29, 2006
A conscientious person is one who has moral integrity and a stri
ct regard for doing what is considered the right thing to do. Con
science is a form of self-
reflection on and judgment about whether one’s actions are righ
t or wrong, good or bad. It is an internal sanction that comes int
o play through critical reflection. This sanction often appears as
a bad conscience in the form of painful feelings of remorse, gui
lt, shame, disunity, or disharmony as the individual recognizes t
hat his or her acts were wrong. Although a person may conscien
tiously object and/or refuse to participate in some action (e.g., a
bortion), that person must not obstruct others from performing t
he same act if the others have no moral objection to it.
Discernment
Get to know two things about a man. How he earns his money a
nd how he spends it. You will then have the clue to his characte

r. You will have a searchlight that shows up the innermost reces
ses of his soul. You know all you need to know about his standa
rds, his motives, his driving desires, and his real religion.
—Robert J. McCracken
Discernment is the ability to make a good decision without pers
onal biases, fears, and undue influences from others. A person
who has discernment has the wisdom to decide the best course o
f action when there are many possible actions from which to cho
ose.
Fairness
Do all the good you can, By all the means you can, In all the wa
ys you can, In all the places you can, At all the times you can, T
o all the people you can, As long as you ever can.
—John Wesley15
In ethics, fairness requires each person to be objective, unbiased
, dispassionate, impartial, and consistent with the principles of e
thics. Fairness is the ability to make judgments free from discri
mination, dishonesty, or one’s own bias. It is the ability to be o
bjective without prejudice or bias. We often tolerate mediocrity.
We sometimes forget to thank those who just do their jobs, and
we often praise the extraordinary, sometimes despite questionab
le faults. To be fair, it is important to see the good in all and to
reward that good.
Fidelity
Nothing is more noble, nothing more venerable, than fidelity. F
aithfulness and truth are the most sacred excellences and endow
ments of the human mind.
—Cicero
Fidelity is the virtue of faithfulness, being true to our commitm
ents and obligations to others. A component of fidelity, veracity
, implies that we will be truthful and honest in all our endeavors
. It involves being faithful and loyal to obligations, duties, or ob
servances. The opposite of fidelity is infidelity, meaning unfaith
fulness.

Freedom
You can only protect your liberties in this world by protecting t
he other man’s freedom. You can only be free if I am free.
—Dorothy Thompson
Freedom is the quality of being free to make choices for oneself
within the boundaries of law. Freedoms enjoyed by citizens of t
he United States include the freedom of speech, freedom of reli
gion, freedom from want, and freedom from physical aggression
.
Honesty/Trustworthiness/Truth Telling
Lies or the appearance of lies are not what the writers of our Co
nstitution intended for our country, it’s not the America we salu
te every Fourth of July, it’s not the America we learned about in
school, and it is not the America represented in the flag that ris
es above our land.
—Message from the Internet
Honesty and trust involve confidence that a person will act with
the right motives. It is the assured reliance on the character, abi
lity, strength, or truth of someone or something. To tell the trut
h, to have integrity, and to be honest are most honorable virtues
. Veracity is devotion to and conformity with what is truthful. It
involves an obligation to be truthful.
Truth telling involves providing enough information so that a pa
tient can make an informed decision about his or her health care
. Intentionally misleading a patient to believe something that th
e caregiver knows to be untrue may give the patient false hopes.
There is always apprehension when one must share bad news; t
he temptation is to gloss over the truth for fear of being the bear
er of bad news. To lessen the pain and the hurt is only human, b
ut in the end, truth must win over fear.
Integrity
Nearly all men can stand adversity, but if you want to test a ma
n’s character, give him power.

—Abraham Lincoln
Integrity involves a steadfast adherence to a strict moral or ethi
cal code and a commitment not to compromise this code. A pers
on with integrity has a staunch belief in and faithfulness to, for
example, his or her religious beliefs, values, and moral characte
r. Patients and professionals alike often make healthcare decisio
ns based on their integrity and their strict moral beliefs. For exa
mple, a Jehovah’s Witness generally refuses a blood transfusion
because it is against his or her religious beliefs, even if such re
fusal may result in death. A provider of health care may refuse t
o participate in an abortion because it is against his or her moral
beliefs. A person without personal integrity lacks sincerity and
moral conviction and may fail to act on professed moral beliefs.
Kindness
When you carry out acts of kindness, you get a wonderful feelin
g inside. It isas though something inside your body responds an
d says, yes, this is how I ought to feel.
—Harold Kushner
Kindness involves the quality of being considerate and sympath
etic to another’s needs. Some people are takers, and others are g
ivers. If you go through life giving without the anticipation of r
eceiving, you will be a kinder and happier person.
Respect
Respect for ourselves guides our morals; respect for others guid
es our manners.
—Laurence Sterne
Respect is an attitude of admiration or esteem. Kant was the firs
t major Western philosopher to put respect for persons, includin
g oneself as a person, at the center of moral theory. He believed
that persons are ends in themselves with an absolute dignity, w
hich must always be respected. In contemporary thinking, respe
ct has become a core ideal extending moral respect to things oth
er than persons, including all things in nature.
Caregivers who demonstrate respect for one another and their pa

tients will be more effective in helping them cope with the anxi
ety of their illness. Respect helps to develop trust between the p
atient and caregiver and improve healing processes. If caregiver
s respect the family of a patient, cooperation and understanding
will be the positive result, encouraging a team effort to improve
patient care.
Hopefulness
Hope is the last thing that dies in man; and though it be exceedi
ngly deceitful, yet it is of this good use to us, that while we are
traveling through life, it conducts us in an easier and more pleas
ant way to our journey’s end.
—Francois de La Rochefoucauld
Hopefulness in the patient care setting involves looking forward
to something with the confidence of success. Caregivers have a
responsibility to balance truthfulness while promoting hope. Th
e caregiver must be sensitive to each patient’s needs and provid
e hope.
Tolerance
There is a criterion by which you can judge whether the thought
s you are thinking and the things you are doing are right for you
. The criterion is: Have they brought you inner peace? If they ha
ve not, there is something wrong with them—
so keep seeking! If what you do has brought you inner peace, st
ay with what you believe is right.
—Peace Pilgrim
Tolerance can be viewed in two ways, positive or negative. (1)
Positive tolerance implies that a person accepts differences in ot
hers and that one does not expect others to believe, think, speak
, or act as himself or herself. Tolerant people are generally free
of prejudice and discrimination. Recognizing this fact, Thomas
Jefferson incorporated theories of tolerance into the U.S. Consti
tution. (2) Negative tolerance implies that one will reluctantly p
ut up with another’s beliefs. In other words, they simply tolerat
e the view of others.

Although tolerance can be viewed as a virtue, not all tolerance i
s virtuous nor is all intolerance necessarily wrong. An exaggerat
ed tolerance may amount to a vice, whereas intolerance may so
metimes be a virtue. For example, tolerating everything regardle
ss of its repugnance (e.g., persecution for religious beliefs) is n
o virtue, and having intolerance for that which should not be tol
erated and is evil is no vice (e.g., brainwashing children to do e
vil).
Forgiveness
Forgiveness is a virtue of the brave.
—Indira Gandhi
Forgiveness is a virtue and a value. It is the willingness to pard
on someone who has wronged you in some way. It is also a form
of mercy. Forgiveness is to forgive and let loose the bonds of b
lame. It is a form of cleansing souls for both those who forgive
and those who accept the forgiveness offered.
Forbearing one another, and forgiving one another, if any man h
ave a quarrel against any: even as Christ forgave you, so also do
ye.
—Colossians 3:13 (King James Version [KJV])
3.6 RELIGIOUS ETHICS AND SPIRITUALITY
The Great Physician: Dear Lord, You are the Great Physician, I
turn to you in my sickness asking for your help. I place myself
under your loving care, praying that I may know your healing gr
ace and wholeness. Help me to find love in this strange world a
nd to feel your presence by my bed both day and night. Give my
doctors and nurses wisdom that they may understand my illness
. Steady and guide them with your strong hand. Reach out your
hand to me and touch my life with your peace. Amen.
—University of Pennsylvania Health System
Religion serves a moral purpose by providing codes of conduct f
or appropriate behavior through revelations from a divine sourc

e. These codes of conduct are enforced through fear of pain and
suffering and/or hope for reward in the next life for adhering to
religious codes and beliefs. Evidence of belief in an afterlife, da
ting between 58,000 and 68,000 BC, was found in Neanderthal b
urial sites, where various implements and supplies were buried
with the deceased. The prospect of divine justice helps us to tol
erate the injustices in this life where goodness is no guarantee o
f peace, happiness, wellness, or prosperity.
Religion is often used as a reason to justify what, otherwise, co
uld be considered unjustifiable behavior. Political leaders often
use religion to legitimize and consolidate their power. Leaders i
n democratic societies speak of the necessity to respect the right
to “freedom of religion.” Militarily, political leaders often use
religion to further their political aspirations, using “God is on o
ur side” propaganda. Jihad often is referred to as a holy war aga
inst infidels (nonbelievers), the purpose of which is to expand t
he territories of Muslim nations. This, however, is not unique to
Muslim nations. Many political leaders have used religion to ju
stify their actions. Religious persecution has plagued humankin
d from the beginning of time. The atrocities of evil men strappi
ng bombs to women and children are but a few of the numerous
examples of what has occurred throughout the ages.
Many Think God’s Intervention Can Revive the Dying
When it comes to saving lives, God trumps doctors for many A
mericans. An eye-
opening survey reveals widespread belief that divine interventio
n can revive dying patients. And, researchers said, doctors “nee
d to be prepared to deal with families who are waiting for a mir
acle.”
—
Lindsey Tanner, “Many Believe God Can Revive the Dying,” Th
e Capital, August 19, 2008
Spirituality in the religious sense implies that there is purpose a
nd meaning to life; spirituality generally refers to faith in a high
er being. For a patient, injury and sickness are frightening exper

iences. This fear is often heightened when the patient is admitte
d to a hospital or nursing home. Healthcare organizations can he
lp reduce patient fears by making available to them appropriate
emotional and spiritual support and coping resources. It is a wel
l-
proven fact that patients who are able to draw on their spirituali
ty and religious beliefs tend to have a more comfortable and oft
en improved healing experience. To assist both patients and car
egivers in addressing spiritual needs, patients should be provide
d with information as to how their spiritual needs can be addres
sed.
Difficult questions regarding a patient’s spiritual needs and how
to meet those needs are best addressed on admission by first co
llecting information about the patient’s religious or spiritual pre
ferences. Caregivers often find it difficult to discuss spiritual is
sues for fear of offending a patient who may have beliefs differe
nt from their own. If caregivers know from admission records a
patient’s religious beliefs, the caregiver can share with the patie
nt those religious and spiritual resources available in the hospit
al and community.
A variety of religious beliefs are presented here to note the imp
ortance of better understanding why patients differ in decision-
making processes and how religion affects one’s beliefs, and to
encourage further study of how each religion affects the decisio
n-
making process. Hospitals often maintain a directory of contacts
for various religious groups for referral and consultation purpo
ses.
Judaism
Jewish Law is the unchangeable 613 mitzvot (commandments) t
hat God gave to the Jews. Halakhah (Jewish Law) comes from t
hree sources: (1) the Torah (the first five books of the Bible); (2
) laws instituted by the rabbis; and (3) long-
standing customs. The Jewish People is another name for the Ch
ildren of Israel, referring to the Jews as a nation in the classical
sense, meaning a group of people with a shared history and a se

nse of a group identity rather than a specific place or political p
ersuasion.16
Judaism is a monotheistic religion based on principles and ethic
s embodied in the Hebrew Bible (Old Testament). The notion of
right and wrong is not so much an object of philosophical inquir
y as an acceptance of divine revelation. Moses, for example, rec
eived a list of 10 laws directly from God. These laws were know
n as the Ten Commandments. Some of the Ten Commandments
are related to the basic principles of justice that have been adhe
red to by society since they were first proclaimed and published
. For some societies, the Ten Commandments were a turning poi
nt, where essential commands such as “thou shalt not kill” or “t
hou shalt not commit adultery” were accepted as law. When cari
ng for the dying, family members will normally want to be prese
nt and prayers said. If a rabbi is requested, the patient’s own rab
bi should be contacted first.17
Hinduism
Hinduism is a polytheistic religion with many gods and goddess
es. Hindus believe that God is everything and is infinite. The ea
rliest known Hindu Scriptures were recorded around 1200 BC.
Hindus believe in reincarnation and that one’s present condition
is a reflection of one’s virtuous behavior, or lack thereof, in a p
revious lifetime.
When caring for the dying, relatives may wish to perform rituals
at this time. In death, jewelry, sacred threads, or other religious
objects should not be removed from the body. Washing the bod
y is part of the funeral rites and should be carried out by the rel
atives.18
Buddhism
Buddhism is a religion and philosophy encompassing a variety o
f traditions, beliefs, and practices, largely based on teachings at
tributed to the Indian prince named Siddhartha Gautama (563–
483 BC). He went on a spiritual quest and eventually became en
lightened at the age of 35, and from there on, he took the name
Buddha. Simply defined, Buddhism is a religion to some and a p
hilosophy to others that encourages one “to do good, avoid evil,

and purify the mind.”
When caring for the dying, Buddhists like to be informed about
their health status in order to prepare themselves spiritually. A s
ide room with privacy is preferred.19
Falun Gong
Falun Gong, also referred to as Falun Dafa, is a traditional Chin
ese spiritual discipline belonging to the Buddhist school of thou
ght. It consists of moral teachings, meditation, and four exercise
s that resemble tai chi and are known in Chinese culture as qigo
ng. Falun Gong does not involve physical places of worship, for
mal hierarchies, rituals, or membership and is taught without ch
arge. The three principles practiced by the followers are truthful
ness, compassion, and forbearance/tolerance toward others. Falu
n Gong claims followers in 100 countries.
Zen
Zen evolved from Buddhism in Tibet. It emphasizes dharma pra
ctice (from the master to the disciple) and experiential wisdom
based on learning through the reflection on doing, going beyond
scriptural readings. In Zen, Buddhism learning comes through a
form of seated meditation known as zazen, where practitioners
perform meditation to calm the body and the mind, experience i
nsight into the nature of existence, and thereby gain enlightenm
ent.
Taoism
Taoists believe that ultimate reality is unknowable and unpercei
vable. The founder of Taoism is believed to be Lao Tzu (6 BC).
Taoist doctrine includes the belief that the proper way of living
involves being in tune with nature. Everything is ultimately inte
rblended and interacts.
Christianity
Christians accept both the Old and New Testament as being the
word of God. The New Testament describes Jesus as being God,
taking the form of man. He was born of the Virgin Mary and sa
crificed his life by suffering crucifixion, and after being raised f
rom the dead on the third day, he ascended into Heaven from wh
ich he will return to raise the dead, at which time the spiritual b

ody will be united with the physical body. His death, burial, and
resurrection provide a way of salvation through belief in Him f
or the forgiveness of sin. God is believed to be manifest in three
persons: the Father, Son, and Holy Spirit.
The primary and final authority for Christian ethics is found in t
he life, teachings, ministry, death, and resurrection of Jesus Chr
ist. He clarified the ethical demands of a God-
centered life by applying the obedient love that was required of
Peter. The Ten Commandments are accepted and practiced by bo
th Christians and Jews.
Christians, when determining what the right thing to do is, often
refer to the Golden Rule, which teaches, “do unto others as you
would have them do unto you,” a common principle in many m
oral codes and religions.
There have been and continue to be numerous interpretations of
the meaning of the scriptures and its different passages. This ha
s resulted in a plethora of churches with varying beliefs. As not
ed later, such beliefs can affect a patient’s wishes for health car
e. However, the heart of Christian beliefs is found in the book o
f John, Chapter 3, Verse 16:
For God so loved the world, that he gave his only begotten and
Son, that whosoever believeth in him should not perish, but hav
e everlasting life.
—John 3:16 (KJV)
The Apostle Paul proclaimed that salvation cannot be gained thr
ough good works, but through faith in Jesus Christ as savior. He
recognized the importance of faith in Christ over good works in
the pursuit of salvation.
That if thou shalt confess with thy mouth the Lord Jesus, and sh
alt believe in thine heart that God hath raised him from the dead
, thou shalt be saved.
—Romans 10:9 (KJV)
The Apostle Paul, however, did not dismiss the importance of g
ood works. Good works are described as the fruit of one’s faith.

In other words, good works follow faith.
When caring for the dying, services of the in-
house chaplain and/or one’s religious minister should be offered
to the patient. A Catholic priest should be offered when last rit
es need to be administered to those of the Catholic faith.
Islam
The Islamic religion believes there is one God: Allah. Muhamm
ad (570–
632 AD) is considered to be a prophet/messenger of God. He is
believed to have received revelations from God. These revelatio
ns were recorded in the Qur’an, the Muslim Holy Book. Muslim
s accept Moses and Jesus as prophets of God. The Qur’an is beli
eved to supersede that of the Torah and the Bible. Muslims beli
eve that there is no need for God’s grace and that their own acti
ons can merit God’s mercy and goodness. Humans are believed t
o have a moral responsibility to submit to God’s will and to foll
ow Islam as demonstrated in the Qur’an.
When caring for the dying, patients may want to die facing Mec
ca (toward the southeast) and be with relatives. Many Muslims f
ollow strict rules in respect of the body after death.20
Religious Beliefs and Duty Conflict
Religious beliefs and codes of conduct sometimes conflict with
the ethical duty of caregivers to save lives. Jehovah’s Witnesses
, for example, believe that it is a sin to accept a blood transfusio
n since the Bible states that we must “abstain from blood” (Acts
15:29). Current Jehovah’s Witness doctrine, in part, states that
blood must not be transfused. In order to respect this belief, blo
odless surgery is available in a number of hospitals to patients
who find it against their religious beliefs to receive a blood tran
sfusion.
The right to refuse a blood transfusion or any other treatment m
ust be honored even in emergent situations where the patient is
unconscious. Whether for a parent or child it may become neces
sary to seek a court’s guidance to make exceptions for such tran
sfusions. Because time is of the essence in many cases, it is imp
ortant that the legal system (e.g., legislative bodies and the cour

ts) work with hospitals and the church to provide guidance in ad
vance in order to protect caregivers while also respecting the rig
hts of patients.
3.7 SECULAR ETHICS
Unlike religious ethics, secular ethics are based on codes develo
ped by societies that have relied on customs to formulate their c
odes. The Code of Hammurabi, for example, carved on a black
Babylonian column 8 feet high, now located in the Louvre in Pa
ris, depicts a mythical sun god presenting a code of laws to Ham
murabi, a great military leader and ruler of Babylon (1795–
1750 BC). Hammurabi’s code of laws is an early example of a r
uler proclaiming to his people an entire body of laws. The follo
wing excerpts are from the Code of Hammurabi.
Code of Hammurabi
215
If a physician make a large incision with an operating knife and
cure it, or if he open a tumor (over the eye) with an operating k
nife, and saves the eye, he shall receive ten shekels in money.
218
If a physician make a large incision with the operating knife, an
d kill him, or open a tumor with the operating knife, and cut out
the eye, his hands shall be cut off.
219
If a physician make a large incision in the slave of a freed man,
and kill him, he shall replace the slave with another slave.
221
If a physician heal the broken bone or diseased soft part of a ma
n, the patient shall pay the physician five shekels in money.
3.8 PROFESSIONAL ETHICS
My life is my message.
—Mahatma Gandhi
Professional ethics are standards or codes of conduct establishe
d by the membership of a specific profession. Most professions
have a code of ethics designed to describe what is right and wro

ng conduct, including acceptable behaviors and expectations of
a profession’s membership. Professionals are expected to follow
ethical guidelines in the practice of their profession.
Healthcare professionals are governed by ethical codes that dem
and a high level of integrity, honesty, and responsibility. It is th
e direct caregiver who is often confronted with complex ethical
dilemmas in the delivery of patient care. Because of the ethical
dilemmas facing healthcare providers, professional codes of ethi
cs have been developed to provide guidance.
Codes of ethics are created in response to actual or anticipated e
thical conflicts. Considered in a vacuum, many codes of ethics
would be difficult to comprehend or interpret. It is only in the c
ontext of real life and real ethical ambiguity that the codes take
on any meaning.
Codes of ethics and case studies need each other. Without guidi
ng principles, case studies are difficult to evaluate and analyze;
without context, codes of ethics are incomprehensible. The best
way to use these codes is to apply them to a variety of situation
s and see what results. It is from the back and forth evaluation o
f the codes and the cases that thoughtful moral judgments can b
est arise.21
The Center for the Study of Ethics in the Professions at the Illin
ois Institute of Technology received a grant from the National S
cience Foundation to put a collection of over 850 codes of ethic
s on the Internet. This center’s website includes links to the ethi
cal codes of professional societies, corporations, government ag
encies, and academic institutions. Additional information can be
found at their website: http://www.iit.edu/departments/csep/Pu
blicWWW/codes/index.html.
The contents of codes of ethics vary depending on the risks asso
ciated with a particular profession. For example, ethical codes f
or psychologists define relationships with clients in greater dept
h because of the personal one-to-
one relationship they have with their clients. Laboratory technic
ians and technologists, on the other hand, generally have little o
r no personal contact with patients but can have a significant im

pact on their care. In their ethical code, laboratory technologists
pledge accuracy and reliability in the performance of tests. The
importance of this pledge was borne out in a March 11, 2004, r
eport by the Baltimore Sun, whereby state health officials disco
vered that a hospital’s laboratory personnel overrode controls in
testing equipment showing results that might be in error and th
en mailed them to patients anyway.
The following cases illustrate some examples of ethical miscond
uct involving health professionals.
Documentation Falsified
The nurse in Williams v. Bd. of Exam’rs for Prof. Nurses22 imp
roperly, incompletely, or illegibly documented the delivery of n
ursing care and failed to adhere to established standards in the p
ractice setting to safeguard patient care. Based on these findings
, the hearing examiner determined that the nurse was guilty of c
onduct derogatory to the morals or standing of the profession of
registered nursing. The West Virginia Board of Examiners for
Registered Professional Nurses has the power to deny, revoke, o
r suspend any license to practice registered professional nursing
upon proof that the nurse is guilty of conduct derogatory to the
morals or standing of the profession of registered nursing. Cond
uct that qualifies as derogatory to the morals or standing of the
nursing profession includes improperly, incompletely, or illegib
ly documenting the delivery of nursing care.
The board proved that the nurse improperly documented the deli
very of nursing care. Williams specifically charted that she was
in the client’s home during lunch hours. The agency, however, i
n reviewing its time sheets found that a homemaker was in the p
atient’s home during lunch hours. Upon its review of the board’
s action, the circuit court upheld the board’s action. The appella
te court affirmed the order of the circuit court.
Psychologist’s Sexual Misconduct
The defendant-
psychologist in Gilmore v. Board of Psychologist Examiners23
claimed that sexual improprieties with clients did not take place
during treatment sessions. The board of psychologist examiners

revoked the psychologist’s license for sexual improprieties. Th
e psychologist petitioned for judicial review. She argued that th
erapy had terminated before the sexual relationships began. The
court of appeals held that evidence supported the board’s concl
usion that the psychologist violated an ethical standard in carin
g for her patients. When a psychologist’s personal interests intr
ude into the practitioner–
client relationship, the practitioner is obliged to recreate objecti
vity through a third party. The board’s findings and conclusions
indicated that the petitioner failed to maintain that objectivity.
Attorney–Minister Misconduct
A minister was paid by an attorney to attend a hospital chaplain
’s course in furtherance of a plan whereby the minister could ga
in access to the emergency areas of a hospital in order to solicit
patients and their families for the purpose of aiding the attorney
in gaining legal cases based on negligence and malpractice. Th
e improper solicitations were a part of organized schemes that l
asted for years with multiple offenses, including two different s
chemes that led to at least 22 improper solicitations. Disbarment
was decided to be appropriate with respect to an attorney who h
ired an ordained minister as a paralegal.24
3.9 ETHICS COMMITTEE
I expect to pass through the world but once. Any good therefore
that I can do, or any kindness I can show to any creature, let m
e do it now. Let me not defer it, for I shall not pass this way aga
in.
—Stephen Grellet25
Healthcare ethics committees address legal–
ethical issues that arise during the course of a patient’s care and
treatment. They serve as a resource for patients, families, and s
taff and offer objective counsel when dealing with difficult heal
thcare issues. Ethics committees provide both educational and c
onsultative services to patients, families, and caregivers. They e
nhance, but do not replace, important patient/family–
physician relationships; nevertheless, they afford support for de

cisions made within those relationships. The numerous ethical q
uestions facing health professionals involve the entire life span,
from the right to be born to the right to die. Ethics committees
concern themselves with issues of morality, patient autonomy, l
egislation, and states’ interests.
Although ethics committees first emerged in the 1960s in the Un
ited States, attention was focused on them in the 1976 landmark
Quinlan case,26 where the parents of Karen Ann Quinlan were
granted permission by the New Jersey Supreme Court to remove
Karen from a ventilator after she had been in a coma for a year.
She died 10 years later at the age of 31, having been in a persis
tent vegetative state the entire time. The Quinlan court looked t
o a prognosis committee to verify Karen’s medical condition. It
then factored in the committee’s opinion with all other evidence
to reach the decision to allow withdrawing her life-
support equipment. To date, ethics committees do not have sole
surrogate decision-
making authority; however, they play an ever-
expanding role in the development of policy and procedural gui
delines to assist in resolving ethical dilemmas. Most organizatio
ns describe the functioning of the ethics committee and how to a
ccess the committee at the time of admission in patient handboo
ks and informational brochures.
Committee Structure
To be successful, an ethics committee should be structured to in
clude a wide range of community leaders in positions of politica
l stature, respect, and diversity. The ethics committee should be
comprised of a multidisciplinary group of people, whose memb
ership should include an ethicist, educators, clinicians, legal ad
visors, and political leaders as well as members of the clergy, a
quality improvement manager, and corporate leaders from the b
usiness community. Ethics committees, all too often, are compri
sed mostly of hospital employees and members of the medical st
aff with a token representation from the community.
Goals of Ethics Committees
The goals of ethics committees often include support, by provid

ing guidance to patients, families, and decision makers; reviewi
ng cases, as requested, when there are conflicts in basic values;
providing assistance in clarifying situations that are ethical, leg
al, or religious in nature and extend beyond the scope of daily p
ractice; assisting in clarifying issues to discuss alternatives and
compromises; promoting the rights of patients; assisting the pati
ent and family, as appropriate, in coming to consensus with the
options that best meet the patient’s care needs; promoting fair p
olicies and procedures that maximize the likelihood of achievin
g good, patient-
centered outcomes; and enhancing the ethical tenor of both healt
hcare organizations and professionals.
Committee Functions
The functions of ethics committees are multifaceted and include
development of policy and procedure guidelines to assist in res
olving ethical dilemmas; staff and community education; conflic
t resolution; case reviews, support, and consultation; and politic
al advocacy. The degree to which an ethics committee serves ea
ch of these functions varies in different healthcare organizations
.
Policy and Procedure Development
The ethics committee is a valuable resource for developing hosp
ital policies and procedures to provide guidance to healthcare pr
ofessionals when addressing ethical dilemmas.
Educational Role
The ethics committee helps to develop resources for educational
purposes to help both in-
hospital and ambulatory staff develop the appropriate competen
cies for addressing legal, ethical, and spiritual issues. Education
al programs on ethical issues are developed for ethics committe
e members, staff, patients, and the community (e.g., how to prep
are an advance directive).
Understanding the spiritual needs of patients of varying beliefs
should be a component of the education, policy development, an
d consultative functions of ethics committees. Most hospitals pr
ovide staff with resources that describe various religious beliefs

and how to access those resources for patients of various religi
ous persuasions.
Consultation and Conflict Resolution
Ethics consultations are helpful in resolving uncertainty and dis
agreements over healthcare dilemmas. Ethics committees often
provide consultation services for patients, families, and caregiv
ers struggling with difficult treatment decisions and end-of-
life dilemmas. Always mindful of its basic orientation toward th
e patient’s best interests, the committee provides options and su
ggestions for resolution of conflict in actual cases. Consultation
with an ethics committee is not mandatory, but is conducted at
the request of a physician, patient, family member, or other care
giver.
The ethics committee strives to provide viable alternatives that
will lead to the optimal resolution of dilemmas confronting the
continuing care of the patient. It is important to remember that a
n ethics committee functions in an advisory capacity and should
not be considered a substitute proxy for the patient.
Requests for Consultations
Requests for ethics consultations often involve clarification of i
ssues regarding decision-
making capacity, informed consent, advance directives, and wit
hdrawal of treatment. Consultations should be conducted in a ti
mely manner considering, for example, who requested the consu
ltation, what are the issues, is there a problem that needs referra
l to another service, and what specifically is being requested of
the ethics committee?
When conducting a consultation, all patient records must be revi
ewed and discussed with the attending physician, family membe
rs, and other caregivers involved in the patient’s treatment. If a
n issue can be resolved easily, a designated member of the ethic
s committee should be able to consult on the case without the ne
ed for a full committee meeting. If the problem is unusual, probl
ematic, or delicate, or has important legal ramifications, a full c
ommittee meeting should be called. Others who can be invited t
o an ethics committee case review, as appropriate, include the p

atient, if competent; relatives, agents, or surrogate decision mak
ers; and caregivers.
Pre-
evaluation case consultations should take the following into con
sideration: the patient’s current medical status, diagnosis, and p
rognosis; the patient’s mental status and ability to make decisio
ns, understand the information that is necessary to make a decisi
on, and clearly understand the consequences of one’s choice; be
nefits and burdens of recommended treatment or alternative trea
tments; life expectancy, treated and untreated; views of caregive
rs and consultants; pain and suffering; quality-of-
life issues; and the financial burden on family (e.g., if the patie
nt is in a comatose state with no hope of recovery, should the sp
ouse deplete his or her finances to maintain the spouse on a resp
irator?).
Decisions concerning patient care must take into consideration t
he patient’s personal assessment of the quality of life; current e
xpressed choices; advance directives; competency to make decis
ions; ability to process information rationally to compare risks,
benefits, and alternatives to treatment; ability to articulate majo
r factors in decisions and reasons for them; and ability to comm
unicate.
The patient must have all the information necessary to allow a r
easonable person to make a prudent decision on his or her own b
ehalf. The patient’s choice must be voluntary and free from coer
cion by family, physicians, or others.
Family members must be identified, and the following questions
must be considered when making decisions: Do family member
s understand the patient’s wishes; is the family in agreement wit
h the patient’s wishes; does the patient have an advance directiv
e; has the patient appointed a surrogate decision maker; are ther
e any religious proscriptions; are there any financial concerns; a
nd are there any legal factors (applicable state statutes and case
law)?
When an ethics committee is engaged in the consulting process,
its recommendations should be offered as suggestions, imposing

no obligation for acceptance on the part of the patient, organiza
tion, its governing body, medical staff, attending physicians, or
other persons. An example of an ethics committee consultation f
orm is presented in Exhibit 3-1.
When conducting a formal consultation, ethics committees shoul
d identify the ethical dilemma (i.e., reasons why the consult was
requested); be sure that the appropriate “Consultation Request”
form has been completed; identify relevant facts (e.g., diagnosi
s and prognosis, patient goals and wishes, regulatory and legal i
ssues, professional standards and codes of ethics, institutional p
olicies and values); identify stakeholders; identify moral issues
(e.g., human dignity, common good, justice, beneficence, respec
t for autonomy, informed consent, medical futility); identify leg
al issues; consider alternative options; conduct consultation (rev
iew, discuss, and provide reasoning for recommendations); revie
w and follow up; include family members in committee discussi
on; ask family members what their hopes and expectations are; a
nd document consultations.
Expanding Role of the Ethics Committee
The role of an organization’s ethics committee is evolving into
more than a group of individuals who periodically gather togeth
er to meet regulatory requirements and review and address adva
nce directives and end-of-
life issues. The function of an organizational ethics committee h
as an ever-expanding role as noted below.
The wide variety of ethical issues that an ethics committee can
be involved in is somewhat formidable. Although an ethics com
mittee cannot address every issue that one could conceivably im
agine, the ethics committee should periodically reevaluate its sc
ope of activities and effectiveness in addressing ethical issues.
• Dilemma of blind trials: Who gets the placebo when the inves
tigational drug looks very promising?
• Informed consent: Are patients adequately informed as to the
risks, benefits, and alternative procedures that may be equally e
ffective, knowing that one procedure may be more risky or dam
aging than another (e.g., lumpectomy versus a radical mastecto

my)?
EXHIBIT 3-1 Ethics Committee Consultation
• What is the physician’s responsibility for informing the patien
t of his or her education, training, qualifications, and skill in tre
ating a medical condition or performing an invasive procedure?
• What is the role of the ethics committee when the medical sta
ff is reluctant or fails to take timely action, knowing that one of
its members practices questionable medicine?
• Should a hospital’s medical staff practice evidence-
based medicine or follow its own best judgment?
• To what extent should the organization participate in and/or s
upport genetic research?
• How should the ethics committee address confidentiality issue
s?
• To what extent should medical information be shared with the
patient’s family?
• To what extent should the organization’s leadership control th
e scope of issues that the ethics committee addresses?
• Who provides information to the patient when mistakes are m
ade relative to his or her care?
Although organizational politics may prevent an ethics committ
ee from becoming involved in many of the issues just described,
ethics committees need to review their functions periodically a
nd redefine themselves. The ethics committee’s involvement in t
he organizational setting has been for the most part strictly advi
sory. However, its full potential and value to an organization ha
s yet to be fully understood and accepted. The ethics committee
membership should provide a full assessment of its activities on
an annual basis to the organization’s leadership, along with sug
gested goals for expanding its role within the organization.
Ethics Committee Serves as Guardian
The Kentucky Supreme Court ruled in Woods v. Commonwealth
27 that Kentucky’s Living Will Directive, allowing a court-
appointed guardian or other designated surrogate to remove a pa
tient’s life support systems, is constitutional. The patient in this

case, Woods, had been placed on a ventilator after having a hea
rt attack. It was generally agreed that he would never regain con
sciousness and would die in 2 to 10 years. After a recommendati
on of the hospital ethics committee, Woods’s guardian at the ti
me asked for approval to remove Woods’s life support. The Ken
tucky Supreme Court affirmed an appeals court decision, holdin
g that:
• If there is no guardian, but the family, physicians, and ethics
committee all agree with the surrogate, there is no need to appoi
nt a guardian.
• If there is a guardian and all parties agree, there is no need fo
r judicial approval.
• If there is disagreement, the parties may petition the courts.28
Removal of life support will be prohibited, absent clear and con
vincing evidence that the patient is permanently unconscious or
is in a persistent vegetative state.
Convening the Ethics Committee
The ethics committee is not a decision maker, but a resource tha
t provides advice to help guide others in making wiser decisions
when there is no clear best choice. A unanimous opinion is not
always possible when an ethics committee convenes to consider
the issues of an ethical dilemma; however, consultative advice a
s to a course of action to resolve the dilemma is often the role o
f the ethics committee. Any recommendations for issue resolutio
n reached by the ethics committee must be communicated to tho
se most closely involved with the patient’s care. Sensitivity to e
ach family member’s values and assisting them in coping with w
hatever consensus decision is reached is a must. Unresolved iss
ues often need to be addressed and a course of action followed.
Each new consultation presents new opportunities for learning a
nd teaching others how to cope with similar issues. Guidelines f
or resolving ethical issues will always be in a state of flux. Eac
h new case presents new challenges and learning opportunities.
Making a decision and suggesting a course of action requires ac
cepting the fact that there will be elements of right and wrong i
n the final decision. The idea is to cause the least pain and provi

de the greatest benefit.
Failure to Convene Bioethics Committee
In a medical malpractice suit, the Stolles (appellants) sought da
mages from physicians and hospitals (appellees) for disregard o
f their instructions not to use “heroic efforts” or artificial means
to prolong the life of their child, Mariel, who was born with br
ain damage. The Stolles argued that such negligence resulted in
further brain damage to Mariel, prolonged her life, and caused t
hem extraordinary costs that will continue as long as the child li
ves. The Stolles had executed a written “Directive to Physicians
” on behalf of Mariel in which they made known their desire tha
t Mariel’s life not be artificially prolonged under the circumstan
ces provided in that directive.
Mariel suffered a medical episode after regurgitating her food.
An unnamed, unidentified nurse–
clinician administered chest compressions for 30 to 60 seconds,
and Mariel survived. The Stolles sued, alleging the following, a
mong other things:
• Appropriate medical entries were not made in the medical rec
ord to reflect the Stolles’ wishes that caregivers refrain from “h
eroic” life-sustaining measures.
• Lifesaving measures were initiated in violation of the physicia
n’s orders. The hospital did not follow the physician’s orders, w
hich were in Mariel’s medical chart, when chest compressions a
nd mechanically administered breathing to artificially prolong
Mariel’s life were applied, and a bioethics committee meeting w
as not convened to consider the Stolles’ wishes and the necessit
y of a do-not-resuscitate (DNR) order.
The central issue in this case is whether appellees are immune fr
om liability under the Texas Natural Death Act. Section 672.016
(b) of the Texas Natural Death Act provides the following: “A p
hysician, or a health professional acting under the direction of a
physician, is not civilly or criminally liable for failing to effect
uate a qualified patient’s directive” [Tex. Health & Safety Code
Ann. A4 672.016(b) (Vernon 1992)]. A “qualified patient” is a
“patient with a terminal condition that has been diagnosed and c

ertified in writing by the attending physician and one other phys
ician who have personally examined the patient.” A “terminal c
ondition” is an “incurable condition caused by injury, disease, o
r illness that would produce death regardless of the application
of life-
sustaining procedures, according to reasonable medical judgmen
t, and in which the application of life-
sustaining procedures serves only to postpone the moment of th
e patient’s death.”
Mariel was not in a terminal condition, as appellees alleged. Th
e Stolles failed to cite any authority that would have allowed th
e withdrawal of life-
sustaining procedures in a lawful manner. The Texas Natural De
ath Act, therefore, provided immunity to the caregivers for their
actions in the treatment and care of Mariel.29
Patient Not in a Persistent Vegetative State
A guardian may only direct the withdrawal of life-
sustaining medical treatment, including nutrition and hydration,
if the incompetent ward is in a persistent vegetative state and th
e decision to withdraw is in the best interests of the ward.
Edna’s sister and court-
appointed guardian, Spahn, sought permission to direct the with
holding of Edna’s nutrition, claiming that her sister would not w
ant to live in this condition; however, the only testimony presen
ted at trial regarding Edna’s views on the use of life-
sustaining medical treatment involves a statement made 30 year
s earlier. At that time, Spahn and Edna were having a conversati
on about their mother, who was recovering from depression, and
Spahn’s mother-in-
law, who was dying of cancer. Spahn testified that during this c
onversation, Edna said to her that she would rather die of cancer
than lose her mind. Spahn further testified that this was the onl
y time that she and Edna discussed the subject and that Edna ne
ver said anything specifically about withholding or withdrawing
life-
sustaining medical treatment. The “ethics committee” at the nur

sing facility where Edna lives met to discuss the issue of withho
lding artificial nutrition from Edna. The committee approved wi
thholding nutrition if no family member objected; however, one
of Edna’s nieces refused to sign a statement approving the with
drawal of nutrition.
The record speaks very little to what Edna’s desires would be, a
nd there was no clear statement of what her desires would be to
day under the current conditions. Her friends and family never h
ad any conversations with her discussing her feelings or opinion
s about withdrawing nutrition or hydration, and she did not exec
ute any advance directives expressing her wishes while she was
competent.
Consequently, the court held that a guardian may only direct the
withdrawal of life-
sustaining medical treatment, including nutrition and hydration,
if the incompetent ward is in a persistent vegetative state and th
e decision to withdraw is in the best interests of the ward. In thi
s case, where the only indication of Edna’s desires was made at
least 30 years ago and under different circumstances, there is no
t a clear statement of intent such that Edna’s guardian may auth
orize the withholding of her nutrition.
The circuit judge concluded his own questioning of one member
of the ethics committee, “The way I understand it, what you rea
lly have is a liability problem, and that’s why you want everybo
dy to consent, is that correct?” Dr. Erickson answered, “That is
correct.”30
3.10 REASONING AND DECISION MAKING
Reason guides our attempt to understand the world about us. Bo
th reason and compassion guide our efforts to apply that knowle
dge ethically, to understand other people, and have ethical relati
onships with other people.
—Molleen Matsumura
Reasoning is the process of forming conclusions, judgments, or
inferences based on one’s interpretation of facts or premises tha
t help support a conclusion. Reasoning includes the capacity for

logical inference and the ability to conduct inquiry, solve probl
ems, evaluate, criticize, and deliberate about how we should act
and to reach an understanding of other people, the world, and ou
rselves.31Partial reasoning involves bias for or against a person
based on one’s relationship with that person. Circular reasonin
g describes a person who has already made up his or her mind o
n a particular issue and sees no need for deliberation (i.e., “Don
’t confuse me with the facts”). For example, consider the follow
ing: “Mr. Smith has lived a good life. It’s time to pull the plug.
He is over 65 and, therefore, should not have any rights to donat
ed organs. Donated organs should be given to younger people.”
The rightness or wrongness of this statement is a moral issue an
d should be open for discussion, fact-
finding, evaluation, reasoning, and consensus decision making.
Ethical Dilemmas
Ethical dilemmas arise when ethical principles and values are in
conflict. Healthcare dilemmas often occur when there are altern
ative choices, limited resources, and differing values among pat
ients, family members, and caregivers. An ethical dilemma arise
s when, for example, the principles of autonomy and beneficenc
e conflict with one another. Coming to an agreement may mean
sacrificing one’s personal wishes and following the road where t
here is consensus. Consensus building can happen only when th
e parties involved can sit and reason together. The process of id
entifying the various alternatives to an ethical dilemma, determi
ning the pros and cons of each choice, and making informed dec
isions requires a clear, unbiased willingness to listen, learn, and
, in the end, make an informed decision. Remember that ethical
decision making is the process of determining the right thing to
do in the event of a moral dilemma.
3.11 MORAL COMPASS GONE ASTRAY
The world is a dangerous place. Not because of the people who
are evil; but because of the people who don’t do anything about
it.
—Albert Einstein

Political corruption, antisocial behavior, declining civility, and
rampant unethical conduct have heightened discussions over the
nation’s moral decline and decaying value systems. The numero
us instances of questionable political decisions; numbers-
cooking executives with exorbitant salaries, including healthcar
e executives working for both for-
profit and nonprofit organizations; cheating at work and in scho
ol; and the proliferation of X-
rated websites have contributed to this decline. Legislators, inve
stigators, prosecutors, and the courts are finally stepping up to t
he plate and are taking action. The question, however, remains:
Can this boat be turned around, or are we just plugging the hole
s with new laws and creating more leaks in a misdirected sinkin
g boat? The answer is more likely to be a return to practicing th
e values upon which this nation was founded.
The continuing trend of consumer awareness of declining value
systems, coupled with increased governmental regulations, man
dates that caregivers understand ethics and the law and their int
errelationships.
The saying goes that if you do not learn from history, you are d
oomed to repeat it. If you have not learned and do not apply the
generally accepted moral principles (e.g., do good and do no har
m) and the moral values (e.g., respect and compassion) describe
d in this chapter, you will not have a moral compass to guide yo
u.
SUMMARY THOUGHT
Be careful of your thoughts, for your thoughts inspire your word
s. Be careful of your words, for your words precede your action
s. Be careful of your actions, for your actions become your habi
ts. Be careful of your habits, for your habits build your characte
r. Be careful of your character, for your character decides your
destiny.
—Chinese Proverb
We No Longer Have Moral Compass

Hartford Police Chief Daryl Roberts questioned the city’s “mora
l compass” a week after bystanders and drivers maneuvered aro
und the motionless body of 78-year-old victim of a hit-and-
run crash….
“At the end of the day we’ve got to look at ourselves and unders
tand that our moral values have now changed,” Roberts said. “W
e have no regard for each other.”
—
WFSB.com, “Chief: ‘We No Longer Have Moral Compass,’” Ha
rtford, CT, June 6, 2008
Although you cannot control the amount of time you have in thi
s lifetime, you can control your behavior by adopting the virtues
and values that will define who you are, what you will become,
and how you will be remembered or forgotten.
Become who you want to be and how you want to be remembere
d. The formula is easy and well described in the previous quote
in what has been claimed to be a Chinese proverb. Read it. Rere
ad it. Write it. Memorize it. Display it in your home, at work, a
nd in your car, and most of all, practice it, always remembering
it all begins with thoughts.
My words fly up, my thoughts remain below: Words without tho
ughts never to heaven go.
—William Shakespeare
Control your thoughts, and do not let them control you. As to w
ords, they are the tools of thought. They can be sharper than any
double-
edged sword and hurt, or they can do good and heal. It is never t
oo late to change your thoughts, as long as you have air to breat
he. Your legacy may be short, but it can be powerful.
Helpful Hints
The reason for studying ethical and legal issues is to understand
and help guide others through the decision-
making process as it relates to ethical dilemmas. The following
are some helpful guidelines when faced with ethical dilemmas:
• Be aware of how everyday life is full of ethical decisions and

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