Principles of Stewardship and Role of Nurses as Stewards

1.1 Nurse Leaders as Stewards At the Point of Service Nurse leaders, including clinical nurse
educators, who exercise stewardship at the point of service, may facilitate practicing
nurses' articulation of their shared value priorities, including respect for persons' dignity
and self-determination, as well as equity and fairness. A steward preserves and promotes
what is intrinsically valuable in an experience. Theories of virtue ethics and discourse
ethics supply contexts for clinical nurse educators to clarify how they may facilitate
nurses' articulation of their shared value priorities through particularism and
universalism, as well as how they may safeguard nurses' self-interpretation and
discursive reasoning. Together, clinical nurse educators and nurses may contribute to
management decisions that affect the point of service, and thus the health care organization. 1.2
Stewardship in Health Care, in the Nursing Profession, and of Self The Potential of Stewardship The
potential for improving and enhancing policy outcomes is the predominant positive
potential of stewardship. Another prospect of stewardship is to revive a sense of social purpose
among public sectors of management, together with assisting to restore a sense of trust and
legitimacy to the role of the state. This‘attractiveness’of a stewardship approach may be a realistic
(and achievable) possibility to channel fresh and emerging systems of integrated care in more
socially responsible ways. Stewardship of Nursing The leadership potential of stewardship in
nursing requires new models of delivery of care, and we need to address the ever-changing
nature of the work of a nurse. With evolving new roles in the nursing profession,
collaboration with nursing research colleagues will be required to develop mechanisms of
evaluation and assessment which further refine evidence that supports the essential and
exclusive contributions of the

professional nurse in outcomes of care and prevention. Development and enhancement of the
evidence in research call for nursing stewards who will embark on such issues to
design new financial models in order to constantly build the business side of nursing care delivery
models. Such leadership will become synergistic with the work in the area of stewardship of
the health care system. Future nurse leaders or stewards will be directly centred on working
with nurse practitioners and nurse educators to transform the practice environments in which
they work. The intended outcome is to make practice environments more positive, healthy and
engaging. Areas for dialogue may be within: •patient-population centredness • safety for patients and
health care personnel •the needs of an ageing workforce •increased autonomy for advanced nurse
practitioners •increased respect for the contributions made by professional nurses •clarification of the
caring work of the nurse, and •enhancement of the collaborative practice of the multidisciplinary
health care team. Lastly, but perhaps most importantly, an opportunity for nursing stewardship lies
in the regulatory and accreditation aspects of the profession. Nurse leaders or stewards are
finding themselves collaborating with regulatory boards to improve on standards of
practice, certification and accreditation, thus ensuring that standards and regulations
support the nurse of the future and new models of care delivery, and remain true to a
patient/population-centred health care system. Another aspect is for nurse leaders or stewards to
influence decision-making at the point of service. An‘invigorating’nurse leader or steward is
urgently needed.8 Storch9 insists on nurses creating health care environments that uphold
value-based nursing practice by acknowledging that who one is –one’s mo
ral character –is essential for leadership. Nurse leaders or stewards need to engage
with how this is to be done, utilizing character, dialogue and shared meanings and values.

Stewardship of Self To meet the domains of stewardship in health care and the nursing
profession, it is crucial that nurse leaders engage with the development of self. Succession
planning to develop and nurture a new generation of transformational nurse leaders may be the
only way to achieve this. To meet the concept of lifelong learning, nurse leaders or stewards
will need to use of mentors and personal coaches to assist them in refining skills and
improving competencies.4 Healthy nurse leader stewards will thus become visible and sound
role models within their institutions to maintain the balance between self and
professional fulfillment. The future of nursing is rapidly changing. Things are somewhat chaotic at
times, but the opportunities for stewardship are many and varied. We are ideally suited to serve
as nurse leaders or stewards in all aspects of health care. By embracing the six aims of
health care improvement, the leadership of nursing can be both invigorating and
transformational.
Principle of Stewardship Requires us to appreciate 2 great gifts that a wise and loving God has given;
the earth, with all the natural resource and out own human nature, with its biological, psychological,
social and spiritual capacities. This principle is grounded in the presupposition that God has the
absolute domain over creation and that in so far as man are made in God’s image and likeness, we
have given the limited dominion over creation and are responsible for care. Gifts of human life and
environment be used with profound respect. Human creativity should be used to cultivate nature,
recognizing our limitation and the risk of destroying these gifts. The principles of stewardship
includes but not reducible to concern scarce resources

1.3 Role of Nurses as Stewards

1. PERSONAL Nurses as one of the health service providers and members in health system who
are responsible for giving care to the clients and patients based on ethical issues. They need
ethical knowledge to conduct their appropriate function to manage situations and to give safe and
proper legal and ethical care in today's changing world. With regard to practical care, they always
try to answer the question of“What can I do?,”whereas they should try to answer what is essential to
be done for the patients in the context of ethical principles. Ethics seek the best way of taking care
of the patients as well as the best nursing function. Nurses are responsible for their clinical
function, and their main responsibility is to take care of the clients and patients who deserve
appropriate and safe care. They act based on the values they have selected. These values
form a framework to evaluate their activities influencing their goals, strategies, and
function.

= Although the nurse steward ought to structure educational opportunities that encourage nurses to
shift their epistemology of practice, integrating a virtue-based practical reasoning, a gap remains to
be filled by the steward’s theoretical lens. MacIntyre’s theory of virtue ethics, which is founded in
Aristotle’s concept of phronesis, provides such a lens. This theory extends understanding of virtue-
based practical reasoning, due to its explanation of how character qualities - or self-identity -
influence practical reasoning, specifically how a moral insight may be evoked through a critical
appraisal of situations generating conflict and ambiguity. The nature of lived experiences may be
appraised through drawing on experience, understanding and values, as well as a continuous
dialogue between the experience and theory and practice. This theory finds itself dual premised: it
embraces a form of realism, specifically, that human experience and sensitivity can yield a
knowledge of moral reality whose properties exist outside subjective awareness; and secondly, it is
grounded in a teleological form of understanding that accepts the end’s or goal’s primacy.

2. Social- Nurses advocate for the health promotion educate patients and public on the prevention
of illness and injury, provide care and assist in cure, participate in rehabilitation and provide support.
Nurses help families become healthy by helping them understand the range of emotional, physical,
mental and cultural experiences they encounter during health and illness. Nurses help people and
their families to cope with their illness and deal with it and if necessary live with it, so that their
normal life can continue.

3. Ecological – Nurses can help with waste management. Health care sectors generates tons of waste
from the hospitals and since nurses are the frontlines of care, they can be helpful in coming up with
policies about hospital waste segregation and recycling. Nurses can lead a way for communities to
have a more sustainable way of living.

4.Biomedical – Over the past decades, the nursing profession has faced a tremendous advancement
in technology and medical practice, a nurse should be familiar and well versed with new equipment
and tools that are being used in the hospital and other clinical setting. According to the theory of
Locsin, entitled Technological competency as caring in nursing, a nurse can be a steward of patients
if they know how to use technology to their advantage. Principle of Totality and Its Integrity The
principle of totality states that all decisions in medical ethics must prioritize the good of the entire
person, including physical, psychological and spiritual factors. The principle of totality is used as an
ethical guideline by Catholic healthcare institutions.

Ethico-moral responsibility of nurses in surgery Though often difficult, ethical decision making is
necessary when caring for surgical patients. Perioperative nurses have to recognize ethical dilemmas
and be prepared to take action based on the ethical code outlined in the American Nurses
Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements. Perioperative nurses
often find ethical decisions difficult to make, but necessary when caring for surgical patients in
practice. Perioperative nurses need to be able to recognize ethical dilemmas and take appropriate
action as warranted. They are responsible for nursing decisions that are not only clinically and
technically sound but also morally appropriate and suitable for the specific problems of the
particular patient being treated. The technical or medical aspects of nursing practice answer the
question, “What can be done for the patient?” The moral component involves the patient's wishes
and answers the question, “What ought to be done for the patient?”

SUPPORTING PATIENT RIGHTS AND CHOICES Perioperative nurses are obligated morally to respect
the dignity and worth of individual patients. Perioperative nursing care must be provided in a
manner that preserves and protects patient autonomy and human rights. Nurses have an obligation
to be knowledgeable about the moral and legal rights of their patients and to protect and support
those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account
both individual rights and interdependence in decision making. By doing so, nurses can recognize
situations in which individual rights to self‐ determination in health care temporarily should be
overridden to preserve the life of the human community. For example, during a bioterrorism attack,
victims infected with transmissible organisms (eg, small pox) require infection control measures to
prevent transmission to others. These infection control measures may require isolation, resulting in
restricting a patient's right to freedom of movement to protect others. Perioperative nurses
preserve and protect their patients' autonomy, dignity, and human rights with specific nursing
interventions, including supporting a patient's participation in decision making, confirming informed
consent, and implementing facility advance directive policies.7 Perioperative nurses explain
procedures and the OR environment before initiating actions, and they respect patients' wishes in
regard to advance directives and end‐ of‐life choices. Perioperative nurses help patients make
choices within their scope of care as applicable. They also provide patients with honest and accurate
answers to their questions, especially related to perioperative teaching, and formulate ethical
decisions with help from available resources (eg, ethics committee, counselors, ethicists). Patients
have the right to self‐ determination (ie, the ability to decide for oneself what course of action will
be taken in various circumstances). The nurse, as a moral agent for the patient, must be ready and
able to advocate for the patient's rights and needs whenever necessary while providing care.
Assuming such a stance involves acting on ethical principles and values. Nurses must be prepared to
identify advocacy issues and take action on them as needed. The nurse‐patient relationship not only
allows the nurse to support the patient, but it also supports the nurse. Nurses can empower patients
by providing opportunities for them to make autonomous decisions about their health care. They
can support patient empowerment through education about appropriate administrative protocols
(eg, patients' rights, hospital policies, procedures) that best meet individual patient's needs. When
dealing with informed consent, the nurse's role is to validate that the patient has been given the
information and understands as much as is possible about the surgical intervention. The nurse's
assessment includes determining whether the patient has any additional questions that might
require another discussion with the physician. The nurse also assesses the level of decision making
the patient is able to demonstrate. The principle of autonomy provides for patients to make
decisions freely, even if those decisions are against medical advice. The criterion that must be met is
that the patient is an adult who is capable of making decisions and has been given the information
necessary to make an autonomous choice. Even if a surgeon and nurse believe that surgery is in the
best interest of the patient, the patient has the right to refuse the procedure at any time, regardless
of whether he or she signed a surgical consent form. Nurses ethically should support patients in their
choices, regardless of whether they agree with the patient's decision. Nursing assessment and care
also applies to situations in which patients identify advance directive choices or decisions related to
do‐not‐resuscitate orders. It is the nurse's role to ensure that surgical team members are aware of a
patient's wishes in these matters. It is important that all team members and the patient discuss and
identify a plan of care before beginning the surgical procedure.

ETHICAL DILEMMAS Perioperative nurses often are faced with an ethical dilemma when a patient is
anxious because he or she does not understand fully what is going to happen in surgery and the
nurse is being pressured for a fast turnover time. The nurse is faced with conflicting expectations (ie,
the patient's emotional needs, expectations to be efficient). Nurses following the ethical principles of
compassion and respect would place a patient's emotional needs above expediting the surgical
schedule. In addition, there may be times when a perioperative nurse is told to get the patient's
signature on a consent form. Nurses must realize that they are not being asked to provide informed
consent for the patient. In cases such as these, the nurse merely is acting as a witness to the identity
of the patient and to the patient's signature on the consent form. If a nurse is present at the time
the patient signs the consent, it is a good opportunity to once again assess the patient's level of
understanding and see if he or she wishes to further discuss the proposed intervention with the
physician.

Sterilization and Mutilation Sterilization refers to any process that eliminates, removes, kills, or
deactivates all forms of life and other biological agents. Female genital mutilation (FGM) comprises
all procedures that involve partial or total removal of the external female genitalia, or other injury to
the female genital organs for non-medical reasons.

Preservation of bodily functional integrity Principle of integrity refers to every individual’s duty to
preserve the view of the human person in which the order/function of the body and its systems are
respected and not duly compromised by medical interventions. Anatomical- material or physical
integrity of the body Functional- systemic efficiency or functionality of the body These principle
dictates that the well-being of the whole person must be taken into account in deciding about any
therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm
or undesirable side effects can be justified only by a proportionate benefit of the patient. For
example: If one person is missing from the person’s body = lack of anatomical integrity But is one
kidney is healthy, present and functioning well =functional integrity is preserved

Issues on Organ Donation Organ donation is when a person allows an organ of their own to be
removed and transplanted to another person, legally, either by consent while the donor is alive or
dead with the assent of the next of kin. Donation may be for research or, more commonly, healthy
transplantable organs and tissues may be donated to be transplanted into another person. Common
transplantations include kidneys, heart, liver, pancreas, intestines, lungs, bones, bone marrow, skin,
and corneas. Some organs and tissues can be donated by living donors, such as a kidney or part of
the liver, part of the pancreas, part of the lungs or part of the intestines, but most donations occur
after the donor has died. Principle of ordinary and extraordinary measures Ordinary measures are
those that are based on medication or treatment which is directly available and can be applied
without incurring severe pain, costs or other inconveniences, but which give the patient in question
justified hope for a commensurate improvement in his health Principle of Personalized Sexuality Sex
is a social necessity for the procreation of children and their education in the family so as to expand
the human community and guarantee its future beyond the death of individual members. Teaches
that God created persons as male and female and blessed their sexuality as a great and good gift.

An organ transplant is a surgical operation where a failing or damaged organ in the human body is
removed and replaced with a new one. • The term “organ transplant” typically refers to transplants
of the solid organs: heart, lungs, kidneys, liver, pancreas and intestines. • Animal and artificial organs
may also serve as transplantable organs

• 1954 living relating kidney transplant( Dr. Joseph Murray and Dr. David Hume Boston) • • 1962
cadaveric kidney transplant by (Dr. Joseph Murray and Dr. David Hume Boston) • • 1963 lung
transplant (Dr. James Hardy Mississippi) • • 1967 liver transplant( Dr. Thomas Starzl Colorado) and
heart transplant(Dr. Christiaan Barnard South Africa) • • 1981 heart/lung transplant(Dr. Norman
Shumway California)

Although the idea of organ transplantation is an old one, successful transplantation did not occur
until the Twentieth Century. • Today the transplantation of many organs between well-matched
human beings is quite successful, with the majority of recipients living five or more years. • With
current advances, even a human head transplant (perhaps better referred to as a body transplant)
may be possible.

Since many people can benefit greatly from organ and tissue transplants, the demand usually
exceeds the supply. • The costs related to some organ transplants are very high as well. • From the
standpoint of deontological ethics, the debate over the definitions of life, death, human, and body is
ongoing.
The use of cloning to produce organs with an identical genotype to the recipient has issues all its
own. Cloning is still a controversial topic • Therefore, many questions are raised today regarding
how best to procure more organs, how to fairly distribute limited resources, and whether all
transplants should be covered by public funds

The ethical and legal issues related to organ and tissue procurement and transplantation are often
discussed in light of such principles as; 1) Autonomy, 2)Benevolence, 3) Non-maleficence, 4)Free and
informed consent, 5) Respecting the dignity, integrity and equality of human beings, fairness, and
the common good.

Ethical Issues Regarding: 1) The Donor 2) The Recipient 3) Allocation of Limited Resources 4)
Procurement of Organs and Tissues 5) Informed consent 6) Some Cases and Questions For
Discussion

Ethical Issues Regarding the Donor 1) From the Deceased 2) From Living Persons (Adults, related,
nonrelated, Mentally Disabled, Minors) 3) From Anencephalic Infants 4) From Human Fetuses

Ethical Issues Regarding the Recipient Should individuals who have abused their bodies through
smoking, drinking, or diet receive new organs, or should organs only be given to those whose organs
were damaged by illness? The recipients for the scarce organs are selected justly

Ethical Issues Regarding Allocation of Limited Resources 1) Criteria for Selection Allocation rules,
defined by appropriately constituted committees, should be equitable, externally justified, and
transparent 2) Using Animals 3) Artificial Substitutes for Tissues and Organs 4) High Costs,
Universality and Justice 5) Distributive justice – How to fairly divide resources – 6) Equal access – 7)
Maximum benefit

Ethical Issues Regarding Procurement of Organs and Tissues 1) Buying and Selling Human Organs and
The vicious cycle – Needs money , has organ. - Has money , needs organ Tissues; 2) Media Publicity
3) Types of Consent (Voluntary or Expressed, Family, Presumed, Required Request, Routine Inquiry)
4) Fears, Confusion and the Need for Education

Informed Consent • The laws of different countries allow potential donors to permit or refuse
donation, or give this choice to relatives • Opt in (only those who have given explicit consent are
donors) • Opt out " (anyone who has not refused is a donor). • consent required by law • deceased
person objected • Minors and legally incompetent people

Some Questions For Discussion 1) Is the body a commodity? Can it be bought? 2) How should
decisions be made on distributing scarce organs? 3) When several healthy organs are available,
should they all go to one person or should several needy people each receive just one? 4)Should a
person in whom a transplant has failed be given a second organ, or should a different person have a
first chance? 5)Should individuals who have abused their bodies through smoking, drinking, or diet
receive new organs, or should organs only be given to those whose organs were damaged by illness?

Some Questions For Discussion 6) Is it appropriate to spend money, time, and energy transplanting
hands and other appendages that are not essential to life? 7) Who can "donate" the organs of
individuals who are unable to give consent? 8) Is it possible to prevent coercion of donors? 9) When
should the courts get involved in organ donation decisions? • The questions go on and on.
Transplants between living persons raise the question whether it can ever be ethical to mutilate one
living person to benefit another. Concerning this many distinguish between parts of the body that can
regenerate (e.g. blood and bone marrow) and parts that do not regenerate. Regarding the latter some
are paired (e.g. kidneys, corneas and lungs), whereas others are not (e.g. heart). Before transplants of
organs such as kidneys were performed, many Catholic theologians considered this unethical between
living persons. They thought it violated the Principle of Totality which allowed the sacrifice of one
part or function of the body to preserve the person's own health or life (i.e. a part could be sacrificed
for the sake of the whole body), but did not allow one person to be related to another as a means to an
end. When such transplants began in the early 1950's ethicists gave the problem closer study.

Gerald Kelly (1956) argued that such donations which have as their purpose helping others could be
justified by the Principle of Fraternal Love or Charity provided there was only limited harm to the
donor. Some ethicists argued this did not violate the Principle of Totality provided that functional
integrity of the body was not destroyed, even though there is some loss to anatomical (physical)
integrity. Donating one of one's kidneys could be justified for proportionate reasons, since one can
function with one healthy kidney. ("Living kidney donors constituted some 15% of the donor pool in
Canada in 1989."[LRCC, 20]) Donating one of one's functioning eyes, however, can not be justified,
since one's ability to see (functional integrity) would be seriously impaired.

Basic to medical ethics is the Principle of Free and Informed Consent. To be properly informed the
potential living donor should be given the best available knowledge regarding risks to him/herself, the
likelihood of success/failure of the transplant and of any alternatives. In some cases there is much
pressure to donate (e.g. from family members if one is a good match). The courts have rightly refused
to compel such donations. Motivated by charity, which includes a properly ordered love for others and
oneself, one could decide not to offer an organ.(Ashley and O'Rourke 1989, 305-8; CHAC, 31 and 34

MANDATED CHOICE= this is voluntary donation

PRESUMED CONSENT= A person is presumed to have consented to organ donation in the case of
their accidental death

The distinction of ordinary and extraordinary means is also applicable to transplants. The Catholic
Church teaches that one is obliged to use ordinary means to preserve life, but not extraordinary
means, that is, means that are very burdensome (very painful, expensive, inconvenient, risky, or even
very psychologically burdensome) or do not offer reasonable hope of benefit, or are disproportionate
(cf. SCDF 1980, section IV; Ashley and O'Rourke 1986, Ch. 11.5; and CHAC, 52-4). Some forms of
organ and tissue transplant from a living donor, especially those involving invasive surgery, involve
considerable burden to the donor. If means are available that do not involve such burdens, such as a
matching organ from a deceased donor, these are certainly to be preferred.

The above principles would allow in some cases such procedures as "transplanting part of the liver
from a living adult donor into a child recipient, whereafter the adult donor's liver regenerates within a
month and the child's new partial liver develops as the child grows"(LRCC, 15), or donating one's
heart if one were to simultaneously receive a heart and lung transplant (Garrett et al., 200).

A competent adult can give free and informed consent to be or not to be a living donor, but an
incompetent person cannot. Can a guardian ethically consent for a legally incompetent person, such as
a severely mentally disabled adult or a minor, to be a living donor? Concerning this issue some
distinguish, for example, between a young child and a mature minor's ability to comprehend the
implications of donating. Regarding medical decisions an incompetent person's guardian is to act for
their benefit or best interests, and, as far as possible, their wishes, if known and reasonable. Some
think children and the mentally disabled should never be living donors. They are simply being used
with a violation of their bodily integrity, risks to their health and life, and no benefit to themselves.
An argument against their being a living donor of an organ such as a kidney, is that an alternative
such as renal dialysis is often available until a suitable deceased donor can be found. Others argue that
in some cases the psychological benefit to the donor (e.g. a child's sibling lives) could outweigh the
risks (e.g. of donating bone marrow).(LRCC, 48-50) The Catholic Health Association of Canada
(CHAC) says that, "Organ or tissue donation by minors may be permitted in certain rare
situations."(44)

Can it be ethical to have another child for transplant purposes (e.g. for a bone marrow transplant)?
Conceiving and having a child for this motive alone would involve treating him/her as a mere means
to another's benefit. This would violate the great dignity of a person, created in God's image, who
should be loved for his/her own sake.(cf. CHAC, 45; Garrett et al., 200)

Concerning the whole issue of living donors, the German Bishops' Conference and the Council of the
German Evangelical Church say:

...No one is obliged to donate tissue or an organ; therefore no one can be forced to do so. The decision
to donate one's organs while still alive can only be made by the individual concerned personally. Not
even parents are allowed to decide on an organ donation by their child; they are allowed to give their
consent only for a donation of tissue (e.g., donation of bone-marrow). The doctor in this case has a
special responsibility because no one can control whether a donation is truly voluntary.

When a living person donates an organ as a result of a personal decision, then the organ's transplant is
to be carried out with due attention, and post-operative medical care of the donors as well as the
recipients must be provided. Further, consideration must be given so that no problems develop in the
relationship between the donor and the recipients (dependence, excessive gratitude, guilt feeling).
(375)

TYPES OF TRANSPLANT

1. AUTOGRAFT= transplant of tissue from one to one self. Skin grafts, vein extraction for
CABG, storing blood in advance of surgery
2. ALLOHGRAFT=transplanted organ or tissue from a genetically non identical member of the
same species
3. ISOGRAFT= A subset of allografts in which organs or tissues are transplanted from a donor
to genetically identical recipient ( ex. Identical twins)
Anatomically identical to allografts, closer to autografts in terms of the recipient immune
response
4. XENOGRAFT= replacement of an individual defective organ with an organ harvested from
another species

Types of Consent (Voluntary or Expressed, Family,

Presumed, Required Request, Routine Inquiry)

Voluntary or expressed consent involves a person making known their free offer to donate one or
more of their organs and/or bodily tissue, after they have died or while alive.(cf. 1.a and b above)
Concerning cadaver donation, a person can express their wishes by some form of advanced directives,
such as by filling out the Universal Donor Card attached to their driver's license. Free and informed
consent is required when the transplant is from a living donor. Previously expressed voluntary consent
regarding a deceased donor is the ideal because it involves an act of love and responsible stewardship
over one's body. It also communicates to others, including one's family and health care professionals,
one's wishes. In the absence of clearly expressed voluntary consent, the family or person lawfully
responsible for the body of the deceased may be approached regarding donation. Proper respect
involves due consideration of the wishes of the deceased and their loved ones.
Many potential organs and tissues for transplantation (e.g. of brain-dead accident victims) are lost
because the person did not previously express voluntary consent and their families were not
approached about donating. Because of this and the shortage of organs and tissues for transplantation,
some have proposed other models of consent including presumed, required request and routine
inquiry, to hopefully increase the supply. Although only a minority of deceased potential donors have
signed donor cards, surveys show that most people favor organ donation. Some argue that it is ethical
to presume consent on their behalf, unless the person while alive gave clear indications to the
contrary, since a transplant does not harm the donor after death and it can benefit others. France,
Belgium and some other countries have various forms of presumed consent legislation in place.
People can opt out by registering their intention not to be a donor. Questions concerning this approach
include: Should minors and the mentally disabled be included? To what extent should health care
professionals check to see if the person has expressed a wish not to donate? Can not this be a form of
exploiting human ignorance and weakness (cf. people ignorant that they can opt out or too
lackadaisical to do so)?

Required request requires hospitals to develop protocols to ensure that families of potential donors are
actually asked to donate. Routine inquiry requires hospitals to develop protocols to ensure that
families of undeclared potential donors have the opportunity to donate - people tend to react more
positively when offered a choice. Some have criticized these approaches as not allowing professional
discretion. Many health professionals are reluctant to approach families who have just lost a loved one
about transplantation. This is considered a major barrier to increasing the supply of organs and
tissues. Most families though do not object to being approached. Required request or routine inquiry
has been widely endorsed in the United States as a preferred public policy option when compared to a
free or regulated market of organ and tissue sales or a presumed consent approach. It is seen as more
respectful of altruism, familial sentiments and religious interests. It can also help the bereavement
process by making something positive come out of the death. Some significant increases in organ and
tissue donation have been recorded where this policy is in place. A few jurisdictions also allow
presumed consent following required inquiry if the family did not object.

Ordinary means must be taken to preserve life, and extraordinary means can be morally
refused.[2] It is, therefore, critical to properly characterize particular means of preserving
human life as ordinary or extraordinary, that is, as morally obligatory or non-morally
obligatory.
To further clarify, extraordinary means are “medical procedures which no longer correspond
to the real situation of the patient, either because they are by now disproportionate to any
expected results or because they impose an excessive burden on the patient and his
family.”[3] In contrast, ordinary means are those “means of treatment available [that] are
objectively proportionate to the prospects for improvement.”[4] There are, however, various
factors that assist in the determination of what is ordinary and what is extraordinary. Such
factors include: “the type of treatment to be used, its degree of complexity or risk, its cost
and the possibilities of using it, and comparing these elements with the result that can be
expected, taking into account the state of the sick person and his or her physical and moral
resources.”[5]
For example, a feeding tube is an ordinary means of preserving life.[6] This is evident when
the factors listed above to differentiate ordinary and extraordinary means are applied.
Regarding the type of treatment to be used, a feeding tube is, strictly speaking, not medical
treatment at all. It is the basic provision of natural food to which all human beings require
and are entitled to by virtue of their humanity. Since a feeding tube is entirely outside the
scope of medical care altogether, there is no need to apply the other elements to conclude
that it is an ordinary means, but for the sake of thoroughness, the application of the
remaining elements demonstrates that a feeding tube is an ordinary means of preserving
life. There is nothing complex or risky about using a feeding tube. Given our health system
in the United States, it may be costly, but is easy to use. The clear result is that the patient
will not starve to death, which is worth all the physical and moral resources[7] a person can
afford. Having concluded, then, that a feeding tube is ordinary care, the denial of a feeding
tube which results in the death of a patient by starvation can be a form of euthanasia,
provided that the motivation in denying the feeding tube is the relief of suffering and the
person who removed the feeding tube intended the death of the patient.[8] In any event,
starving someone to death with the evident intention to kill him/her is murder.[9]
While the distinction between ordinary and extraordinary means of preserving life can be
rationally applied to any fact pattern and produce a reasonable result, there are those who
argue that euthanasia—killing a patient to relieve his/her pain—is morally equivalent to
letting a patient die by refusing to administer extraordinary care.[10] This position endangers
human life because it creates confusion regarding the essential question of when there is a
duty to preserve human life. This confusion can then be used to justify euthanasia. Since
the death of the patient results in both cases, it is, perhaps, understandable why some have
a difficult time seeing the moral distinction between euthanasia and letting die.