NURSING ETHICS

• ETHICS came from the Greek word ethos which means

moral duty. Ethics refers to a standard to examine and
understand moral life. Ethical theories, principles and
codes of conduct serve as guides of human conduct
provided by ethical systems. Ethics studies how people
make judgment in regard to right or wrong.
• Morals, on the other hand, are specific ways of behavior
or of accomplishing ethical practices. Morality is derived
from the 1 Greek word moralis which refers to social
consensus about moral conduct for human beings and
society. Human decency, right or wrong, good or evil,
proper or improper, cruel or benevolent acts are explained
in terms of morality.
• Ethics is about making choices that are best for the
individual or society at certain times and in particular
situations and then evaluating such choices and
outcomes. Ethicist Joseph Fletcher differentiates morality
from ethics. He states that morality is what you believe is
right and good while ethics is the critical reflection about
morality and rational analysis about it.
• Professional ethics is a branch of moral science
concerned with the obligations that a member of the
profession owes to the public. Health care ethics, on the
other hand, is the division of ethics that relates to human
health. It resides in the realm of human values, morals,
customs, personal beliefs, and faith.
• Bio-ethics is a specific domain of ethics that focuses on
moral issues in the field of health care. It evolved into a
discipline all on its own as a result of life and death
dilemmas faced by health care practitioners. It is a
systematic study of human behavior in the field of life
science and health care in the light of moral values and
principles. While originally, bio-ethics was concerned with
ethical issues described with medical practice, it has
expanded to issues surrounding health and biological
sciences and social issues including environmental
concerns
• As members of the health team, nurses have to make
independent decisions in the performance of their daily
duties. Within the health team, however, many decisions
are also made interdependently. Also, nurses are
expected to exhibit bio-ethical behavior in their
professional duties. Knowledge of ethical challenges
enable them to hone their skills in decision making
regarding their patients' life-and-death issues and
integrate ethical principles and theories into their practice
thereby helping them resolve moral conflicts.
• Nursing ethics is related to all the principles of right
conduct as they apply to the profession. Nursing ethics
reinforces the nurses' ideals and motives in order to
maximize the effectivity of their service.
• Oftentimes, nurses find it difficult to resolve ethical issues
partly because they do not have the sensitivity to
recognize ethical problems and conflicts or to display the
needed knowledge and experience in every situation that
they face.
• Johnstone defines nursing ethics as the "examination of
all ethical and bio-ethical issues from the perspective of
nursing theory and nursing ethics.“
• Vercoe, et.al., emphasize that "the field of nursing ethics
be focused on the needs and experiences of practicing
nurses, the exploration of its meaning and that of ethical
practice in terms of the perception of these nurses
ETHICAL PRINCIPLES AND OTHER
APPROACHES
• Teleological Approach
• Teleology comes from the Greek word telos or "goal
or end." This is expressed in the maxim, "the right thing to
do is the good thing to do." The teleological approach is
also termed as act utilitarianism where the good resides in
the promotion of happiness or the greatest net increase of
pleasure over pain.
• In recent formulation of act utilitarianism, Joseph
Fletcher, a situation ethicist, holds that good is agape, the
general goodwill or love for humanity. In the final analysis
human need determines what is or what is not ethical. If
the act helps people, then it is a good act, and if it hurts
people, then it is a bad one.
• In his writings, Fletcher provides the guidelines for making
ethical decisions: These are:
• 1. consideration for people as human beings;
• 2. consideration of consequences;
• 3. proportionate good to come from the choices;
• 4. propriety of actual needs over ideal or potential
needs;
• 5. a desire to enlarge choices and reduce chance; and
• 6. a courageous acceptance of the consequence of the
decision
• An example may be given of a City Health Department
planning for their annual budget. To which program
should they allot a bigger budget—the modernization of
the city hospital or the nutrition and immunization
programs of the poverty-stricken families of the city? Will
promotion of health and prevention of illness have priority
over treatment of illness and rehabilitation?
• Deontological Approach or Duty-Oriented Theory
• The word deontology came from the Greek word
deon which means duty. In this theory, the ethicist feels
that the basic rightness or wrongness of an act depends
on the intrinsic nature rather than upon the situation or its
consequences.
• Immanuel Kant, a German philosopher and ethicist in the
18th century, defines a person as a "rational human being
with freedom and social worth." A person is morally good
and admirable if his actions are done from a sense of duty
and reason. He states that it is only through dutiful actions
that people have moral worth. Even when individuals do
not want to fulfill their duty, Kant believes that they are
required to do so.7
• Suppose a nurse is assigned to care for a patient with
AIDS. Could she reasonably refuse to care for the patient
on the ground that the patient's condition may threaten
her health? As practitioners of the art of healing, nurses
are to take care of the sick even if patients have
conditions that threaten their personal health. Nurses,
however, must observe the necessary precautions to
protect their health
• Virtue Ethics Approach
• Virtue ethics, known as aretaic ethics (from the Greek
word arete), is focused primarily on the heart of the person
performing the act. It focuses on the traits and virtues of a good
person such as courage, temperance, wisdom, and justice.
However, doing the right thing is not all that is needed.
One must have the right motivation, disposition and traits for
being good and doing right such as courage, magnanimity,
honesty, justice, and beneficence.
• Intellectual virtue is the power to deliberate about things
good for oneself. Moral virtues, on the other hand, must be
lived over time in order to be learned. Nurses, when faced with
a particular situation must be able to know what to do. They
must be able to integrate virtue ethics with duty.
• Suppose a student is requested by her classmate, who is
also her best friend, to let her copy in their examination so
that she will pass. The student should not allow this to
happen as formal cooperation in an evil act is never
allowed. She will be as equally guilty as the one who will
cheat as she will be serving as an accomplice to the evil
act.
• DIVINE COMMAND ETHICS
• Divine command ethics is based on the theory that there
is a Supreme or Divine being that sets down the rules to
provide guidance to moral decisions. For Christians, these
rules are found in the Ten Commandments. Differences in
religion, however, pose problems such as what to do when the
decision would conflict with one's religious beliefs. For
example, members of the Jehovah's Witnesses will not receive
blood transfusion even if their lives will be put in danger.
Suppose a nurse is approached by a friend who quests
for re an abortion. The nurse refuses but refers the friend to a
doctor who can perform it. This is a violation of the divine
command, "Thou shall not kill." It violates the principle relating
to the origin and destruction of life which states, "The owner of
life is man, but it is God who gave him that life, therefore no
one has a right to take life except God."
• The divine command is also applicable to cases of
euthanasia, which is the direct killing of people who may
not have committed any crime deserving of death, but
because of mental, or physical conditions are considered
worthless to society. Examples of these are patients in
persistent vegetative state whose relatives request that
the respiratory ventilators be turned off or the feeding
tubes be removed to put an end to both the patients' and
the relatives' suffering.
UNIVERSAL PRINCIPLES OF
BIOMEDICAL ETHICS
• In health care delivery, basic ethical principles assist the
health professionals to determine right or wrong in regard
to value issues involving the pursuit of health, alleviation
of suffering, and assisting patients towards peaceful
death. These are autonomy, veracity, beneficence,
nonmaleficence, and justice
Autonomy
• Autonomy comes from the Greek word autos meaning
self and nomos meaning governance. It involves self-
determination and freedom to choose and implement
one's decision, free from deceit, duress, constraint or
coercion. This is called informed consent. The kind of
information provided the patient and his family is within
their level of understanding that they may evaluate the
risks and the other options open to them. This includes
allowing the patient to refuse treatment if he so decides;
disclosure of his ailment, prognosis, mode of treatment;
and maintaining confidentiality. Restrictions on autonomy
may occur when there is potential harm to others such as
communicable diseases or acts of violence.
• The person making the decision must be deemed
competent. He must have the intellectual capacity to
make a rational decision and he must be of legal age. The
decision should be of his own free will and he should not
be coerced or put under duress to do so. Every adult of
sound mind must have the right to determine what should
be done to his body. Therapeutic privilege is the legal
exception of the rule of informed consent, which allows
the caregiver to proceed with the care in case of
emergency, incompetence, waiver or implied consent
Veracity
• To maximize the efficiency of healthcare, the patient and
the healthcare providers are bound to tell the truth. The
patient has the responsibility to provide, to the best of his
knowledge, accurate and complete information about his
complaints, past illness, previous hospitalizations,
medications being taken, allergies, religious restrictions,
and other matters relevant to his health. If the patient
cannot provide the information, his family or significant
others should do so in order that accurate diagnosis could
be arrived at and immediate treatment provided.
• The physician should tell the patient and his family
his diagnosis, plan of care, treatment and possible risks
involved, length of treatment, possible expenses, and
other options they make take if there be any.
• There are times, however, that the physician or health
practitioner is requested not to tell the relative the exact nature
of the patient's illness. Sometimes, the relative requests the
physician not to tell the patient his true diagnosis or condition.
At times the practitioner himself intentionally withholds
information according to his sound judgment when such
revelation would do more harm to an emotionally unstable or
depressed person. This is called a benevolent deception.
• Several cases are therein cited:
• 1. A young, married male who was diagnosed to have
AIDS, requests the doctor not to tell his diagnosis to his wife.
• 2. The children of an aged grandmother suffering from
metastatic cancer request the doctor not to tell their mother her
diagnosis and instead to proceed with the chemotherapy.
• In the case cited above of the young, married man who
has AIDS, telling the wife would be far more
advantageous so that she can be examined, protected or
treated as the case may be. She would be able to use
proper precautionary measures for herself, understand
the husband's illness, and participate in his care.
• In the case of the grandmother, gently telling her the
truth would help convince her to participate in the
treatment plan including spiritual preparation towards
peaceful death.
• It is very important that health care workers be very
discreet in providing information. While telling the truth
increases their credibility, it is oftentimes how they say
this information that makes them acceptable or not.
Beneficence
• The principle of beneficence refers to acts of kindness
and mercy that directly benefit the patient. These acts
promote the health of the patient, prevent illness or
complications, alleviate suffering, and assist towards
peaceful death if the inevitable comes
• The Patient's Bill of Rights helps the health practitioners
provide more effective patient care. The patient has the right to
• 1. considerate and respectful care;
• 2. relevant, current and understandable information
concerning diagnosis, treatment prognosis, specific
procedures, treatment, risks involved, medically reasonable
alternative benefits needed to make informed consent;
• 3. make decisions regarding his plan of care; in case of
refusal, he is entitled to other appropriate care and service or
be transferred to another hospital;
• 4. have advance directive (such as a living will) concerning
treatment or designating a surrogate decision maker;
• 5. every consideration of his privacy such as in case
discussion, consultation and treatment;
• 6. confidentiality of communications and records;
• 7. review his records concerning his medical care and have
these explained to him except when restricted by law;
• 8. be informed of business relationship among the hospital,
educational institution, health care providers that may influence
the patient's treatment and care;
• 9. consent or decline to participate in experimental research
affecting his care;
• 10. reasonable continuity of care when appropriate and be
informed of other care options when hospital care is no longer
appropriate; and
• 11. be informed of hospital policies and practices that relate
to patient care.
*All activities provided to patients must be conducted with deep
considerations of their values and dignity.
Nonmaleficence
• In some way the principle of nonmaleficence is similar to
the principle of beneficence. The distinction lies in the fact
that the principle of beneficence is stated in a positive
form while nonmaleficence is stated as an admonition in
the negative form to remind health practitioners to do no
harm.
• Examples of nonmaleficence is not assisting in or
performing abortion, not assisting persons to commit
suicide, not performing euthanasia or mercy killing, or not
willfully subjecting patients to experimental drugs whose
potential harm may be greater than the expected benefit,
and not harming a person's reputation by revealing
confidential information
• What benefit does it give a patient who is in persistent
vegetative state to be attached to a respirator, or for a dying
person to be given cardiopulmonary resuscitation? Should a
dying person in pain be given a sedative, when the health
practitioner knows it would cause respiratory depression or
arrest?
• Nurses should remember that human life is inviolable.
They should do what is best for the patient. When biological
death is imminent, they should not abandon the patient.
Treating them with respect, providing nursing measures safely,
gently and with kindness, and providing psychological and
spiritual support allow the patient to die with dignity and peace..
Nurses should not participate in treatments or procedures that
will harm the patient. They should make their stand known and
should withdraw from the team if what is to be done is against
their conscience
Justice
• In healthcare, refers to the right to demand to be treated justly,
fairly and equally.
• Article XIII of the Philippine Constitution guarantees that
the state shall adopt an integrated and comprehensive
approach to health development and shall endeavor to make
essential goods, health and social services available to all
people at affordable cost. There shall be priority for the needs
of the underprivileged, the sick, the elderly and the disabled,
the women and children. The state shall endeavor to provide
free medical care to paupers, establish and maintain an
effective food and drug regulatory system, and undertake
appropriate health manpower development and research
responsive to the country's health needs and problems. It shall
establish a special agency for disabled persons for their
rehabilitation.
• To this end, the Department of Health affirms that health
is a basic human right. To make this right a reality, the
DOH shall work to make quality health services available
and affordable by mobilizing resources, providing means
to better health, and arousing community participation.
• The National Health Insurance Act of 1995 provides
for a universal compulsory health insurance program in
the country. Employees from private and public sectors
are covered with Medicare privileges. Even the self-
employed such as drivers, vendors, beauticians, may
become members of the Social Security System and will
be entitled to insurance benefits, hospitalization, and
discounted out-patient services.
• Republic Act 7432( now RA 9994) called the Senior
Citizens Act, gives honor and justice to the elderly by
giving 20 percent discount in public establishments such
as restaurants, and pharmacies; public utility vehicles;
and hospitals including free medical and dental check-up
and free hospitalization in all government hospitals.
• In allocating budget for the promotion of health,
prevention of illness, and for health education and
immunization, more benefits can be expected in terms of
lessened morbidity and mortality rates.
• Common methods for distribution of goods and
resources are based on fair opportunity rule where every
person is given an equal share according to need, merit,
contribution, effort and social worth.
• The fair opportunity rule is based on the egalitarian theory that
emphasizes equal access to goods and services. The "the
greatest good for utilitarian theory employs the maxim, the
greatest number." Thus government authorities should carefully
think about the dilemma of whether the government should
spend more for the care of one child with congenital defect
over the need to protect the lives of thousands of children who
would benefit from mass immunization against communicable
diseases.
• Hospitals put up triage schemes to determine who should
be served first. One criterion often put up is that of medical
prognosis or medical utility or who among the patients is most
likely to survive. The next criterion is social utility or social
value or worth, the ability to pay, or first-come-first-served
basis.
• To be ethically sound, the criteria selected must favor
more the socially disadvantaged, and those incapacitated
by illness. Nurses should utilize their critical thinking
ability and skills, listen carefully and objectively and
analyze facts. Ethical principles and values should be
used in making moral decisions. Open communication
between patients, their families, and the health team
results in acceptance of decisions and congenial
relationships
ETHICS COMMITTEES IN
HOSPITALS AND THE ROLE OF
MEDICAL ETHICISTS
• There is a growing trend for hospitals to have formal ethics
committees. These may be composed of philosophers, doctors,
nurses, lawyers, clergy or social workers. They discuss
sensitive issues such as when to withdraw or withhold
treatment for an adult and the treatment of a severely
handicapped newborn. Some may include topics such as the
right to die, informal consent, right to choose or refuse
treatment, right to know who is treating the patient.
• Discussion usually begins with a description of the
patient's condition and medical history. Most often, conflicts
involve families and doctors; and where doctors want to treat or
continue to treat a patient and the family wants to do nothing.
Research proposals involving human subjects are also
reviewed
Some cases that have reached
worldwide attention are:
• 1. the removal of Terri Schiavo's stomach feeding tube
upon his husband's request to the Court as she was in a
persistent vegetative state for 15 years;
• 2. the Nancy Beth Cruzan case in Missouri, United States
where the Supreme Court denied her parents' request to
remove her feeding tube. She was in vegetative state for seven
years;
• 3. the California couple who conceived a child in the hope
that the baby would be a bone marrow donor for its seventeen
year-old sister who is acutely ill of leukemia;
• 4. the couple convicted of manslaughter for the death of
their 2-1/2 year-old son because they failed to seek medical
attention and the baby died of intestinal obstruction; and
• 5. the doctor who assisted a woman sick of Alzheimer's
disease to commit suicide
RESPONSIBILITIES OF NURSES TO
THE PATIENTS
• The primary responsibility of nurses to the patients is to give
them the kind of care their condition needs regardless of their
race, creed, color, nationality or status. In so doing, the
patients' care shall be based on needs, the physician's orders,
and the ailment; and shall involve the patients and their families
so that they or any number of the family can participate in their
care.
• Nurses are advised to become familiar with the patient's
Bill of Rights and observe its provisions14.
• Because nurses are given compensation for their
services, they should not accept tips or expensive gifts that
may induce them to give more care to favored patients and
neglect those who cannot give. It is advocated that they treat
patients in a manner that will show concern whether the patient
is rich or poor.
• When nurses are engaged by patients or any agency,
they shall complete said service on the length of time
stipulated in the contract. They may not leave their
patients or any agency without proper permission or
resignation or without relief. Nurses can be sued for
breach of contract or abandonment of duty if they do.
• Nurses should commit themselves to the welfare of
those entrusted to their care. They should be loyal to their
sworn duty This is termed role fidelity.
CONFIDENTIALITY OF
INFORMATION
• Confidential information is also termed as privileged
communication because it is given based on trust.
Patients and/or their relatives are expected to give the
necessary information so that proper diagnosis and
treatment could be made. Patients and their
families are entitled to know information or facts within the
limits determined by the physician. If the patients insist on
knowing their diagnosis, nurses may only repeat what
doctors wish to disclose.
• Any information gathered by nurses during the
course of caring for their patients should always be
treated confidential.
• This duty extends even after the patients' death. Confidential
information may be revealed only when:
• 1. patients themselves permit such revelation as in the case 00 of
claim for hospitalization, insurance benefits, among others;
• 2. the case is medico-legal such as attempted suicide, gunshot
wounds which have to be reported to the local police or NBI or
constabulary;
• 3. the patients are ill of communicable disease and public safety
may be jeopardized; and
• 4. given to members of the health team if information is relevant
to his care.
• Confidential information may also be revealed as provided for
by law in Article IV, Section 4(1) of the New Constitution, which states
that: "The privacy of communication and correspondence shall be
inviolable except upon lawful order of the court or when and order
require otherwise."
PATIENTS' RESPONSIBILITIES
• 1. Providing information. A patient has the responsibility to
provide—to the best of his/her knowledge—accurate and
complete information about his/her complaints, past illnesses,
hospitalization, medications, and other matters relating to
his/her health. Changes in status and level of understanding
must also be communicated. If the patient cannot provide said
information, the family is responsible for doing so in his/her
behalf.
• 2. Complying with instructions. A patient is responsible for
complying with the treatment plan recommended by the
attending physician or health team that is primarily responsible
for his/her health care. He/She is expected to keep his/her
appointments, abide by the hospital rules, and inform those
concerned if he/she cannot keep them.
• 3. Informing the physician of refusal to treatment. A
patient who refuses treatment or to be compliant with the
treatment regimen must inform the physician of his
decision.
• 4. Paying hospital charges. If the patient is in the Pay
Service, he/she is responsible for ensuring that financial
obligations of his/her health care are fullfilled as promptly
as possible.
• 5. Following hospital rules and regulations. The patient
is responsible for following the hospital's rules and
regulations and shall advise his/her family to do so, too.
• 6. Showing respect and consideration. The patient
must be considerate of the rights of other patients and
hospital personnel and shall assist in the control of noise,
smoking, and/or playing of loud music on radio. The
patient must respect the property of other persons and
that of the hospital. Since the nurses are the closest
caregivers, they are the most logical guardians of the
patient's rights. It shall also be part of their duties to
inform the patients and their relatives, upon admission, of
the responsibilities expected of them.
Bill of Rights for Registered Nurses

• Registered nurses promote and restore health,

prevent illness, and protect the people entrusted to their
care. They work to alleviate the suffering experienced by
individuals, families, groups, and communities. In so
doing, nurses provide services that maintain respect for
human dignity and embrace the uniqueness of each
patient and the nature of his or her health problems,
without restriction in regard to social or economic status.
To maximize the contributions nurses make to society, it
is necessary to protect the dignity and autonomy of
nurses in the workplace
To that end, the following rights must
be afforded.
• 1. Nurses have the right to practice in a manner that fulfills their
obligations to society and to those who receive nursing care.
• 2. Nurses have the right to practice in environments that allow
them to act in accordance with professional standards and legally
authorized scopes of practice.
• 3. Nurses have the right to a work environment that supports and
facilitates ethical practice, in accordance with the Code of Ethics for
Nurses and its interpretive statements.
• 4. Nurses have the right to freely and openly advocate for
themselves and their patients, without fear of retribution.
• 5. Nurses have the right to fair compensation for their work,
consistent with their knowledge, experience, and professional
responsibilities.
• 6. Nurses have the right to a work environment that is safe for
themselves and their patients.
• 7. Nurses have the right to negotiate the conditions of their
employment, either as individuals or collectively, in all practice
settings.
NURSES' RESPONSIBILITIES IN
RESEARCH ON HUMAN SUBJECTS
• The Helsinki Declaration of 1964 issued guidelines
on medical research. In 1975 it differentiated two major
types of research: that which is essentially therapeutic
and that which is directed toward developing scientific
knowledge and has no therapeutic value for the subjects.
The declaration emphasizes that the research subjects
must be informed when a clinical or non-clinical study will
be of no personal benefit to them to avoid any suspicion
to the contrary
• The American Nurses Association's Human Rights Guidelines for
Nurses in Clinical and Other Research specified several important
entities:
• 1. Employment in Settings Where Research is Conducted.
Employees in work settings that carry potential risks shall be informed
about these, how to recognize these risks and how to take the proper
precautions to counteract harmful effects and unnecessary danger.
• 2. Vigilant Protection of Human Subject's Rights. Prior to
participation in any activities that go beyond established and accepted
procedures, the prospective subjects must be informed. Special
mechanisms shall be devised to safeguard the confidentiality of
information and protection of human dignity.
• 3. Scope of Application. These guidelines apply to all individuals
involved in research activities, including patients, organ donors,
informants, normal volunteers, students and vulnerable populations,
such as the mentally retarded and prisoners.
• 4. Supporting Accrual of Knowledge. Nurses have an
obligation to support the accrual of knowledge that broadens
scientific underpinnings of nursing practice and delivery of
nursing services.
• 5. Informed Consent. Consent to participate in researches
safeguards the basic rights to self-determination. There shall
be no direct nor indirect coercion. He should be given in detail
the full benefits or possible harm that may happen to him. If
possible, the investigator shall secure the consent himself so
that any questions or clarifications can be made immediately.
• 6. Representation on Human Rights Committee. A Human
Rights Committee is formulated to ensure that the individual
rights of patients are not denied. The nursing profession has an
obligation to publicly support the inclusion of nurses to these
committees
BASIC HUMAN RIGHTS OF
RESEARCH SUBJECTS
• 1. Right to Informed Consent. Recognition of self-
determination and thorough comprehension of the
proposed participation are the two components of self-
determination. Self-determination means free consent is
pre-requisite to any human involvement. The subjects
must also understand the risks involved, the benefits
anticipated, time and energy requirements and any
anticipated loss of dignity or autonomy; any anticipated
pain or discomfort, psychological stress or
embarrassment; and the way the data will be handled and
reported.
• 2. The Right to Refuse and/or Withdraw from
Participation. The person has the right to refuse to
participate. There shall be neither recrimination for refusal
nor for withdrawing from participation. Nurses shall
explore the subject's reason for refusing. Refusal to
participate can be minimized, if at the onset the subject
has been given careful and honest opinion on what is to
be done.
• 3. Right to Privacy. This right includes privacy of one's
thoughts, opinions and physical presence and privacyof
one's records. The subject has the freedom to decide the
time, the extent and circumstances willingly share his/her
presence, thoughts, beliefs, attitudes and behavior with
others.
• 4. Right to Confidentiality or Anonymity of Data. Data
about the research subjects shall be handled
confidentially. Data shall be available only to the research
staff and shall be reported anonymously. Data shall not
be used other than for the specific purpose for which the
subject gave consent and shall not be made public or
available to others. The identity of the agency shall be
protected. This shall be done unless knowledge about the
setting is necessary in the interpretation of the data. After
the report is written, all data by which individuals can be
identified shall be destroyed. They shall be burned or
shredded and not dropped into the wastebasket as
someone may find and use them for other purposes.
• 5. Right to be Protected from Harm. There shall be
appropriate balance between potential benefits of the
research and the risks assumed by the subjects. This is
called the risk-benefit ratio in which the benefits outweigh
the harm. Minimal risk is defined as exposure to the
possibility of injury going beyond everyday situations.
These include physical, legal, emotional, financial, and
social harm.
• Sometimes, the subject may experience undue
anxiety if the instrument evokes disturbing feelings.
Debriefing is a process of disclosing to the subject all
information that was previously withheld. Referral to
counselling shall be included in the study protocol if
necessary
VULNERABLE SUBJECTS
• Subjects who are mentally ill or legally incompetent such as the
unconscious, or are in unique situations, like fetuses, require
special attention. Those who are mentally ill, mentally retarded,
unconscious and minors are incapable of evaluating the risks
involved and cannot be given consent in their own behalf.
Consent of parents or guardians are required.
• Investigative studies regarding fetuses shall have the consent
in the presence of a third person because of the possible
danger or injury to it. The Philippine Constitution guarantees
the protection of the life of the mother and the life of the
unborn.
• Students are vulnerable as their participation or non-
participation may affect their grades. Employees may
participate because of the influence it may bring to their
promotion, salary increases or bonuses. It must be explained to
them that this is not so.
INVESTIGATIVE STUDIES AND
MEDICAL REGIMEN
• When the medical regimen of a research subject will be
affected, it is best that there be proper coordination with the
physician in charge. The investigative study shall not, in any
way, be in conflict with the medical regimen. Drugs to be used
by the investigators must have a medical prescription.
• An example of this was an experiment done in a
government hospital where banana leaves were used to
promote healing of decubitus ulcers of bedridden patients. This
study was coordinated with the physicians in the unit. Even
though the treatment method which consisted of cleaning,
massaging the area around the wound, relief of pressure, and
putting banana leaves beneath the area with ulcer were all
within the scope of nursing practice, the success of the study
was further enhanced since the doctors refrained from ordering
topically-applied medications
EXPERIMENTAL SUBJECT'S BILL OF
RIGHTS
• 1. be told what that study is trying to find out;
• 2. be told what will happen to himself/herself and
whether the procedure, drugs, or devices are different
from what are used in standard practice;
• 3. be told of the frequent or important risks, side effects
or discomforts of the things that will happen to himself/
herself for research purposes;
• 4. be told if he/she can expect any benefit from
participating, and if so, what the benefits may be;
• 5. be told the other choices he/she has and how
he/she may become better or worse than being in the
study;
• 6. be allowed to ask y any question concerning the
stud both before agreeing to be involved and durin course
of the study; g the
• 7. be told what sort of treatment is available if any
complications arise;
• 8. refuse to participate at all or to change his/her mind
about participation after the study is started. This decision
will not affect his/her right to receive the care he/she
would receive if he/she were not in the study;
• 9. receive a copy of the signed and dated consent
form; and
• 10. be free from pressure when considering whether
he/she wishes to agree to be in th
• If the subject has other questions, he/she may ask the
research, or his assistant, if he/she may contact the
agency's review board concerned with the protection of
volunteers in research projects.
• Participation in research is voluntary. One has the
right to refuse to participate, and the right to withdraw
without any jeopardy to his/her care.
RESPONSIBILITIES OF THE NURSE
TO THE PHYSICIAN
• Section 28 (a) of R.A. 9173 states that:
• It shall be the duty of the nurse to:
• (a) Provide nursing care through the utilization of the
nursing process. Nursing care includes, but not limited to,
traditional and innovative approaches, therapeutic use of
self, executing health care techniques and procedures,
comfort measures, health teachings, and administration of
written prescription for treatment, therapies, oral, topical
and parenteral medications, internal examination during
labor in the absence of antenatal bleeding and delivery. In
case of suturing of perineal laceration, special training
shall be provided according to protocol established.
• It is therefore expected that nurses will not only carry out
doctor's orders but help plan and implement patient care
as well. Patient's condition should be reported including
results of therapies so that management of care can be
properly monitored and modified as necessary.
• If any of the medical orders were not carried out for
some reason (e.g., medications are unavailable, or a
patient refuses to accept them), such shall not only be
brought to the attention of the physician but also noted
properly in the patient's chart. Explore patient's reason for
refusal. Clarify misconceptions as needed
• Nurses shall familiarize themselves with the various
routines, methods or idiosyncrasies of physicians, so that
smooth relationships can be maintained. In case the
patient has a complaint against the physician, this shall be
tactfully brought to the latter's attention.
• Any case of illegal, incompetent or unethical practice
by any member of the health team shall be brought to the
attention of the appropriate authority through channels
within the institutional or agency setting.
• Nurses shall remember that any medical act
relegated to them is illegal because it is specified in the
Medical Law that any licensed nurse who does this, even
if supervised, can be held for illegal practice of medicine
RESPONSIBILITIES OF NURSES TO
THEIR COLLEAGUES
• Nurses are expected to be able to get along smoothly with
their colleagues. There may be instances where a nurse
may have a different opinion, or may not like certain
people. This shall be the exception rather than the rule. A
mature person easily blends in any situation. Nurses shall
adjust themselves to the organization and know its
policies and procedures. They shall establish good
working relationships with co-workers. If one has a
grievance he/she should bring it to the attention of the
proper authority rather than talk about it with others who
may not be able to help. Most agencies have grievance
procedures to be followed.
• It is important that nurses know their place in the total
organization so that they may cooperate, coordinate and
maximize their work. Loyalty and consideration of others while
at work will foster these relationships further.
• Nurses who are cranky, too sensitive, who "backbite,"
who do not see any good in their colleagues, are the type of
nurses who will not be happy in their wor
• Situations, such as when nurses see their colleagues neglect
their duties or are incompetent shall be brought to the attention
of the immediate supervisor or appropriate authority within the
agency setting before any life could be endangered.
Constructive criticism is always welcome but not fault-finding.
Fault-finders, gossipers, and those who are fond of intrigues
will surely resent it too if they become the target of their own
practices.
RESPONSIBILITIES OF NURSES TO
THEMSELVES
• Since nurses carry personal responsibility for nursing practice and for
maintaining competence by continuous learning, it is expected that
every possible means shall be utilized by them to develop their skills.
Their conduct must bring credit to the profession. Just like any other
professional, nurses are looked upon with respect in the community.
They shall therefore endeavor to live a life that will uphold their self
respect.
• Especially when nurses are on duty, they shall try to look neat
and attractive. Female nurses are advised to use moderate make-up
and have a neat hair style. They shall wear uniforms that are neither
too short nor tight-fitting that will tend to restrict movement, nor
expose unnecessarily any part of the body while giving care to the
patients. Clean uniforms and clean bodies tend to enhance the image
of nurses. Use of anti-perspirant is advised most especially during hot
summer months. Male nurses are likewise advised to be clean-
shaven, with hair clipped close to the nape instead of flowing to the
shoulders.
• The use of the uniform shall be specified in the policy of the
hospital/agency. It shall be worn only when on duty. Dining in
public, shopping or going to the market while in uniform is
discouraged. Nurses' caps are worn only while on duty. These
are either carried in bags or are left in their places of
assignment. Jewelry such as earrings, necklaces or bracelets
are not worn while on duty. However, wedding rings, school
rings or school pins may be worn.
• Nurses are looked upon by nursing students as their role
models. Therefore, especially while they are on duty, they must
act in a manner that is worth emulating. Sincere and
compassionate attitudes towards patients are caught by those
around them. Soon their working environment becomes
permeated with a good working relationship that is so vital in
dealing with patients.
LIVING WILLS OR ADVANCE
DIRECTIVES
• There is a trend in the use of living Wills or advance
directives. While this is not yet widely used in the
Philippines, it is used extensively in the United States.
Hospitals are required to provide health-care proxy forms
to patients being admitted. These are called living wills
and advance directives. The patient designates a health
care representative, usually a member of the family, a
friend, or a family physician to make decisions for him/her
when he/she is unable, due to physical or mental
incapacity, to make his/her own health care decision. This
includes decisions to accept or refuse any treatment,
service or procedure used to diagnose or treat his/her
physical or mental condition and decisions to provide,
withhold or withdraw life-sustaining measures
• Circumstances are stated in which various forms of
medical treatment including life-sustaining measures shall
be provided, withheld or discontinued. The desire to make
anatomical gifts after death are also indicated in the will, if
the patient desires to do so.
• This living will is signed by the patient. It is
witnessed by two other persons who declare that the
patient signed the will, that the latter appears to be of
sound mind, free of duress or undue influence. The
witnesses must be 18 years of age or older, and are not
designated as the person's health care representative or
alternate as such. This living will is attached to the
patient's chart. This directive has a force of law.
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