Bioethics and research

A. PRINCIPLES OF RESEARCH ETHICS

● 1st goal- To protect and safeguard human participants, their dignity, rights, and welfare.
● 2nd goal – ensure that research is focused on improving the welfare of individuals, groups, and
/or the community as a whole.
● 3rd goal- assess the ethical reliability of specific research events and schemes, taking into account
concerns such as managing risk, privacy, confidentiality protection, and the informed consent
process.

Philosophy of Research Ethics

Plato (427- 347 BCE) – scholar of Socrates. His writing transmits Socrates’ teachings.
- He emphasizes virtue, which he connects with knowledge, to know the good, which is
changeless, immaterial, transcendent, and absolute, is to be virtuous.
- Plato’s pupil was Aristotle ( 384- 322 BCE). His ethical writings are based on the pursuit of
the highest human good.

History of Research Ethics

- The Nuremberg Code- starting point for research ethics.
- Early evidence suggests ethical issues in human research when deciding how to perform
human experiments.
- William Osler (John Hopkins Professor)- advocated conducting medical research on animals
before moving on to humans.

- Declaration of Helsinki (World Medical Association)- set of ethical standards for human
research for the medical community.

- Belmont Report’s principles- the foundation for methods that provide informed consent, risk
assessment, and participant selection.

- As a result of the Belmont Report, federal research regulation has become more systematic
(Miller, R.L (2016).

NUREMBERG CODE

The Nuremberg Military Tribunals(1946) revealed atrocities done by Nazi doctors in the name of medical
science, providing little doubt the most powerful reason to try to regulate research involving human
subjects.

Essential principles of the Nuremberg Code:

- The permission of the human subject must be given voluntarily.

- Each person who starts, directs, or participates in the experiment has the duty and
obligation of determining the quality of consent. A personal obligation and duty that cannot
be transferred to others without repercussions.
- The experiment must produce useful results for the society
 - The experiment should be carried out in such a way that no needless bodily or mental
hardship or injury occurs.
- The Code was established as part of the trial ruling. The World Medical Association adopted
and developed the Nuremberg principles in the Declaration of Helsinki (1964) substantially
revised in 2000, stating that while scientific progress is a valuable public good,
“…considerations related to the well-being of the human subject should take precedence
over the interest of science and society.”

The Belmont Report (1979) (National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research)

- Statement of fundamental ethical principles and standards that should aid in the resolution
of ethical issues that arise in the conduct of human subject research.
- Contains the Ethical Principles and Guidelines for the Protection of Human Subjects of
Research (guide the conduct of biomedical and behavioral research involving human
subjects.
- The Commission was instructed to consider: boundaries between biomedical and behavioral
research and accepted and routine medical practice
- The role of risk-benefit criteria in determining the appropriateness of research involving
human subjects
- Appropriate guidelines for the selection of human subjects for participation in research
- The nature and definition of informed consent in various research settings

Extracts from the Belmont Report

- “Systematic, nonarbitrary analysis of risk and benefits should be emulated insofar as

possible.”
- “ The nature, probability, and magnitude of risk should be distinguished with as much as
clarity as possible.”
- “ Assessment of risk and benefits requires careful arrayal of relevant data.”

ETHICAL ISSUES IN EVIDENCE-BASED NURSING PRACTICE: AN OVERVIEW

- Nurses frequently encounter ethical difficulties when caring for a large number of patients.
These ethical dilemmas come in a variety of shapes and sizes.
- CODES OF ETHICS FOR NURSES- reflect the many issues that nurses confront, and serve as a
social compact between nurses and the general public.

Following ETHICAL ISSUES:

-inadequate competencies- when nurses are not fully equipped to do their tasks.

- Informed consent- when there is concern that patients and their families have not been informed, or do
not understand the treatments being administered to them, a dilemma can arise

- Protecting patient privacy and confidentiality- nurses should act in the best interest of their patients
- setting professional boundaries- patients should not place undue reliance on nurses, nor should they
form sexual ties with them or give them presents.

- shared patient decision-making- increases patients’ autonomy by allowing collaboration

- addressing advanced care planning- tough topic to discuss when it involves end-of-life care

- inadequate resources and staffing- Patients are at risk of not receiving adequate care when medical
institutions are short on resources

DEALING WITH ETHICAL ISSUES IN EVIDENCE-BASED NURSING PRACTICE

-NURSES’ CODE OF ETHICS- guidelines for nursing responsibilities

Ethical Dilemmas that nurse supervisors confront:

● Honesty vs withholding information:

● Science vs spirituality
● Healthcare needs vs resource allocation
● Autonomy vs beneficence

GUIDELINES AND PROTOCOL IN DOCUMENTATION AND HEALTH CARE RECORDS

Documentation in health care includes all forms of documentation by health care professionals (doctor,
nurse or other allied health professionals) recorded in a professional capacity to the provision of patient
care.

Documentation should follow 5C’s

1. Clarity- be specific, use only accepted medical terminology and standard abbreviation
2. Conciseness- short, brief and direct to the point.
3. Completeness- fill out ALL forms with the correct information and provide complete data in the
medical record
4. Confidentiality- the patient’s medical records must be kept confidential and safe
5. Chronological order- well-organized medical records are easy to access and manage

PURPOSE OF GUIDELINES

Guidelines provided by WHO support employers, policymakers, managers, and clinical staff in
documentation practices and policies that demonstrate professional obligation. Professional
documentation encompasses any type of documentation created by a clinician in the course of providing
patient care.

PURPOSES OF PROFESSIONAL DOCUMENTATION

1. Communication- serves as the foundation for communication among health providers.

2. Accountability – demonstrate responsibility and chronicle the clinician’s professional practice.
Can be used to establish who is responsible for providing care.
 3. Legislative requirement- nurses and midwives are obligated to create and maintain records of
their professional practice in compliance with their profession’s standards.
4. Quality improvement- to assess professional practice as part of quality assurance procedures.
5. Research – medical record documentation is a major source of data for health researchers.
6. Funding and resource management- data extracted and classified from medical records may be
utilized as a useful tool for determining the sort of treatment that the patient requires
7. Maintaining quality documentation practice- these recommendations urge employers and other
clinical personnel to implement strategies, policies, and procedures that promote successful
documentation practices in the workplace.

Strategies to maintain quality documentation practice include:

1. Organizational support
2. Leadership -This encourages clinical personnel to participate in decision-making about the
selection, implementation, and evaluation of documentation systems.
3. Professional development- processes for performance management that give opportunities
to enhance documentation procedures.
4. Communication systems- encourage proper information exchange throughout the
interdisciplinary team.
5. Responsive to change- documentation system and practices that are adaptable to change.
6. Documentation policy- medical records officers should make certain that they have
established policies, procedures, and quality assurance processes.
7. Monitoring documentation- audit procedure is one aspect of effective risk management.

GUIDING PRINCIPLES FOR DOCUMENTATION

1. COMPREHENSIVE AND COMPLETE RECORD

2. PATIENT-CENTERED AND COLLABORATIVE
3. ENSURE AND MAINTAIN CONFIDENTIALITY

ETHICAL CONSIDERATION IN LEADERSHIP AND MANAGEMENT

A. Moral decision making- is imperative to arrive at an ethical action or intervention. Develops from
clinical expertise and is a core competency for nurse leaders

The phase of Development of Core Competency for Ethical Decision- Making

Phase 1: Knowledge Development- Moral Sensitivity

Phase 2: Knowledge Application

Phase 3: Creating an ethical Environment

Phase 4: Promoting social justice within the Healthcare System

 - Nurses employ ETHICAL DECISION MAKING whenever there are Ethical Dilemma
- Ethical Paradox/ Ethical Dilemma- decision-making problem between two possible moral
imperatives, neither of which is unambiguously acceptable or preferable.
- Ethical decisions engender trust and thus indicate responsibility, fairness, and caring.
- Comes from a place of conscience.
- Ethical Decision-making process- the process of choosing the best alternative for achieving
the best results or outcomes in compliance with individual and social values, morals, and
regulations.
- The process of making ethical decisions requires:
● Commitment: the desire to do the right thing regardless of the cost
● Consciousness: the awareness to act consistently and apply moral convictions to
daily behavior
● Competency: the ability to collect and evaluate information, develop alternatives,
and foresee potential consequences and risk
- Good decisions are both ethical and effective
● Ethical decisions- generate and sustain trust, demonstrate respect, responsibility,
fairness, and caring and consistent with good citizenship
● Effective decisions- effective if they accomplish what we want to accomplish and if
they advance our purposes.
B. Principles of Moral Discernment
To make a conscientious ethical decision, one must do the following:
- Proceed based on a fundamental commitment to God and to humans (including oneself)
according to their God-given and grace human nature
- Among possible actions that might seem to be means of fulfilling that commitment
- Consider how one’s motives and other circumstances may contribute to or nullify the
effectiveness of these other possible actions as means to fulfill one’s fundamental
commitment
- Among the possible means not excluded or nullified, select one by which one is most likely
to fulfill that commitment and act on it.

C. Principle of Well-Formed Conscience

To attain true goals of human life through responsible actions, in every free decision involving an
ethical question, people are morally obliged to do the following:
- Inform themselves as fully as practically possible about the facts and the ethical norms
- Form a morally certain judgment of conscience based on this information
- Act according to this well-formed conscience
- Accept responsibility for their actions

CONSCIENCE FORMATION:

- The word conscience arises from Latin, conscienta and the French word conciense.
- Defined as the internal sense of what is right and wrong, and one’s ability to choose
between, as well act upon, what one perceives to be the right thing to do.
- In nursing, conscience is broadly perceived as an authority, a warning signal
- Nurses’ troubled conscience have been associated with feelings of guilt when:
 ● Nurses’ core beliefs conflict with social or professional belief
● Nurses cannot fulfill their care obligations to patients due to time constraints
● Nurses are placed in scenarios where they feel they are working against their
conscience

Conscience Formation

- Making moral decisions demand mature responsibility – free, correct, clear and certain
- Discern what is right and what is wrong

QUALITY OF CONSCIENCE

OBJECTIVE VALUE
- Correct- subjective conforms to the objective moral values
- Objective- norms of morality
- Erroneous- lack of conformity to the objective norms of morality
- Culpable- one is in error and therefore responsible
- Inculpable- has erred in good faith

MORAL ATTITUDE

- Lax- careless in its effort to seek the truth

- Strict- follow to the letter
- Scrupulous- tends to judge sin to be present when there is none
- Pharisaical- judgmental towards others
- Clear
- Callous- worst type- no sensitivity to sin

DEGREE OF CERTITUDE

- Perplexed- wrong if don’t do, wrong if you did

- Doubtful- lack of sufficient evidence
- Probable- made a decision already but still admitting the possibility that the opposite is true
- Certain- with sufficient factual evidence

c. Meaning and Service Value of Medical Care

- another important area of concern for nursing leaders is the medical care that is often
rendered to patients in need of medical attention based on urgency.
The concept of VALUE-BASED HEALTH CARE is introduced- this concept and strategy was a result
of decades of research into organizations that have achieved better outcomes while often
lowering costs (Teisberg et al, 2020)
- GOAL: enable the healthcare system to add more value to patients’ lives. Because value is
created only when a person’s health outcomes improve, cost-cutting descriptions of
value-based healthcare are inadequate.
 - Cost reduction is important, but it is not sufficient. If the true goal of value-based health care
was cost reduction, pain relievers and compassion would suffice.
a. Allocation of resources
- Healthcare requires resources and resources in turn entails cost and budgetary requirements
therefore as value-based healthcare is to be promoted it is imperative to allocate adequate
resources that are cost-effective to meet the patient’s outcome.
- According to Teisberg et al (2020), Value aligns care with how patients experience their
health by focusing on the outcomes that matter most to patients. Health outcomes can be
described in terms of capability, comfort, and calm
● Capability- the ability of the patients to do the things that define them as individuals
and enable them to be themselves. Often tracked with functional measures.
● Comfort- relief from physical and emotional suffering, requires addressing the
distress and anxiety that frequently accompany or exacerbate illness.
● Calm the ability to live normally while getting care. It encompasses freedom from
the chaos that patients often experience in the healthcare delivery system, and it is
especially important for people with chronic and long-term conditions
b. Issues involving access to care
- Having “the timely use of personal health services to achieve the best health outcomes”
(AHRQ, 2018 on IOM, 1993).
- The elements of access to healthcare according to the Agency for Healthcare Research and
Quality (AHRQ) in 2018:
● Coverage: facilitates entry into the healthcare system. Uninsured people are less
likely to receive medical care and more likely to have poor health status
● Services: having a usual source of care is associated with adults receiving
recommended screening and prevention services.
● Timeliness: ability to provide healthcare when the need is recognized
● Workforce: capable, qualified, culturally competent providers

Issues on access to healthcare:

“ BAHALA NA” mentality drains our healthcare system.

- Shortage of healthcare workers

- Limited access to healthcare facilities
- High out of pocket expenses for hospitalization and healthcare needs
 NCM 108
HEALTHCARE ETHICS
Dignity in Death and Dying
Intended Learning Outcomes:
-Implement safe and quality interventions with the client to address ethical
health concerns, needs, problems, and issues:
- Relate the inviolability of life to ethical death and dying.
3.2 Dignity in Death and Dying
Euthanasia, suicide, Dysthanasia, Misthanasia, Orthothanasia
-comes from Greek words, “eu” (good) and “thanatos” (death).
- to allow the patient to experience a relatively “good death”.
Euthanasia (mercy killing, assisted suicide). the painless killing of a patient
suffering from an incurable and painful disease or in an irreversible coma.
The practice is illegal in most countries.
- the act or practice of killing or permitting the death of hopelessly sick or
injured individuals (such as persons or domestic animals) in a relatively
painless way for reasons of mercy.
TYPES OF EUTHANASIA
• Active euthanasia : killing a patient by active means, e.g.
injecting a patient with a lethal dose of a drug. Sometimes called”
aggressive” euthanasia.
• Passive euthanasia: intentionally letting a patient die by
withholding artificial life support such as ventilator or feeding tube.
Some ethicists distinguish between withholding life support and
withdrawing life support (the patient is on life support but then
removed from it).
• Voluntary euthanasia: with the consent of the patient
• Involuntary euthanasia : without the consent of the patient, for
example if the patient is unconscious and his or her wishes are
unknown. Some ethicists distinguish between “involuntary” (against
the patient’s wishes) and “nonvoluntary” (without the patient’s
consent but wishes are unknown) forms
• Self- administered euthanasia: the patient administers the means of
death.
• Other administered euthanasia: a person other than the patient
administers the means of death.
Assisted: the patient administers the means of death but with assistance
of another person, such as a physician.
▪ Mercy-killing: the term “mercy-killing” usually refers to active,
involuntary or nonvoluntary, other-administered euthanasia. In other
words, someone kills a patient without their explicit consent to end
the patient’s suffering.
• Physician-assisted suicide: the phrase “physician-assisted suicide”
refers to active, voluntary, assisted euthanasia where a physician
assist the patient. A physician provides the patient with a means, such
as sufficient medication, for the patient to kill him or herself.
• Euthanasia is illegal in the Philippines
Dysthanasia term generally used when a person is kept alive artificially,
in a condition where otherwise they cannot survive; sometimes for some
sort of ulterior motive. Occurs when a person who is dying has their
biological life extended through technological means without regard to
the person’s quality of life.
Technologies such as implantable cardioverter defibrillator and artificial
ventilation can extend the dying process. In some cases,
cardiopulmonary resuscitation can be considered a form of dysthanasia.
❖ Social euthanasia, or misthanasia (miserable death)has no relation with
the search for a good , smooth and painless death. Common examples of
misthanasia are as follows:
[Link] default structural assistance, where the absence or precariousness of
medical care services ensures that people with physical or mental disabilities
or with diseases that could be treated die early, live in pain and suffering, In
principle avoidable.
B. A medical error (malpractice) where patients suffer, for example, with
delayed diagnosis or lack of the correct forms of analgesia.
[Link] misthanasia, occurs when there is omission of relief when the
physician-patient relationship has already been established or the patient is
abandoned.
❖ These forms are based on the fragility of human nature- whether by
negligence, imprudence or malpractice- and not by the deliberate
intention of harming someone.
❖ Whereas, misthanasia for malpractice occurs when the physician/s and
their associates, freely and on purpose, use medicine to violate the
human rights of a person, for their own benefit or not, directly or
indirectly damaging the patient to the point of underestimating their
dignity and cause a painful and /or early death. Example , removal of a
vital organ for transplantation before the person has died.
Orthothanasia (art of dying well) rejects all forms of mithanasia
without however, falling into the trap of euthanasia or dysthanasia.
Seeks to deal with the terminal patient, helping him to face his
destiny with greater tranquility , maintaining a distinction between
healing and caring, between maintaining life and allowing the
person to die, when the time comes.
Euthanasia and suicide
Suicide is the intentional termination of one’s own life. Cases in
which a person wants to kill himself or herself, whether the person
does this by omitting something (passive suicide) or by doing
something (active suicide).
ETHICS OF THE PATIENT
Two basic questions:
[Link] refusing treatment suicide?
[Link] suicide always unethical?
❖ In medical ethics, we can be faced with this situations in which a
patient or the patient’s surrogate may intend the patient’s death, not
because he or she wants to die, but because a medical condition or
the treatment for it is intolerable. They intend their deaths only
because of inhumaneness of their circumstances.
❖ The real issue (what is intended) is the elimination of suffering, and
the means is perhaps discontinuing ventilation. A test for this would
be that given a life without this suffering, the patient would prefer to
be alive. It is in this sense that we view refusing treatment not a
suicide by common sense or practical wisdom standards (Baillie, H. , et
al, 2009p.168).
Why is suicide thought to be unethical?
Baillie, et al. (2019)state that the notion the suicide is wrong has been
supported by a number of arguments. The first argument is religious and
theological. It holds that our lives belong to God and are merely loaned to us,
so we have no right to dispose our own lives, even though we have the right
to use them without limits.
We have no more right to kill ourselves than we would have to take the life of
another. However, a patient is not required to use extraordinary means to
continue existence.
• The second argument holds that human life is so precious that to act against
it is to act against the greatest of all human goods, or at least against the
good on which all other human goods depend. In the real world, life may be
experienced as an overwhelming burden, and the word life may designate no
more than a vegetable existence in a specific case.
• Furthermore, life can be so painful and so crushing that it renders all other
goods impossible. This gives emphasis to the ethical principle that a patient is
not required to use extraordinary means to continue existence.
• Finally, life can be barely recognizable as human, as in the cases of those who
are in permanent vegetative state. Even though medical science has become
adept at controlling pain, it often succeeds at the cost of the patient’s
consciousness. When the choice becomes overwhelming pain or
unconsciousness, it appears that life is no longer the substratum for all other
good things.
A third argument, this one consequentialist, condemns suicide because
it harms the community. Certainly, the individual must consider the
impact of their actions on the society.
A fourth argument proposes that suicide is wrong because it has
substantially harmful consequences for other individuals.
HEALTHCARE PROVIDERS AND THE ETHICS OF SUICIDE PREVENTION
[Link] has a clear interest in the preservation of life itself. Life has
fundamental value, and important advantage to living in the society is
the protection social life affords to life itself.
[Link] individual are valuable to society, and society has a legitimate
interest in preserving most of its citizens.
• At times there may even be a very strong overriding social interest.
Society could, then, legitimately forbid suicide or cooperation with
suicide on the grounds that the suicide robbed society of someone
valuable.
• Societies recognize that suicides do affect the rights of others.
Spouses and children, in particular,have important legal and moral
claims on a would be suicide.
• For some reasons, many societies have made suicide a crime, that
is, an offense against the society.
• Finally, the society may conclude that groups, such as the health
care professions, need to be insulated from the active suicide to
protect the functioning of the profession.
HEALTH CARE PROVIDERS AND THE ETHICS OF THE DEATHOF A
PATIENT
Is it ethical for the healthcare provider to cooperate when a
competent patient refuses treatment?
Further, may a healthcare provider cooperate with a patient’s active
suicide?
In using the word cooperation, we mean to stress that the competent
patient has asked for or consented to the cooperation. When there is
an incompetent or doubtfully competent patient or only surrogate
consent, we are dealing with an even more delicate problem.
Cooperation with a Patient who refuses treatment

- The patient or surrogate has the right to refuse treatment or demand the
discontinuance of treatment in order to avoid suffering or to avoid the difficulties of
continued treatment.

- There may be an emotional problem in admitting defeat, but there should be no

ethical problem, although the patient may not be competent at the end , refusal of the
treatment may be accomplished through a living will or a surrogate, especially through
a surrogate who has a durable power of attorney for health matters.

- When a patient is in a terminal condition but not in immediate danger, and provided
that the patient or their surrogate has given consent, it seems ethically justifiable to
refrain from treatment as it would be futile in impeding the advancement of the
disease. However, it is crucial to emphasize that withholding care is not ethical, as it is
imperative to uphold human dignity.
Discontinuing treatment
- It is illogical to extend life when the ultimate outcome is the
prolongation of suffering and deterioration. Moreover, when
treatment only serves to prolong the agony experienced by the
patient, its continuation becomes unethical as it undermines human
dignity.
-In the realm of medical ethics, it is crucial to consider the well-being
and quality of life of terminally ill patients. While it may seem intuitive
to exhaust all available treatment options, it is essential to recognize
that prolonging life does not always equate to enhancing its quality. In
fact, in cases where the patient's condition is irreversible and their
suffering is exacerbated by ongoing treatment, it becomes ethically
imperative to reevaluate the continuation of such interventions.
- The ethical correctness of not initiating or discontinuing treatment
for consenting terminally ill patients is grounded in several
compelling reasons. By prioritizing the patient's well-being,
respecting their autonomy, and considering the allocation of limited
resources.
- In such cases, the health care provider would be ethically justified
in discontinuing treatment except when the patient insists on
treatment. There can be exceptions. Where there is a shortage of
medical resources, the physician might be justified in stopping non
indicated treatment.
- The cessation of life-sustaining treatment does not always bring about
swift and painless death, even though it may speed up the process of
dying. It is always the obligation of the physician to ensure that the
patient receives proper continuous care. This obligation to care for the
patient demands that every ethical effort be made to alleviate these
sufferings with drugs and other methods that will prolong life.
FEEDING AND HYDRATION
Are nutrition and hydration medically indicated for terminal patient?
- in treating the terminally ill or irreversibly comatose patient, the physician should
determine whether the benefits of treatment outweigh its burdens. At all times the
dignity of the patient should be maintained.
The AMA Council on Ethical and Judicial Affairs expressed the emerging
consensus that it is not wrong to withdraw these treatment under appropriate
circumstances
[Link] procedure are futile, since the procedures are unlikely to achieve their
purpose
[Link] procedures would be no help to the patient even if succesful
[Link] burdens outweigh the benefits
(Lynn,J. and Childress, J., 1983. Cited in Baillie, H., et al, 2019, p.177)
Examples of FUTILE Treatments
[Link] patient has burns over most of his body and severe clotting
deficiency that would make it nearly impossible to control the
bleeding caused by the burns.
[Link] patient has severe congestive heart failure with cancer of the
stomach, which delivers food to the colon without passing through
intestine and being absorbed.
In the second class of cases, there is no possibility of benefit to the
patient who has permanently lost of consciousness, as in patients
with anencephaly (the absence of a major portion of the brain,
skull and scalp), vegetative state, and preterminal coma. In this
cases, feeding is sometimes done for the sake of the family, but it
is not medically indicated.
 There are cases in which feeding and hydration impose a
disproportionate burden.
[Link] patient’s need for nutrition arises in near death, a point at which
hydration causes terminal pulmonary edema, nausea and mental
confusion
[Link] who, although might benefit in one way, have fairly severe
dementia, such that restraints are needed, with the result that the patient
suffer constant fear and discomfort as he or she struggles to be free.
Life is prolonged but in a captive state(Lynn, J. and Childress, J.,1983. Cited
in Baillie, H., et al.,2019, pp.177-178).
IN CAPSULE:
When hydration and nutrition become medical procedures,
the ethics of their omission is based on the ethics of medical
indications and not on commonsense notions.
When a competent patient is sedated to control pain, his
resulting incompetence is due to the sedation. Hydration and
nutrition cannot be withdrawn at that time, if his incompetence
is cited as part of the justification for the withdrawal. The
physician cannot create an adverse condition and then use that
as justification for ceasing treatment.
In some cases nutrition and hydration are indicated on the
compassionate ground that such a death is sometimes more painful
than death from the particular disease. The patient may be faced with
the choice between slow death from cancer with adequate pain control
or a slightly more rapid and more painful death from dehydration and
starvation.
Healthcare professionals involve in hospice work have observe that,
although deprivation of nutrition and hydration is painful in healthy
people, they do not as a rule produce pain and suffering in the
terminally ill (Cox, 1987).
Medication can almost completely eliminate the possible
discomforts associated with the deprivation of nutrition and
hydration.
One cannot, then, simply assume that starvation or dehydration is
always painful, or for that matter that is never painful. Each case
must be evaluated individually, and ultimately the choice of the
manner of death belongs to the competent patient.
COOPERATION WITH THE REFUSAL OF TREATMENT BY A NON TERMINAL
PATIENT
The most emotionally challenging cases arise when patients refuse
treatment, even though they are not currently in a terminal condition.
However, their condition will inevitably deteriorate if the respirator is
disconnected or if the treatment is not initiated or discontinued.
This situation often occurs when patients believe that living indefinitely
on a respirator or being artificially fed for an extended period is not a
meaningful existence. It is a decision made by patients who choose not
to settle for a life below their personal ideals.

In such instances, healthcare professionals are faced with complex
ethical dilemmas that require careful consideration and sensitivity. These
cases demand a delicate balance between respecting the patient's
autonomy and ensuring their well-being. The decision to forego
treatment is deeply personal and can be profoundly distressing for both
the patient and their loved ones.
It is vital to provide patients with comprehensive information about
alternative options and potential consequences. This includes discussing
palliative care, pain management, and other supportive measures that
can enhance their quality of life. By presenting a range of possibilities,
patients can make informed decisions that align with their values and
aspirations.
Ultimately, the goal is to ensure that patients feel empowered and
respected throughout the decision-making process. By acknowledging
their autonomy and providing compassionate care, healthcare
professionals can navigate these emotionally challenging cases with
professionalism and integrity.
Only a court order or a court-appointed guardian has the right to overrule
the patient in these cases. The justice of even such court rulings is not
beyond question if the death will not injure society or third parties.
What, however, the said case in which the non terminal patient
not only refuses indicated treatment, but ask the healthcare
provider to keep him/her comfortable while he /she dies?the
health care can ethically refuse to cooperate in such situations,
because the health care professions should not be involve in
helping non terminal patients shorten their lives significantly.
Healthy or mildly ill patients do not have the right to force
physicians or hospitals to provide positive support for their
attempts at self-destruction.
PHYSICIAN INITIATIVES
▪ The physician is obligated to inform the patient clearly and
completely about his condition in order to obtain consent for
treatment. This should include an accurate description of the burdens
and benefits of continued treatment and the odds of success.
▪ The physician is obligated to provide treatment that does not harm
the patient.
▪ A no-code order is a written order to do nothing if certain situation
arise. Most, commonly DNR (Do Not Resuscitate) order, a written
order not to attempt resuscitation in case of cardiac arrest.
▪ No code order is correct when, from a medical point of view, more
harm than good will be done to the patient by treatment or
resuscitation. It should be noted that this is a written order for which
the physician accepts public responsibility and that should be medically
justified on chart. Granted these condition and consent, no-code order
is ethical.
▪ The slow code used to give families the impression that everything is
done for the patient in situations in which most of the time a no-code
order would be medically and ethically justified.
▪ The partial code a written order to omit some medical interventions,
but to employ others. There may be sound medical reasons to attempt
chest compression and electrical defibrillation or to omit intubation.
The reasons for these specific orders and omissions should be entered
on the chart, to avoid any ambiguity, all no-code orders should specify
what is not to be done with respect to each illness. Such specification
will clarify thinking and accountability and help reduce the risk of
carelessness (Baillie, H., et al., 2019, p.182)
ADMINISTRATION OF DRUGS TO THE DYING
❖ Care for the Dying and Pain Control
- as death approaches and the technical devices of medically intensive care
become useless, there is need for humanily intensive care. The dying
patient needs support and comfort of staff, family and friends.
- Limits on visit should be removed.
- Long-absent relatives should be encouraged to come so that
reconciliations may be made or memories shared.
❖ Pain Control, especially in the dying patient, has been a neglected
area in health care. Studies suggest that patients in pain want pain
relief, not death.(Colburn, 1996). one of the central problems in pain
control is the issue of who decides when the patient when the patient is
in pain.
❖ Fear of the patient getting high or becoming an addict binds the
caregiver to the reality of the patient’s suffering. Generally, when the
patient says he is in pain, his judgment should be the one that matters
(Henkelman, 1994). there is a little reason a dying patient should not be
kept comfortable, particularly when that is her request (Catholic Health
Association, 1993)
SURROGATES AND THE TERMINATION OF TREATMENT
❖ When the patient is often incompetent, the health care team needs to
consult the surrogates about discontinuing treatment for the terminal
patient.
❖ Ethically, the health care professional generally has no obligation to do
what is not medically indicated. The exceptions arise when the patient
or the surrogate has non medical reasons for continuing the treatment.
ETHICAL PROBLEMS OF DEATH AND DYING
Advance Directives
• Includes living wills , healthcare proxies, and durable powers of attorney
for health care (Blais and Hayes, 2011).
• They are values of informed consent , patient autonomy over end-of-life
decisions, truth telling and control over the dying process.
Living Wills represent written documents that direct treatment in
accordance with a patient’s wishes in the event of terminal illness and
condition. Are often difficult to interpret and not clinically specific in
unforeseen circumstances.
• Healthcare proxies or Durable Power of attorney for Health Care- is a
legal document that designates a person or people of one’s choosing to
make decisions on his or her own behalf.
ETHICAL CONCERNS IN THE END-OF-LIFE CARE
❖ Ethics in Medical Decision Making
❖ Patient’s goals of care are what patients place highest value on and
would hope to achieve in regard to their illness. Sometimes, there can
be conflicts between what the clinician believe to be the best for the
patient and what the patient and family want to have done.
❖ Difficult Decisions in End-of-life care
❖ The nurse should focus on helping the patient weigh the benefits and
burdens of the intervention, rather that focus in the intervention itself
(Kennedy Swartz, 2001).
Difficult decision that patients often need to make in end-of-life are as as
follows:
• Withholding or withdrawing of Medical Interventions
• Do not attempt Resuscitation(DNAR)
• Allows natural death (AND)
• Medical Order for Life sustaining Treatment (MOLST))- sometimes
referred to as Physician order to life-sustaining treatment
• Hastening death (principle of Double Effect)
• Terminal / Palliative sedation
Criterias required for Palliative Sedation
- Patient has a terminal illness
-Severe symptoms are not responsive to treatment and intolerable to
patient
-A “do no resuscitate” order is in effect
-Death is imminent (hours to days)
Terminal sedation has been compared with slow euthanasia and
assisted dying; how ever they are not the same thing. The key difference
is based on the intent or purpose of the intervention. The intent is not
to hasten death but to relieve suffering that cannot be relieved by any
other available method.
Assisted dying
- an action in which an individual’s death is intentionally hastened by the
administration of a drug or other lethal substances” (Volker, 2010). there
are two distinct subcategories:
Assisted suicide- the patient is provided with the means to carry out
suicide, such as providing with a lethal dose of a medication.
active euthanasia- someone other than the patient is the one who carries
out the action that ends the patients life (Volker, 2010).
The vast majority of ethical codes from the main nurses’ organizations
prohibit the involvement of a nurse in the assisted dying of patients.
IN CAPSULE:
❑ Nurses caring for patient at the end have a moral and professional
obligation to follow guidelines depicted in their professional and ethical
standards.
❑ The absence of an directive can make end of life decision-making
difficult for families of dying patients who are no longer able to speak
for themselves.
❑ Nurses need to advocate to ensure that their patients’’ goals of care are
met while following ethical principles.
Right to self-determination
✔ The patient has the right to avail himself/herself of any recommended
diagnostic and treatment procedure. Any person of legal age and of
sound mind may make an advance written directive for physicians to
administer terminal care when they suffer from the terminal phase of
terminal illness, provided that:
• He is informed of the medical consequences of his choice;
• He releases those involved in his care from any obligation relative to
the consequences of his decisions;
• His decision will not prejudice public health and safety;
• He/she is informed of the medical consequences of his/her decision;
THE LIVING WILL AND DURABLE POWER OF ATTORNEY
The living will- a document signed and witnessed at a time when the
patient is clearly competent. It is a patient’s directive to continue or to
withhold treatment or to administer pain killing drugs if the person has an
incurable disease, illness or condition from which the patient has become
incompetent and can no longer speak for himself or herself.
• In practice, it is most frequently used to discontinue treatment.
• The durable (or permanent) power of attorney appoints for health
affairs and gives general direction to that surrogate. It is more flexible
than the living will in that powers of the surrogate or agent are not
limited to desire concerning life- prolonging treatment.
• Both the living will and the durable power of attorney in health matters
are useful because they provide clear instructions of the will of a
competent person and help to avoid conflicts among surrogates as well
as debates as to which surrogates has the authority to consent or the
correct interpretation of the wishes of the patient.
• The most difficult cases are when the wishes of the now-incompetent
patient are unknown, the surrogates insists on aggressive treatment to
assuage their own guilt, and the physician regards the treatment as
prolonging the agony of a dying patient.
THE PLACE OF ETHICS COMMITEES
The mission of ethics committees:
[Link] are supposed to educate the hospital and its employees, as well as
the other constituencies of the hospitals.
2. They are to develop policies with regard to the problem areas, especially
the problems of death and dying.
[Link] are to act as advisory consultants to healthcare providers and
possibly families (Levine, 1984)
• this 3rd function can be looked at as support mechanism for
decision-makers, both lay and professional.
THE PLACE OF THE FAMILY IN DEATH AND DYING
• At a certain point in the dying process, the family members become
secondary patients in need of information about the state of affairs and
emotional support.
Some hospitals have formed bioethics teams to provide support to
families and to aid them in making difficult decisions about terminating or
continuing treatment.
Team consist of:
-Physician
-nurse
- social worker
- member of the clergy
THE VALUE AND QUALITY OF LIFE FOR THE INDIVIDUAL
PERSONS
• Biological human life has value as a means, a precondition
for specifically human activities of a human person. This makes
us face the crucial questions of what activities are specifically
human, such that lacking or a reasonable hope of getting them
back makes biological human life cease to have value for
anyone.
IN CAPSULE:
The main issue is that the patients may ethically refuse treatment
for proportionate reasons, and health care professionals may
cooperate with those patients’ requests.
The central issue remains caring for the dignity of the patient,
which involves respecting the patient’s wishes, protecting the
integrity of the profession, and sparring the patient life under
conditions which are generally understood to be extremely
burdensome either because of pain, suffering or
degradation(Baillie, et al., 2019, pp..167-195).
• Reference:
• Quiambao-Udan, Josie, Cu, Neugene Rowan S., Cañete, Geraldine S.,
Bartolata, Richard L. – Health Care Ethics 1st edition 2023
 Week 11
Bioethics and Research
A. Principles of Ethics in Research
B. Nuremberg Code
C. Declaration of Helsinki
D. Belmont Report
 Week 11
E. Ethical Issues in Evidenced Based
Practice
F. Ethico-moral Obligations of the
Nurse in Evidenced Based Practices
G. Introduction to Good Clinical
Practice Guidelines
 NCM 108
HEALTHCARE ETHICS
ETHICAL ISSUES RELATED TO TECHNOLOGY
AND DELIVERY OF HEALTH CARE
Intended Learning Outcomes:
- identify the ethical considerations in the use of appropriate technology in
delivering safe and efficient health care services
A. Data Protection and Security
- The act of protecting information, both sensitive and personal sensitive
to unauthorized access and use.
- Protection has various advantages:
→ allows employees to safely share shared logical and physical address
spaces.
→ Staff have particular authorization to access the information needed to
execute their duties.
→ Different users can access a system’s memory via physical address
spaces inside a system, boosting resource efficiency
• 3 main attributes of SECURITY:
AVAILABILITY- relates to the prevention of unauthorized actors
withholding information,
CONFIDENTIALITY-
INTEGRITY -(both are concerned with information staying private
and undamaged by malevolent actors)
- External dangers are often classified as either INDIRECT or DIRECT
• INDIRECT threats examples:
- Trojan
- Worm
- Computer virus
• DIRECT threats example:
- Targeted attack by a hacker
• Protection is a strategy used within systems to handle hazards and
ensure proper operation.
• Provides the framework for controlling access to data, processes
programs, and other resources.

∙ Security is employed to deal with threats from outside systems to keep

the system running effectively.
∙ Provides a technique for protecting both user and system resources
from unauthorized external entities in terms of functionality
∙ The primary distinction between security and protection is
POLICY.
∙ SECURITY POLICY, determines whether or not a person may
use a system
∙ PROTECTION POLICY the user’s access to certain data
resources.
 IMPLICATIONS TO PRACTICE
Healthcare services rely heavily on the open exchange of information
among all participants- whether the customer, the healthcare professional,
or the health institution.
Clients are more likely to offer complete and accurate data when they are
convinced that their information is safe and secure in the hands of their
healthcare practitioner.
A health organization that values data privacy cares about its patients.
The majority of the data you process as a healthcare professional is
classified as sensitive personal information. Data privacy safeguards
guarantee that your client’s information is safe and secure.
It ensures that their data is secure at all times and is not vulnerable to risk
and vulnerabilities such as unlawful access, processing, sharing, and
disclosure.
 DATA PRIVACY ACT (National Privacy Commission, 2021)
Republic Act No. 10173- also known as the Data Privacy Act of 2012
(DPA).
1. It protects the privacy of individuals while ensuring the free flow of
information to promote innovation and growth.
2. Regulates the collection, recording, organization, storage, updating or
modification, retrieval, consultation, use, consolidation, blocking, erasure,
or destruction of personal data.
3. Ensures that the Philippines complies with international standards set for
data protection through the National Privacy Commission.
NATIONAL PRIVACY COMMISSION (NPC)- an independent
body mandated to administer and implement the DPA, and to
monitor and ensure compliance of the country with
international standards set for data protection.
The country’s privacy watchdog.
WHO ARE COVERED BY THE DPA?
This applies to the processing of all types of personal information and
any natural or juridical person involved in personal information
processing, including personal information controllers and processors
who, while not located or established in the Philippines, use equipment
located in the Philippines, or those who maintain an office, branch, or
agency in the Philippines subject to the immediately following
paragraph: Provided, that the requirements of Section 5 are complied
with.
DOES THE HOSPITAL OR HEALTHCARE SETTING NEED A DATA PRIVACY OFFICER?
Appointing a Data Protection Officer(DPO) is a legal requirement for personal
information controllers (PICs) and personal information processors (PIPs), under the Data
Privacy Act of 2012.
You should assign a DPO if you are a natural or juridical person or any other body in the
government or private sector engaged in the processing of personal data of individuals
living within and outside the Philippines. An individual PIC or PIP shall be a de facto DPO.
In the healthcare industry, among such PICs or PIPs are the following: hospitals including
primary care facilities, multi-specialty clinics, custodial care facilities, diagnostic or
therapeutic facilities, specialized out-patient facilities, and other organizations processing
genetic data.
A DPO increases your chance to remain competitive in the dynamic global landscape of
data protection. At the same time, it improves your customer service and enhances your
responsiveness to growing public awareness and regard for personal data protection.
•
WHAT IS A PRIVACY NOTICE?
A privacy notice is a statement made to a data subject that describes how
the organization collects, uses, retains, and discloses personal information.
Sometimes referred to as a privacy statement, a fair processing statement,
or a privacy policy.
Aims to inform the public, it must be easy-to-read, transparent, and
compelling.
A Privacy Notice is different from a Consent.
A privacy notice is only meant to inform data subjects of the intended
collection and processing by an entity. Meanwhile, privacy consent is an
indication of will, whereby the data subject agrees to the processing of his
or her information.
WHAT IS A PRIVACY IMPACT ASSESSMENT (PIA)?
Is a process undertaken and used to evaluate and manage impacts on the privacy
of a particular program, project, process, measure, system or technology product
of a PIC or PIP.
It takes into account the nature of the personal data to be protected, the personal
data flow, the risk to privacy and security posed by the processing, current data
privacy best practices, the cost of security implementation, and, where applicable,
the size of the organization, its resources, and the complexity of its operations.
PIA helps PIC or PIP navigate the process of understanding the personal data flows
in the organization. It identifies and provides an assessment of various privacy
risks, and proposes measures intended to address them.
WHAT IS A PRIVACY MANAGEMENT?
Privacy Management Program (PMP) refers to a process intended to embed
privacy and data protection in the strategic framework and daily operations of a
PIC or PIP, maintained through organizational commitment and oversight of
coordinated projects and activities.
It provides an easier way to explain to the management and staff: why we are
doing this, what are the results we expect, what are the benefits of those results,
and what we need to do to get there.
A PIC or PIP is instructed to implement reasonable and appropriate measures to
protect personal data against natural dangers such as accidental loss or
destruction, and human dangers such as unlawful access, fraudulent misuse,
unlawful destruction, alteration, and contamination.
PRIVACY MANUAL- serves as a guide or handbook for ensuring the
compliance of an organization or entity with the DPA, its implementing
Rules and Regulations (IRR), and other relevant issuances of the
National Privacy Commission (NPC).
It also encapsulates privacy and data protection protocols that need
to be observed and carried out within the organization for specific
circumstances (e.g., from collection to destruction), directed toward
the fulfillment and realization of the rights of data subjects.
DATA PROCESSING GUIDELINES
Under the DPA, the consent of the data subject is defined as any freely given,
specific, informed indication of will, whereby the data subject agrees to the
collection and processing of personal information about and /or relating to him
or her.
Note that consent is just one of many other lawful criteria for processing
personal information (Section 12, DPA) and sensitive personal information
(Section 13, DPA).
When processing information, PICs should determine whether consent is the
most appropriate basis for such.
Consent shall be evidenced by written, electronic, or recorded means.
It may also be given on behalf of the data subject by an agent specifically
authorized by the data subject to do so.
 WHAT IS THE CONSENT OF THE DATA SUBJECT?
To protect privacy, the law requires organizations to notify and furnish
their data subjects with the following information before they enter
personal data into any processing system, or at the next practical
opportunity:
1. Description of the personal data to be entered into the system.
2. Purposes for which data will be processed (e.g., direct marketing,
statistical, scientific, etc.)
3. Basis for processing, especially when it is not based on consent (e.g.
public health and safety, mandatory reporting of illness, disease
surveillance)
4. Scope and method of the personal data processing
5. Recipients to whom data may be disclosed
 WHAT IS THE CONSENT OF THE DATA SUBJECT?
6. Methods used for automated access by the recipient and the extent
to which such access is authorized
7. Identify and contact details of the PIC or its representative
8. The duration for which data will be stored
9. Existence of the rights of the data subjects
WHAT ARE THE GUIDELINES IN COLLECTING AND ACCESSING
PERSONAL DATA?
As the Commission has often said, health practitioners and anyone
involved in the delivery of health care services must gather only
the required personal information.
Recipients should not be saddled with personal data obligations
that go beyond the bare minimum, since this would simply slow
the delivery of relief in this time of need.
Access to health data must be granted solely on a “need-to-know”
basis, which implies that only individuals on the health team must
have the minimum and essential access to execute their tasks.
 • WHAT DO I NEED TO KEEP IN MIND WHEN STORING CLIENTS’
INFORMATION?
The DPA and its IRR provide that personal data shall not be retained
longer than necessary:
1. For the fulfillment of the declared, specified, and legitimate purpose,
or when the processing relevant to the purpose has been terminated;
2. For the establishment, exercise, or defense of legal claims; or
3. For legitimate business purposes, which must be consistent with
standards followed by the applicable industry or approved by the
appropriate government agency.
Likewise, retention of personal data shall be allowed in cases provided by
law.
For members of the Health and Hospitals Sector, reference may be made
to DOH Memorandum Circular No. 70, series of 1996 for the Revised
Disposition Schedule of Medical Records
PIC must implement reasonable and appropriate organizational, physical,
and technical measures intended for the protection of personal
information against any accidental or unlawful destruction, alteration, and
disclosure, as well as against any other unlawful processing.
HOW MAY PERSONAL DATA BE DISPOSED OF?
Under the IRR, personal data shall be disposed of or discarded in a
secure manner that would prevent further processing,
unauthorized access, or disclosure to any other party or the public,
or prejudice the interests of the data subjects. The DPA penalizes
improper disposal of personal information and sensitive personal
information.
•
 B. BENEFITS AND CHALLENGES OF TECHNOLOGY
Technology has its advantages on the healthcare system primarily in
streamlining the services and making the workload of healthcare
professionals lighter and more efficient.
The 3 major benefits of technology in healthcare according to Ross
(2019) are as follows:
1. IMPROVED CARE COORDINATION
Improving coordination has been a goal of healthcare, serving as a
cornerstone of The Joint Commission’s National Patient Safety Goals
program and a component of meaningful use attestation.
Despite the increased focus, care coordination remains a
difficulty for organizations, particularly during transitions of care,
resulting in inadequate care quality and safety.
Technological advancements have the potential to improve
provider communication and minimize mistakes during care
transitions.
In response to the increased need for support with care
transitions, innovative IT businesses have introduced many
solutions.
2. IMPROVED POPULATION HEALTH MANAGEMENT
Population health is a novel term that may be described as “the health
result of a group of individuals, including the distribution of such
outcomes within the group, “according to an article published by Barton
Associates.
“Without data on the (health) populations you serve,” Evan Wade of
Barton Associates writes “any population health initiatives become
educated guesses at best.”
According to a survey conducted by West Corp., 35% of all respondents,
including hospital and health system providers, physicians, and other
medical professionals, did not have adequate access to clinical data from
disparate systems.
3. IMPROVED PATIENT EDUCATION
Patient education used to be mostly based on written information
regarding illness processes, medications, medical management, and
self-care teaching instructions. Patients may now get health
information from anywhere thanks to the Internet and mobile
technologies.
Telemedicine advancements now allow people to consult with
healthcare experts anytime they need one. New education formats,
such as interactive walkthroughs, instructive films, and SMS reminders,
provide patients with new ways to absorb health information and
become more involved in their treatment.
Enhanced functionality in current technologies, such as patient portals,
can provide patients with personalized health education based on their
unique requirements and situations.
 CHALLENGES OF TECHNOLOGY IN HEALTHCARE
The challenges of technology in healthcare can be viewed into three
categories according to Zarif (2022) namely:

1. HEALTHCARE ORGANIZATIONS
The expense of technology is one of the most significant difficulties for
enterprises in terms of installation and subsequent upkeep.
The inability to precisely measure intangible patient and cost
advantages makes valuing and justifying capital spending on new
technologies problematic. When compared to broad deployments,
remote monitoring may be viewed as a compromise.
Proponents say that reducing needless hospitalization can reduce healthcare
expenses, which may be especially important in chronic illness management. This is
advantageous from the utilitarian standpoint in terms of achieving successful
outcomes for as many patients as feasible. However, the evidence reveals that remote
monitoring does not save costs for a great majority of people.
Most studies according to Zarif (2022) show little, if any, cost reductions and
occasionally increased expenses, nevertheless, favorable clinical results for chronic
illness treatment have been observed.
According to Rawls’ Difference Principle, the literature is not in favor of cost-cutting
measures that help the majority of most vulnerable people. It has been proposed that
remote monitoring may incur higher expenditures for underrepresented communities.
As a result, it is vital to avoid developing a false feeling of organizational autonomy,
which might lead to a shift in the healthcare organization’s role from a
patient-centered to a profit-centered agenda.
Interoperability is a concern raised by the idea of “new” technology.
Integration and cross-access of data and use between multiple systems or
even different versions may be problematic due to the timeframes
involved. This, according to some, is a blatant breach of organizations’
ethical responsibilities, arising from their fiduciary connection with
patients, to guarantee that the absorption of old systems meets
integration criteria (Zarif, 2022).
2. HEALTHCARE PROVIDERS
Although healthcare technology offers great opportunities to enhance
healthcare outcomes, improper use must be addressed. The technological
imperative relates to the inevitability of new technology and its necessary
character, which indicates the necessity for adoption for social benefit. The
dominance of technology in healthcare arguably modifies the objective of
healthcare from preservation and restoration under responsible autonomy
to death prevention.
• This raises the moral plight of utilizing the patient as a way of achieving
end-of-life prevention, breaching one of the core guiding principles of
medical ethics: autonomy.
3. PATIENTS
The implications of the moral obligation bleed over into the issues that
patients face. The necessity to ensure the appropriate use of costly
equipment (at least during the early adoption period) and the moral
obligation to use new technology directly contradicts the need to
protect patient autonomy, as drawn from the application of
personalism to healthcare systems.
Their manifestation is their one-of-a-kind worth, which includes
inherent attributes like free will. The person’s participation in decisions
centered on them can achieve their causal potential. Thus, the
challenge to the moral imperative is a clear breach within the
patient-centered paradigm of modern medicine.
The position of technology, on the other hand, does not have
to be limited to a false dichotomy of either the
value-neutrality dictum or the value-ladenness thesis. The
acceptance of technical value does not mean our subjection to
the technological imperative and loss of autonomy. Zarif
(2022) on Cassell contends that the value-ladenness of
technology stems from its inherent features, which correlate
to human nature’s shortcomings. Thus, managing the
value-ladenness of technology involves governance of our
values and self-control, whereas managing its ethical issues
necessitates management of our ethics.
C. CURRENT TECHNOLOGY: ISSUES AND DILEMMA
1. PRIVACY AND SECURITY
∙ The issue of privacy and security will always be in question once
technology is applied in the healthcare setting. Autonomy and
transparency relate to this issue as to what choice can the patient make.
∙ According to Shaw and Donia (2021) it is in the interest of technology
developers and other supporters of digital health to keep attention
focused on technical challenges that can be contained and addressed
using technical approaches.
2. SOCIOTECHNICAL HEALTH
∙ Shaw and Donia (2021) defined sociotechnical as the observation that issues
on technologies such as applications of digital health are never solely about
the material technology itself, but about the mutual dependencies between
technologies and the social arrangements in which they are built and used.
∙ By the same token, “social arrangements” are always infused with various
technologies, ranging from chairs and whiteboard design rooms to
smartphone applications and videoconferencing software that mediate human
interactions.
∙ The term “sociotechnical” thus denotes a broadening of focus from the issues
defined by technology itself, to the broader universe of issues opened up by
the recognition that technologies are built and embedded in the social world
in ways that profoundly shape and are shaped by human life.
 2.1 APPLICATION OF SOFTWARE
∙ Shaw and Donia (2021) identified that the ethical issues at the
level of application software include effectiveness, usability,
inclusiveness, transparency, and other issues related to the
functioning and direct use of the digital health offering.
 2.2 MATERIAL DEVICE AND SUPPLY CHAINS
∙ The actual materials used to build and distribute the devices through
which humans interact with digital health technologies are frequently
overlooked in ethical analysis, but they are crucial for a comprehensive
view of digital health ethics.
∙ The materials used to manufacture smartphones and other digital
devices are extracted from the earth and shipped internationally,
reinforcing low-wage labor in low-income countries while benefiting
primarily large corporations in high-income countries (Shaw and Donia,
2021).
 2.3 INFRASTRUCTURES
∙ This refers to the hardware and software required to operate digital
devices. Shaw and Donia, (2021) added that infrastructures include
buildings in which healthcare providers work when delivering virtual
care, the cables and wires that enable digital signals to travel over
distance, and the corporate structures of the organizations that make
digital communication available. Ethical issues relevant to infrastructure
include a lack of high-speed internet availability that precludes a
particular community from accessing digital health care.
 2.4 INDIVIDUAL HEALTH-RELATED PRACTICES
∙ Shaw and Donia (2021) highlighted that digital technologies are used in a variety of
health-related applications, many of which are intended to promote healthy activity
and the management of disease among individual people. Digital health is often
infused with self-tracking mechanisms that have an impact on encouraging people
about whether and how their actions align with expected social norms.
∙ Ethical issues include the power of self-tracking and “nudge” technologies to shape
and constrain human behavior. The power of technology to influence mental
well-being as a result of reduced self-esteem, and its power to influence individual
actions, are ethically relevant and should be acknowledged in related ethical analysis
of digital health.
 2.5 INTERPERSONAL RELATIONSHIP
∙ Digital health technologies have the potential to have a wide range of
effects on interpersonal relationships. (Example. Significant impact of
social media applications on public understanding of health-related
science and policy).
∙ Health-related social media use has the potential to foster interpersonal
networks that reinforce specific epistemic viewpoints on health-related
issues, potentially harming public health.
∙ Another case in point is the impact of technology-mediated
communication on the relationship between a healthcare provider and a
patient.
 2.6 ORGANIZATIONAL POLICIES
∙ Digital technologies have the potential to dramatically alter daily work
practices, and thus the structure and function of organizations.
∙ How healthcare organizations navigate the transition from analog to
digital work environments is likely to have far-reaching consequences for
the nature of healthcare work and patient care.
∙ Then impact of organizations such as insurance companies that use
digital health technologies to collect information about individual
behaviors and shape their product offerings accordingly. Advances in
digital health technologies have made such practices more effective, and
the role they should play in the insurance industry in the future is an
organizational policy issue that requires careful ethical consideration.
Digitalization of the healthcare setting workflow is here to stay.
A relevant socio-technical approach to ethical analysis must be
done to avoid overshadowing the concerns brought about by
using technology. Usability and ethical use can always go hand
in hand given the proper moral and ethical standpoint of
developers and healthcare professionals.
• Reference:
• Quiambao-Udan, Josie, Cu, Neugene Rowan S., Cañete, Geraldine S.,
Bartolata, Richard L. – Health Care Ethics 1st edition 2023
 NCM 108
HEALTHCARE ETHICS
CONTINUING EDUCATION PROGRAMS ON
ETHICO-MORAL PRACTICE IN NURSING
Intended Learning Outcomes:
- Demonstrate beginning professional behavior
-Exemplify love for country in service of the Filipinos.
 • CONTINUING EDUCATION PROGRAMS ON ETHICO-MORAL
PRACTICE IN NURSING
A. LOBBYING/ ADVOCATING FOR ETHICAL ISSUES IN HEALTHCARE
• Advocacy- the act or process of promoting a cause or proposal
• Lobbying- the act or process of influencing public officials to promote
(something, such as a project) or secure the passage of (legislation)
❖ Nurse advocates or lobbies to raise awareness of an issue- the actual
intent of the act is different.
❖ To advocate is to raise and publicize an issue within a community, such
as making health care a topic of national debate and media attention.
❖ Lobbying is the process of directing one’s efforts toward individuals
in positions of authority, such as public officials, politicians,
government bodies, and regulatory agencies (Bradley University,
n.d.)
❖ Nurses’ advocates can communicate from various platforms (social
media, professional conferences).
❖ Nurse lobbyists are distinguished by their explicit effort to steer
those talks toward a specific goal: influencing public policy or
legislation formation. While advocacy is the catalyst for a grassroots
movement, lobbying is the mechanism to achieve the desired
change.
• NURSES’ PRIMARY RESPONSIBILITIES include the preservation and
promotion of human rights in health and health care (ANA, 2016).
The following initiatives to advocate for ethical issues in health care:
∙ Nurses may advocate for ethical and just nursing practice by building
and maintaining environments that promote established norms of
professional behavior.
∙ Nurses may improve the practice environment by refusing to practice in
ways that are detrimental to patient care quality.
∙ Nurses may reinforce and strengthen nursing beliefs and ideals through
their professional organization, which interprets and explains nursing’s
place and role in society.
∙ Human rights abuses involving patients, nurses, healthcare
professionals, and others must be closely monitored by healthcare
institutions/organizations.
∙ Healthcare institutions must support policies and practices that actively
maintain environments that ensure ethical nursing practice, safeguard
human rights and means for reporting infractions, as well as take action
to prevent recurrence.
∙ Nurses from all practice settings may serve on ethics committees, seek
to encourage colleagues to consider ethics and human rights, and take
political action to clarify and promote health policy that improves access
to and equality treatment.
∙ Nurses must examine the conflicts that arise between their own
personal and professional values and the values and interests of others
who are responsible for patient care and healthcare decisions, and
they must resolve these conflicts in ways that ensure patient safety and
promote the patient’s best interests.
∙ Nurses may collaborate with other healthcare professionals to build
moral communities that promote, protect, and preserve ethical
practice and the human rights of all patients and professional
stakeholders.
❖ Nurse educators must use the following notions of justice and care as
guiding principles in teaching students about ethics and human rights in
healthcare settings all over the world from local communities to global
communities.
❖ Through material, clinical and field experiences, and critical thinking, nurse
educators must firmly anchor students in nursing professional duty to
challenge unjust systems and structures, reflecting the profession’s
commitment to social justice and health.
❖ Nurse researchers must ensure that human rights are respected by
obtaining ongoing informed permission, assessing the risk vs benefit of
research participants, and avoiding damage.
❖ Nurse researchers may undertake research relevant to communities of
interest, are guided by community participation in identifying research
challengers, and endeavor to improve patients, society, and professional
practice.
❖ Nurse administrators must put ethical and human rights concepts into
practice by keeping an eye on the practice environment for actual or
potential human rights breaches by patients, nurses, and other
healthcare employees.
❖ Nurse administrators must evaluate policy and practice to detect the risk
of diminished care quality as a result of unrecognized human rights
breaches.
• In their organizations and beyond, nurse administrators may
actively foster a caring, just, inclusive, and collaborative
environment.
• NURSES MUST BE COMPLETELY AWARE OF THEIR PATIENT’S
RIGHTS IN ALL SITUATIONS, AGES, AND DEVELOPMENTAL SKILLS,
AND BE WILLING TO ADVOCATE FOR THEM AND WORK WITH
OTHERS TO FIND ETHICAL SOLUTIONS (COUNCIL OF EUROPE,
n.d.)
• Nurses fight for patient’s rights in a caring environment,
especially for those whose rights are more readily infringed or
not met. Nurses are concerned about the human rights of
themselves, their patients, their coworkers, and both local and
global communities. Respect for the inherent dignity, value,
distinctive traits, and human rights of all individuals underpins
effective nursing practice in all situations (ANA, 2016.)
 • B. CODE OF ETHICS FOR NURSES
• 1. INTERNATIONAL CODE OF ETHICS
❖ The ICN Code of Ethics for Nurses is a statement of the ethical values,
responsibilities, and professional standards of nurses. It guides
everyday ethical nursing practice and can serve as a regulatory tool to
guide and define ethical nursing practice.
• An international code of ethics for nurses was first adopted by the
International Council of Nurses (ICN) in 1953. It has been revised and
reaffirmed at various times since, most recently with this review and
revision completed in 2012.
❖ Nurses have four fundamental responsibilities to promote health, to prevent
illness, to restore health, and to alleviate suffering. The need for nursing is
universal.
❖ Inherent in nursing is a respect for human rights, including cultural rights,
the right to life and choice, to dignity and to be treated with respect.
Nursing care is respectful of and unrestricted by considerations of age,
color, creed, culture, disability or illness, gender, sexual orientation,
nationality, politics, race or social status.
• Nurses render health services to the individual, the family, and the
community and coordinate their services with those of related groups
 • ELEMENTS OF THE CODE
1. NURSES AND PEOPLE
nurse’s primary professional responsibility is to people requiring nursing
care.
In providing care, the nurse promotes an environment in which the human
rights, values, customs and spiritual beliefs of the individual, family and
community are respected.
The nurse ensures that the individual receives accurate, sufficient and
timely information in a culturally appropriate manner
The nurse holds in confidence personal information and uses judgement in
sharing this information
The nurse shares with society the responsibility for initiating and
supporting action to meet the health and social needs of the public, in
particular those of vulnerable populations.
The nurse advocates for equity and social justice in resource
allocation, access to health care and other social and economic
services.
The nurse demonstrates professional values such as respectfulness,
responsiveness, compassion, trustworthiness, and integrity.
2. NURSE AND PRACTICE
The nurse carries personal responsibility and accountability for nursing
practice, and for maintaining competence by continual learning.
The nurse maintains a standard of personal health such that the ability
to provide care is not compromised.
The nurse uses judgment regarding individual competence when
accepting and delegating responsibility.
The nurse at all times maintains standards of personal conduct which
reflect well on the profession and enhance its image and public
confidence.
The nurse, in providing care, ensures that use of technology and
scientific advances are compatible with the safety, dignity and rights
of people.
The nurse strives to foster and maintain a practice culture promoting
ethical behavior and open dialogue.
3. NURSES AND THE PROFESSION
The nurse assumes the major role in determining and implementing
acceptable standards of clinical nursing practice, management,
research and education.
The nurse is active in developing a core of research-based
professional knowledge that supports evidence- based practice.
The nurse is active in developing and sustaining a core of
professional values.
The nurse, acting through the professional organization, participates
in creating a positive practice environment and maintaining safe,
equitable social and economic working conditions in nursing.
The nurse practices to sustain and protect the natural environment and
is aware of its consequences on health.
The nurse contributes to an ethical organizational environment and
challenges unethical practices and settings.
4. NURSES AND CO-WORKERS
The nurse sustains a collaborative and respectful relationship with
co-workers in nursing and other fields.
The nurse takes appropriate action to safeguard individuals, families,
and communities when their health is endangered by a co-worker or
any other person.
The nurse takes appropriate action to support and guide co-workers
to advance ethical conduct.
To achieve its purpose the Code must be understood, internalized and
used by nurses in all aspects of their work. It must be available to
students and nurses throughout their study and work lives.
❖ APPLYING THE ELEMENTS OF THE ICN CODE OF ETHICS FOR
NURSES
• The four elements of the ICN Code of ethics for Nurses: nurses
and people, nurses and practice, nurses and the profession, and
nurses and co-workers, give a framework for the standards of
conduct.
→ Nurses and nursing students can therefore:
- Study the standards under each element of the Code.
- Reflect on what each standard means to you. Think about how you
can apply ethics in your nursing domain: practice, education,
research or management.
- Discuss the Code with co-worker and others.
- Use a specific example from experience to identify ethical dilemmas
and standards of conduct as outlined in the Code. Identify how you
would resolve the dilemmas.
- Work in groups to clarify ethical decision making and reach a
consensus on standards of ethical conduct.
- Collaborate with your National Nurses Association, co-workers, and
others in the continuous application of ethical standards in nursing
practice, education, management, and research
ELEMENT OF THE CODE #1:
PRACTITIONERS AND MANAGERS
∙ Provide care that respects human rights and is sensitive to the values,
customs, and beliefs of people.
∙ Provide continuing education on ethical issues.
∙ Provide sufficient information to permit informed consent to nursing and
/or medical care, and the right to choose or refuse treatment.
∙ Use recording and information management systems that ensure
confidentiality.
∙ Develop and monitor environmental safety in the workplace.
EDUCATORS AND RESEARCHERS
∙ In curriculum include references to human rights, equity, justice,
and solidarity as the basis for access to care.
∙ Provide teaching and learning opportunities for ethical issues and
decision-making.
∙ Provide teaching/ learning opportunities related to informed
consent, privacy and confidentiality, beneficence and maleficence.
∙ Introduce into curriculum concepts of professional values.
∙ Sensitize students to the importance of social action in current
concerns.
NATIONAL NURSES ASSOCIATIONS
∙ Develop position statements and guidelines that support human rights
and ethical standards.
∙ Lobby for the involvement of nurses in ethics committees.
∙ Provide guidelines, position statements, relevant documentation and
continuing education related to informed consent.
∙ To nursing and medical care.
∙ Incorporate issues of confidentiality and privacy into a national code of
ethics for nurses.
∙ Advocate for safe and healthy environment.
ELEMENT OF THE CODE #2:
PRACTITIONERS AND MANAGERS
∙ Establish standards of care and a work setting that promotes
quality of care.
∙ Establish systems for professional appraisal, continuing education
and systemic renewal of licensure to practice.
∙ Monitor and promote the personal health of nursing staff about
their competence for practice.
EDUCATORS AND RESEARCHERS
∙ Provide teaching/learning opportunities that foster lifelong learning and
competence for practice.
∙ Conduct and disseminate research that shows links between continual
learning and competence to practice.
∙ Promote the importance of personal health and illustrate its relation to
other values.
NATIONAL NURSES ASSOCIATIONS
∙ Provide access to continuing education, through journals, conferences,
distance, education, etc.
∙ Lobby to ensure continuing education opportunities and quality care
standards.
∙ Promote healthy lifestyles for nursing professionals. Lobby for healthy
workplaces and services for nurses.
ELEMENT OF THE CODE #3
• PRACTITIONERS AND MANAGERS
∙ Set standards for nursing practice, research, education and
management.
∙ Foster workplace support of the conduct, dissemination and utilization
of research related to nursing and health.
∙ Promote participation in national nurses’ associations to create
favorable socioeconomic conditions for nurses.
•
EDUCATORS AND RESEARCHERS
∙ Provide teaching/learning opportunities in setting standards for the
nursing process, research, education and management.
∙ Conduct, disseminate and utilize research to advance the nursing
profession.
∙ Sensitize learners to the importance of professional nursing associations.
NATIONAL NURSES ASSOCIATIONS
∙ Collaborate with others to set standards for nursing education, practice,
research and management.
∙ Develop position statements, guidelines and standards related to nursing
research.
∙ Lobby for fair social and economic working conditions in nursing. Develop
position statements and guidelines in workplace issues.
ELEMENT OF THE CODE #4:
PRACTITIONERS AND MANAGERS
∙ Create awareness of specific and overlapping functions and the potential
for interdisciplinary tensions and create strategies for conflict management.
∙ Develop workplace that support common professional ethical values and
behavior.
∙ Develop mechanisms to safeguard the individual, family or community
when their care is endangered by health care personnel.
EDUCATORS AND RESEARCHERS
∙ Develop understanding of the rules of other workers
∙ Communicate nursing ethics to other professions.
∙ Instill in learners the need to safeguard the individual, family or
community when care is endangered by healthcare personnel.

NATIONAL NURSES ASSOCIATIONS

∙ Stimulate cooperation with other related disciplines
∙ Develop awareness of ethical issues of other professions.
∙ Provide guidelines, position statements and discussion forum related to
safeguarding people when their care is endangered by healthcare
personnel.
•
• Reference:
• Quiambao-Udan, Josie, Cu, Neugene Rowan S., Cañete, Geraldine S.,
Bartolata, Richard L. – Health Care Ethics 1st edition 2023
 NCM 108
HEALTHCARE ETHICS
CODE OF ETHICS FOR FILIPINO NURSES
Intended Learning Outcomes:
- Demonstrate Filipino ethico-moral culture and values appropriate to health care
needs of the individual and family
-observe the Code of Ethics when dealing with members of the health team in
the delivery of quality nur
• 2. CODE OF ETHICS FOR FILIPINO NURSES
• BOARD OF NURSING
• Board Resolution No. 220
• Series of 2004
• PROMULGATION OF THE CODE OF ETHICS FOR REGISTERED NURSES
• WHEREAS, the Board of Nursing has the power to promulgate a Code
of Ethics for Registered Nurses in coordination and consultation with
the accredited professional organization (Sec.9, (g), [Link] of R.A.
No.1973, known as the “Philippine Nursing Act of 2002);
• WHEREAS, in the formulation of the Code of Ethics for Registered
Nurses, the Code of Good Governance for the Professions in the
Philippines was utilized as the principal basis therefore: All the
principles under the said Code were adopted and integrated into
the Code of Ethics as they apply to the nursing profession;
• WHEREAS, the promulgation of the said Code as a set of guidelines,
regulations or measures shall be subject to approval by the
Commission (Sec.9, ArtII of R.A. No. 9173);
• WHEREAS, the Board, after consultation on October 23, 2003 at
Iloilo City with the accredited professional organization of
registered nurses, the Philippine Nurses Association, Inc. (PNA),
and other affiliate of Registered Nurses, decided to adopt a new
Code of Ethics under the afore-mentioned new Law;
• NOW, THEREFORE, the Board as a result of this resolved, as it now
resolves, to promulgate the hereunder Code of Ethics for Registered
Nurses:
• ARTICLE I. PREAMBLE
• SECTION I.
• Health is a fundamental right of every individual. The Filipino registered
nurse, believing in the worth and dignity of each human being,
recognizes the primary responsibility to preserve health at all cost. This
responsibility encompasses promotion of health, prevention of illness,
alleviation of suffering, and restoration of health. However, when the
foregoing is not possible, assistance towards a peaceful death shall be
his/her obligation.
SECTION 2.
To assume this responsibility, registered nurses have to gain knowledge
and understanding of man’s cultural, social, spiritual, psychological, and
ecological aspects of illness, utilizing the therapeutic process. Cultural
diversity and political and socio- economic status are inherent factors to
effective nursing care.
SECTION 3.
The desire for the respect and confidence of clientele, colleagues,
co-workers, and the members of the community provides the incentive
to attain and maintain the highest possible degree of ethical conduct.
 ARTICLE II. REGISTERED NURSES AND PEOPLE
SECTION 4
Ethical Principles
1. Values, customs, and spiritual beliefs held by individuals shall be
respected.
2. Individual freedom to make rational and unconstrained decisions shall
be respected.
3. Personal information acquired in the process of giving nursing care
shall be held in strict confidence.
 SECTION 5. GUIDELINES TO BE OBSERVED:
REGISTERED NURSES MUST:
a. Know the definition and scope of nursing practice which are in the
provisions of R.A. No. 9173, known as the “Philippines Nursing Act of 2002”
and Board Res. No. 425, Series of 2003, the “Rules and Regulations
Implementing the Philippine Nursing Act. Of 2002”, (the IRR).
b. Be aware of their duties and responsibilities in the practice of their
profession as defines in the “Philippine Nursing Act of 2002” and the IRR.
c. Acquire and develop the necessary competence in knowledge, skills and
attitudes to effectively render appropriate nursing services through varied
learning situations.
d. If they are administrators, be responsible in providing favorable
environment for the growth and development of Registered Nurses in their
charge.
e. Be cognizant that professional programs for specialty certification by the
BON are accredited through the Nursing Specialty Certification Council
(NSCC).
f. See to it that quality nursing care and practice meet the optimum
standard of safe nursing practice.
g. Ensure that modification of practice shall consider the principles of safe
nursing practice.
h. If in position of authority in a work environment, be normally and
legally responsible for devising a system of minimizing occurrences of
ineffective and unlawful nursing practice.
i. Ensure that patients shall be available only if they are not to be issued to
those who are professionally and directly involved in their care and when
they are required by law.
 SECTION 8
Ethical Principle
• Registered Nurses are the advocates of the patients: they shall take
appropriate steps to safeguard their rights and privileges.
• Guidelines to be observed:
• REGISTERED Nurses must:
a. Respect “the Patients’ Bill of Rights” in the delivery of nursing care
b. Provide the patients or their families with all pertinent information
except those which may be deemed harmful to their well- being.
c. Uphold the patients’ rights when conflict arises regarding management
of their care.
 SECTION 10. Ethical Principle
• Registered Nurses are aware that their actions have professional, ethical,
moral, and legal dimensions. They strive to perform their work in the best
interest of all concerned.
SECTION 11. Guidelines to be observed:
• REGISTERED NURSES must:
a. Perform their professional duties in conformity with existing laws, rules
regulations, measures and generally accepted principles of moral conduct
and proper decorum.
b. Not allow themselves to be used in advertisement that should demean the
image of the profession (i.e. indecent exposure, violation of dress code,
seductive behavior, etc.)
c. Decline gift, favor or hospitality which might be interpreted as capitalizing
on patients.
d. Not demand and receive any commission, fee or other compensations to
the one referring or recommending a patient to them for nursing care.
e. Avoid any abuse of the privilege access allowed to their property, residence
or workplace.
 ARTICLE IV. REGISTERED NURSES AND CO-WORKERS
SECTION 12. Ethical Principles
1. The Registered Nurse is in solidarity with other members of the
healthcare team in working for the patient’s best interest.
2. The Registered Nurse maintains collegial and collaborative working
relationship with colleagues and other health care providers.
 SECTION 13. Guidelines to be observed:
REGISTERED Nurses must:
a. Maintain their professional role/ identity while working with other
members of the health team.
b. Conform with group activities as those of a health team should be
based on acceptable, ethico-legal standards.
c. Contribute to the professional growth and development of other
members of the health team.
d. Actively participate in professional organizations.
e. Not act in any manner prejudicial to other professions.
f. Honor and safeguard the reputation and dignity of the members of
nursing and other professions; refrain from making unfair and
unwarranted comments or criticisms on their competence, conduct, and
procedures; do not do anything that will bring discredit to a colleague
and any member of other professions.
g. Respect the rights of their co-workers.
 ARTICLE V. REGISTERED NURSES, SOCIETY, AND ENVIRONMENT
SECTION 14. Ethical principles
1. The preservation of life, respect for human rights, and promotion of
healthy environment shall be a commitment of a Registered Nurse.
2. The establishment of linkages with the public in promoting local,
national, and international efforts to meet health and social needs
of the people as a contributing member of society is a noble concern
of a Registered Nurse.
 SECTION 15. Guidelines to be observed:
REGISTERED NURSES must:
a. Be conscious of their obligations as citizens and, as such, be involved in
community concerns.
b. Be equipped with knowledge resources within the community, and take
active roles in primary healthcare.
c. Actively participate in programs, projects, and activities that respond to
the problems of society.
d. Lead their lives in conformity with the principles of right conduct and
proper decorum.
e. Project as image that will uplift the nursing profession at all times.
 ARTICLE 16. Ethical principles
• Section 16. Ethical principles:
1. Maintenance of loyalty to the nursing profession and preservation of
its integrity are ideal.
2. Compliance with the by-laws of the accredited professional
organization (PNA), and other professional organizations of which the
Registered Nurse is a member is a lofty duty.
3. Commitment to continual learning and active participation in the
development and growth of the profession are commendable
obligations.
4. Contribution to the improvement of the socio-economic conditions
and general welfare of nurses through appropriate legislation is a
practice and a visionary mission.
 SECTION 17. Guidelines to be observed:
• Registered Nurses must:
a. Be members of the Accredited Professional Organization (PNA).
b. Strictly adhere to the nursing standards
c. Participates actively in the growth and development of the nursing
profession
d. Strive to secure equitable socio-economic and work conditions in
nursing appropriate
e. Assert for the implementation of labor and work standards.
• Reference:
• Quiambao-Udan, Josie, Cu, Neugene Rowan S., Cañete, Geraldine S.,
Bartolata, Richard L. – Health Care Ethics 1st edition 2023