MORAL FRAMEWORK - Moral framework guide moral decision but they do not determine the outcome.

Four Types of Moral Frameworks 1. CONSEQUENCE-BASED THEORIES Teleological theories Look at the outcomes of action in judging whether that action is right or wrong. Utilitarianism, a form of consequential theory, views a good act as one that brings the most good and the least harm for the greatest number of people. (Also known as the PRINCIPLE OF UTILITY) This approach is often used in making decisions about the funding and delivery of health care. These theories focus on issues of justice (fairness) 2. RELATIONSHIP-BASED (Caring) THEORIES Stress commitment, courage, generosity and the need to nurture and maintain relationship. Caring theories judge according to a perspective of caring and responsibility, stressing individual rights that promote the common good or the welfare of the group. 3. PRINCIPLE-BASED (Deontological) THEORIES Involve logical and formal processes and emphasize individuals rights, duties and obligations. The morality of an action is determined not by its consequences, but by whether it is done according to an important objective principle. Deontological theories justify the rules of acceptable behavior differently. 4. DIVINE MANDATE THEORY Used in ethical debate. The idea is a simple, believing that there is a divine being who has set down a finite series of rules that adherents claim can provide guidance to most, if not all moral decisions. From the Judeo-Christian traditions, the ten commandments includes moral prohibitions common to most cultures as well

as some specific rules set down to exact adherence to a particular region, providing rules against stealing, adultery, murder and so on. MORAL PRINCIPLES These are statements about broad, general, philosophical concepts such as autonomy and justices. They provide the foundation for moral values, which are specific prescriptions for actions. They are useful in ethical discussions because even if people disagree about which action is right in a situation, they maybe able to agree on principles that apply. For example, most people would agree on the principle that nurses are obligated to respect their clients, even if they disagree as to whether the nurse should deceive a particular client about her prognosis. THE DIFFERENT MORAL PRINCIPLES Principle of Autonomy comes from the Greek word autos meaning self and nomos meaning governance. The right to make ones own decisions Nurses who follow this principle recognize that each client is unique, has the right to be what the person is and has the right to choose personal goals. People have inward autonomy if they have the ability to make choices; they have outward autonomy if their choices are not limited to choose personal goals. Honoring the principle of autonomy means that he nurse respects a clients right to make decisions even when those choices seem to the nurse not be in the clients best interest. Respect for autonomy means that people should not be treated as an impersonal source of knowledge or training. This principle comes into play, for example, in the requirement that clients provide informed consent before tests, procedures or participating as a research subject can be carried out. Principle of Nonmaleficence

This is the duty to do no harm. Harm can mean intentionally causing no harm, placing someone at risk of harm and unintentionally causing harm. Example of nonmaleficence is not assisting in or performing abortion, not assisting person to commit suicide or not performing euthanasia. Principle of Beneficence Beneficence means doing good. Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons. This principle promotes doing acts of kindness and mercy that directly benefit the patient. These acts promote the health of the client, preventing illness or complications, alleviate suffering and assist towards peaceful death if the inevitable comes. Principle of Justice In the health care, this refers to the right to demand to be treated justly, fairly and equally. This is often referred to as fairness. Nurses often face decisions in which sense of justice should prevail. For example, a nurse making home visits finds one client depressed and crying and she knows she could help by staying for 30 minutes to talk. However, that would take time for her next client who is diabetic who needs a great deal of teaching and observation. Thus the nurse needs to weigh the facts carefully in order to divide time justly among her clients. Principle of Fidelity Fidelity means to be faithful to agreement and promises. Nurses have responsibilities to clients, employers, government and society such as the observance of code of ethics. Principle of Veracity This refers to telling the truth. Although this seems straightforward, in practice choices are not always clear. Should a nurse tell the truth when it is known that it will cause harm? Does a nurse tell when it is known that the lie will relieve anxiety and fear? Lying to a sick or dying is rarely

justified. The loss of trust in the nurse and the anxiety caused by not knowing the truth, for example, usually outweigh any benefits derived from lying. Accountability means answerable to oneself and others for ones action Responsibility refers to the specific accountability or liability associated with the performance of duties of a particular role, as in the case of a young married man who has AIDS, requests not to tell his diagnosis to his wife. In this case, telling the wife would be more advantageous so that she can be examined, protected or treated. She would also be able to use precautionary measures, understand her husbands condition and participate in his care.

ETHICAL THOUGHTS KANTIANISM Advocated by Immanuel Kant, a German philosopher of the 18th century. Attempted to define a person s a rational human being with freedom and moral worth. A person is morally good and admirable if actions are done from a sense of duty. Stated that people ought to follow a universal framework of maxims or rules to guide right actions and duties because it is only through dutiful actions that people have moral worth. He emphasized that people should regard everyone with dignity and respect and when they do not individuals feels used and demoralized. According to Kant, there are two types of duties: 1. Hypothetical imperatives a. These are duties or rules that people ought to observe if certain ends are to be achieved. b. They are sometimes called if-then imperatives, which are conditionals. 2. Categorical imperatives a. These are moral actions based on reason. b. Where moral actions are concerned, duties and laws are absolute, unconditional and universal. c. The acting according to a categorical imperative

would ask If I perform this action, should it become universal law? d. No action can ever be judged as right, if the action cannot have a potential to become a binding law for all people. According to Kant, suicide is never acceptable. A person when committing suicide cannot rationally wish that all people should feel free to commit suicide, the world become chaotic. Kants contributions summarize the ethics of respect for persons such as: principles of autonomy, fidelity, veracity, formalism, the positive and negative rights.

PRINCIPLE OF AUTONOMY Synonymous with self-determination In health care this means personal liberty, where the individual is free to choose and implement her own actions, free from deceit, duress, constraint or coercion. Application of Autonomy 1. Informed Consent a. Derives it rules from autonomy. Health workers are obliged to seek a valid consent because consenting party is an autonomous person. Respect for autonomy of the patient means that the patient has the capacity to act intentionally, with understanding and without controlling influences that would act against a free and voluntary act such as coercion or undue influence. b. Nurses do not provide advice or recommendations as to what course of action the patient and his family must resort to, instead the primary task is to inform them with all the information, there is about the options available, including their cost, procedure, benefits and risks and it is the patient and his family who shall make their own decision. c. Patients decision must be complied with even if the health care provider disagrees with him/her. Autonomy is not absolute for the law has set forth

certain limitations. 2. Standards of Disclosure for Consent to be Adequately Informed a. PROFESSIONAL STANDARD this is the traditional standard which requires a physician to disclose what colleagues similarly situated would have disclosed in similar circumstances. This standard appears to be built on the premise that deciding how much information to disclose is something that only professionals can know, which is related to Hippocratic ideology. The physicians duty is to keep confidence with certain exceptions, including when the physician believes that it is in the patients interest to disclose. b. REASONABLE PERSON STANDARDS it requires that the physician must disclose what a reasonable patient would want to be told or find significant, even if none of the physicians colleagues would agree. c. SUBJECTIVE STANDARD the goal is to give the information the patient wants personally meaningful, in that case it is based on the actual subjective interest of the patient, not to those other persons. In order to do this, the health care provider must learn all of the patients idiosyncratic interests and tastes, lifestyle and preferences. Paternalism a. In the health care, the concept of paternalism is applied when the health care givers, especially physicians, assume the authority to make decisions for the patients. b. Paternalism is often thought of as violation of patients autonomy or the right to make his own decisions, in instances where patients have diminished decision making capacity wherein the patient is mentally incompetent, delirious,

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unconscious or under the influence of substances, nurses can make the decision for the patient to promote patients well being or to protect patient from harm or injury. 4. Standards of Best Interest a. This pertains to health care providers making decisions about a clients health care when they are unable to make informed decisions about their own care. In this situation, the health care provider decides the best course of action for the patient to be carried out.

PRINCIPLE OF FIDELITY This refers to the obligation of a person to be faithful to agreements, responsibilities and commitments that he has made to himself and to others. This principle supports the concept of accountability of nurse and other professionals. PRINCIPLE OF VERACITY This principle holds that actions or rules are morally right insofar as they involve communicating truthfully and avoiding dishonesty. Veracity binds the health practitioner and the patient. The patient must tell the truth in order to provide appropriate care. The practitioner needs to disclose factual information so that the patient can exercise personal autonomy. In nursing, veracity is applied in the nurses responsibility never to mislead or deceived the patient. FORMALISM this theory sates that actions or rules are morally right as long as they conform to a specified form rather than being based on the consequences they created. POSITIVE and NEGATIVE RIGHTS POSITIVE RIGHTS implies not only to act autonomously but also have access to the means to necessary to carry out ones actions.

NEGATIVE RIGHTS the right to be left alone, to be free from the interference of others to act autonomously.

SOCIAL JUSTICE THEORY Advocated by John Rawls. Proposed that fairness and equality be evaluated under a veil of ignorance, which means that if people had veil to shield them from their own or others economic, social and class standing, each person would be more likely to make justice-based decisions from a position free from all biases. His theory examines of how justice in distribution should be related to maximizing social utility. Definition of Social Justice 1. Virtue that guides in creating those organized human interactions we call institutions. In turn, social institution when justly organized provides access to what is good for the person, both individually and in association with others. 2. Social justice also imposes personal responsibility to work with others to design and continually perfect institutions as tools for personal and social development. Rawls Contribution to Political and Moral Philosophy Two Principle of Equality and Justice That everyone should be given equal liberty no matter what adversities exist for people. That difference among people should be recognized by making sure that the least-advantaged people be given what they deserve or their share for improvement. Application to Health Care It could support a practice of paying high salaries to physicians, but only if were necessary as an incentive to get physicians to expand effort to help those patients who are considered indigent. It could justify shifting some resources to healthier patients if that were the only way to benefit the indigent patients. Standards to be Applied or Considered When Distributions

are made: Distribute according to market that is, to those who can afford to pay. Distribute according to social merit may be according to position in the society or standards of living Distribute according to age that is to the older and younger age groups who are more susceptible to disease. Distribute according to medical need that is to those who have greater need of medical attention. Distribute according to queuing or first come, first served Distribute according to random selection that is, to select unsystematically without standards or rules to follow. Theory of the Inviolability of an Individual 1. Rawls maintains that all men are inviolable. That is, an individual should not be used as a means in order to attain what is good for others. In this case, all men should be considered of equal worth. Tolerable-Erroneous theory Principle 1. This is a case of choose-the-lesser evil principle. An act of injustice can be tolerable if only if, it is necessary to avoid an even greater act of injustice. In the case of this principle, it is the only available at hand, and so reason dictates that it must be carried out for the sake of those who are supposed to be benefit or affected by it.

CHRISTIAN ETHICS Advocated by St. Thomas of Aquinas Teaches that there exists a natural moral law, which is manifested by the natural light of human reason, demanding the preservation of the natural order and forbidding its violation. The source of the moral law is reason itself, which guides us to do good and avoid evil. The Christian ethics otherwise known as natural law ethics are:

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Voice of Reason or Voice of Conscience directs one to do good and avoid evil. The natural ethicists say that one cannot run away from ones conscience. a. We know that we are acting rightly, if we heed the voice of reason; we know we are acting wrong, if we act against it. b. I know I am doing the right thing, if and when I follow the voice of conscience; otherwise, I feel a sense of guilt, self-reproach, or remorse. c. What is the good? It is that which is suitable to and proper to human nature. When an act is suitable to human nature, then it is good and it must be done; whenever it is not proper for human nature, it is bad and it must be avoided. d. How does one know that a particular act is or is not suitable to human nature? By mean of whether or not one is following and obeying the voice of reason or acting contrary to it. Three Natural Inclinations the natural inclination urges us to care for or health, not to harm or kill ourselves, or put ourselves in danger. The tree inclinations are self-preservation, just dealing with others and propagation of our species. a. SELF-PRESERVATION It is natural for man to preserve his life, which urges man to care for his health, not top harm or kill himself or to put others in danger. Any act that violates this basic inclination is wrong because it contradicts the creators very purpose for human nature. Acts such as suicide, self-immolations, mercy killing or easy death, smoking, habitual drinking and putting oneself in unnecessary jeopardy are by nature evil. On the other hand, acts that promote health, vim, vigor and vitality are by nature good. b. JUST DEALING WITH OTHERS Nature leads us to treat others with the same

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dignity and respect that we accord ourselves Any act of injustice, such as subjecting other to indignities, degradations and inhumanities is against nature. All forms of mans inhumanity to man, such as exploitation, sexploitation, oppression, seduction, abduction, swindling, cheating, kidnapping for ransom, murder, rape, harassment and intimidation are by nature evil. c. PROPAGATION OF LIFE The propagation of our species is viewed as a natural good. We are obliged not to pervert or thwart the natural design of the human nature. Any alterations, interventions that will stifle the very purpose for which each member of the human organism is unnatural and hence is evil. The Tree Moral Principle of Christian Ethics which are very relevant in the health care profession, are principle of double effect, principle of totality and the percept a good end does not justify an evil means a. PRINCIPLE OF DOUBLE EFFECT this applies to situation in which a good effect and an evil effect will result from good cause. Important distinctions to consider in the discussion of the principle of double effect. First, performances of various actions acts are followed by various effects, some of which we desire, others of which we do not desire but merely allow or tolerate. Second, sin is an act of the will. Any act done whether willed or intended and what is tolerated or merely permitted enters at times into moral judgments. Thirdly, there is a difference between performing a good act, which has both good and evil effects and performing an evil act in order that good may result.

FOUR CONDITIONS UNDER THE PRINCIPLE OF DOUBLE EFFECT Under the principle of double effect, the following basic principles or conditions must be fulfilled to justify an action that has both a good and bad effect. 1. The course taken must be good or at least morally neutral 2. The good effect of the action must not come from evil effect but must come from the action itself directly. 3. The foreseen effect must not be intended or approved but merely permitted to occur. 4. The good must outweigh the harm or there must be a sufficient reason for allowing the evil effect to occur while performing the action. b. PRINCIPLE OF TOTALITY this principle states that an individual has the right to cut off, mutilate or remove any defective or worn out nonfunctioning part of his body. The Whole is Greater than any of its parts The question, Is it lawful to sacrifice a member of the body for the good of the whole part? To be complete human being is not merely to have the higher level of functioning, but to have all the basic human functions in harmonious order The following norms pertain to human integrity: Primarily, human health is not merely a matter of organs but capacities to humanly function Generally, any particular human functional capacity can be diminished when necessary for the goods of the whole person. Secondary functions can always be sacrificed for more basic ones. Primary or basic functional capabilities, however, cannot be destroyed to promote even more important capacities except when it is the only way to preserve life. Under Christian ethics, it is our natural obligation not only to preserve our lives but also to preserve the integrity of our bodies. It

further teaches that no matter how good an end maybe, we may not employ any evil means to attain. W.D ROSSs SEVEN PRIMA FACIE DUTIES He believes in two principles rightness and goodness This theory is rule-based in nature which considers the value of consequences of actions. A PRIMA FACIE duty is one that dictates what I should do when other relevant factors in a situation are not considered. These are morally significant duties as they relate to individual circumstances at first sight. These are not absolute but are conditional. Actual duties are those real duties that a person is obligated to perform. W.D. Ross describes a set of moral rules that should guide a persons universal principles. These are called PRIMA FACIE DUTIES Duties of Fidelity telling the truth, keeping actual and implicit promises Duties of Reparation righting the wrongs we have done to others Duties of Gratitude recognizing the services others have done for us Duties of Justice preventing a distribution of pleasure or happiness that is not in keeping with the merit of the people involved. Duties of Beneficence providing help to improve the condition of others. Duties of Self-improvement bettering ourselves with respect to virtue and intelligence. Duties of Nonmaleficence avoiding or preventing an injury to others.