useful for nurses

1. Bioethical
Issues in
Nursing
Presented By;
Ms. Priyaniranjana J.
PBD-Operation Room Nursing,
CON,JIPMER.

2. INTRODUCTION TO
BIOETHICS

3. Introduction to
Bioethics
• The study of the ethical and moral
implications of new biological discoveries
and biomedical advances, as in the fields of
genetic engineering and drug research is
bioethics.
• The term “bioethics” was introduced in the
70’s by Van Rensselaer Potter for a study
aiming at ensuring the preservation of the
biosphere.
• It was later used to refer a study of the
ethical issues arising from health care,
biological and medical sciences.

4. IMPORTANCE OF
BIOETHICS

5. Importance of Bioethics
• Bioethics education for medical practice is
essential in today’s complex world because;
• Medical policies and patient rights
legislation are ever-changing
• Health care system function differently than
before
• Clinical practice now involves decision-
making about many new issues.

6. DEFINITION OF
TERMS

7. Definition of terms
• Ethics: ethics is a set of principles of right
conduct which is motivation based on ideas of
right and wrong. It guides to moral behavior by
making choices or judgments.
• Ethics Vs Moral: Morals are an individual
frame work for decision making that includes
personal values. Ethics are a generalized
conceptual frame work for decision making.
• Nursing Ethics: it is a system of principles that
govern the actions of the nurse in relation to
patients, families, other health care providers,
policymakers and society.

8. Definition of terms
• Bioethical Issues: areas of health sciences
that are the subject of published, peer-
reviewed bioethical analysis.
• Health ethics: health ethics or medical ethics
are the rules or standards governing the
conduct of a person or the members of a
profession relating to the study or practice
of medicine.
• Professional ethics: professional ethics are
the rules or standards governing the conduct
of a person or the members of a profession.

9. Definition of Bioethics
Bioethics is a branch of applied ethics
that studies the philosophical, social
and legal issues arising in medicine
and the life sciences. It is chiefly
concerned with human life and
well-being, though it sometimes also
treats ethical questions relating to
the non-human biological
environment.

10. When does an issue in practice/
research be an ethical issue?
• When there is conflict of moral values, beliefs and
objectives
– E.g. between the health care providers and the
patients.
• When there is conflict of commitments and
responsibilities
– E.g. saving patients’ lives Vs. using the
available resources ‘rationally’
• When there is the concern that our patients rights/
values are not respected
• When the issues in focus is related to justice in
allocating the available resources
• Finally, when we, as care providers feel that we are
not sure what we should do

11. THE THREE QUESTIONS & the three
categories
• The three questions are:
How to take an (and not the) ethically
acceptable decision to the issue in focus?
Why did we take this decision? (I.e. why
we chose this ethical option and not
another?)
How to implement the decision we have
taken?

12. The three questions & THE THREE
CATEGORIES
• The three categories are:
Clinical ethics is the one which is
concerned with the ethical issues related
to clinical practice in health care settings
Research ethics is concerned with the
protection of humans participating in
research
Organizational ethics which is concerned
more with fair allocation of health care
resources

13. BIOETHICAL ISSUES
CLASSIFICATION

14. Agricultura
l bioethics
Animal
bioethics
Human
bioethics
Environme
ntal
bioethics
Bioethical
issues
classification

15. ETHICAL ISSUES

16. Ethical issues
• Abortion
• Euthanasia
• Suicide
• Determination of death
• Cloning
• Human
experimentation
• Fetal tissue and Stem
cell technology research
• Reproductive sterilization
• HIV and other infections
• Quality of life
• Death and dying
• Homosexuality
• Birth control
• Organ donation and
transplantation

17. BIOETHICAL
SITUATIONS

18. Reproductive situation

19. Reproductive situations
• Voluntary reproductive sterilization as a
contraceptive method may be contrary to the
moral, ethical or religious beliefs of a
caregiver. Consent is required to perform
reproductive sterilization. Some facilities
require consent from the patient’s spouse.

20. Abortion

21. Abortion
• Legalized abortions allows for induced termination of
pregnancy.
• In 1973, the US Supreme Court ruled that any licensed
physician can terminate pregnancy during the 1st trimester
with the woman’s consent.
• During the 2nd trimester, the court requires a state statute that
regulates abortion on the basis of preservation and protection
of maternal health.
• During the 3rd trimester, legal abortion should consider
meaningful life for the fetus outside the womb and
endangerment to the mother’s life and health.
• By selective abortion, one or more fertilized ova may be
aborted so that others may mature properly in a multiple
pregnancy, which is perhaps a result of fertility drugs.
• Although, by law, physicians may perform abortions in health
care facilities, many people, individually and collectively,
oppose abortion, believing that it is a form of active
euthanasia because it takes the life of an innocent victim
without consent.

22. Human Experimentation

23. Human experimentation
• Procedures still in development stages are
performed in clinical research-oriented
facilities with the patient’s informed
consent. Those willing to be pioneers in
human experimentation have given or will
give hope to many patients with poor
prognoses. A caregiver should decide if he or
she wants to participate in experimental
procedures.

24. Fetal tissue and Stem cell
research

25. Fetal tissue and Stem cell
research
• Experimentation with human tissues may be of moral
concern to some individuals.
• The acquisition of the tissues in the form of
embryonic tissue and implantation may take place.
Fetal tissues lacks in lymphocytes that can cause
graft-versus-host response.
• Advantages of fetal tissue include rapid proliferation
of cells, quick reversal of the host’s condition and
differentiation in response to cues of the host tissue.
• Studies have shown promise in treatment of diabetes
mellitus, Parkinson’s disease and certain blood
disorders.
• Tissues from spontaneous abortion and ectopic
pregnancy has generally undergo pathologic
degradation and is not suitable for this use

26. HIV and other infections

27. HIV and other infections
• Underlying attitudes about homosexuality and IV drug abuse
may subconsciously influence the care of such patients.
• Should it?
– Are these patients any different from patients with
hemophilia and those who become infected through a
contaminated blood transfusion?
– Should the infant with HIV be treated any differently than
an infant with a congenital anomaly?
– Does the diagnosis make a difference to the health care
provider and to the quality of care that the patient receives?
• Knowing that HIV infection is transmitted by blood and body
secretions, conscientious application of standard precautions for
infection control should provide protection against occupational
exposure to HIV, hepatitis, tuberculosis and other communicable
or resistant infections.

28. HIV and other infection
• Other ethical questions concern screening and the reporting of test
results versus confidentiality.
– Do the same considerations apply to team members as to
patient?
– What constitutes valid reasons for restricting or terminating
employment on the basis of health status?
• Confidentiality, privacy and informed consent are human rights
that should be protected, but the right to health care should be
protected also.
• Certain organism like AORN and AST believe that providers have
a right to know the HIV or other infectious status of patients but
that caregivers do not have the right to discriminate against HIV-
positive patients. This question has broader implications than just
the issue of being seropositive for HIV and no state mandates by
law that a health care providers can refuse to provide care for a
patient with HIV infection.

29. Quality of life

30. Quality of life
• Physician often must make critical decisions before
or during any interventions regarding the quality of
patients’ lives after procedures. Palliative
procedures may relieve pain. Therapeutic procedures
may be disfiguring. Life-support systems may
sustain vital functions. Life-sustaining therapy
may prolong the dying process.
• Many questions arise regarding care of terminally
ill, severely debilitated or injured and comatose
patients.
– What will be the outcome in terms of mental or physical
competence?
– When should cardiopulmonary resuscitation be initiated
or discontinued?

31. Quality of life
• Physicians decide, but all team members are
affected by the decisions.
• Patients with advance directives have made
many of these difficult decisions while in a
lucid mental state.
• This saves the family or legal guardians the
anguish of making the decision during times of
duress.
• This helps provide some closure and a small
sense of satisfaction that the loved one’s wishes
were known and followed.

32. Euthanasia

33. Euthanasia
• How is euthanasia defined? Is mercy killing ethical, legal or
justified? Does the patient, family or guardian, physicians
or courts have the right to decide to abandon heroic
measures to sustain life? The patient who is aware of the
options and whose decision-making capacity is intact has
the right of self-administration.
• The idea of euthanasia seems to violate traditional
principles of medicine to preserve life, but our modern
technologies can prolong life without preserving quality.
• Quality of life can be interpreted as life that has a
meaningful value. Most human beings value having
cognitive abilities, physical capabilities, or both and living
free of undue pain and suffering.
• This raises the ethical question of whether physicians should
do what they technologies can do.

34. Right-to-die

35. Right–to-die
• Courts have determined that patients have a
constitutional right to privacy in choosing to die
with dignity or a common law right to withhold
consent and refuse treatment. A mentally
competent adult older than the age of 18 years
can execute a living will, advance directive,
directing physicians and other health care
providers not to use extraordinary measures to
prolong life.
• No law or court precedents deal specifically with
issue of DNR orders in the peri-operative
environment. Institutional policies should
address this matter.

36. Right–to-die
• In an emergency, if there is doubt about the validity
of DNR order or a question concerning
reconsideration of the order, the caregiver should
participate in the resuscitation. If there is a
question of patient changing his or her mind, a
second chance may not be an option during
emergency situation.
• The issue of discontinuation of life-sustaining
measures becomes more difficult in a comatose,
mentally incompetent patient who has executed an
advance directive. Family members, in consultation
with physician, may request DNR orders.
Caregivers are obligated to follow DNR order.

37. Organ donation and
transplantation

38. Organ donation and
transplantation
• As a result of the uniform Anatomical Gift Act of 1968,
many adult carry cards stating that at death they wish to
donate their body organs or parts for transplantation,
therapy, medical research or education. Most states include
this information on a driver’s license. If this legal
authority is not available, some states have a required
request law. In the event of legally defined brain death, the
caregivers are required by this law to ask the family if they
wish to allow organ retrieval for transplantation.
• The accepted definition of irreversible coma for potential
donors includes unresponsiveness, no spontaneous
movement of respiration, no reflexes and a flat ECG.
• Caregivers learn to cope with feeling associated with the
procurement of donor organs in a manner similar to dealing
with the sudden death of any patient.

39. Death and dying

40. Death and dying
• Intellectually, we know that death is inevitable. Death can be a
difficult burden for caregivers to bear because our education,
experience and philosophy are dedicated to survival.
• Regardless of religious or cultural beliefs, death is a mystery, a
passage from the known to the unknown.
• Coping strategies that can help team members may include the
following;
– Realize that everyone involved is part of a team effort.
– Believe in greater power than the skills of the team.
– Sharing feelings with others. Encourage each other to share
feelings associated with the loss. Crying is acceptable
behavior.
– Deal with patient’s death by identifying personally with the
loss. Empathy is a positive emotion. Working through the
grieving process brings a sense of closure to the relationship.
– Arrange a visit with the hospital chaplain or rabbi.

41. BIOETHICAL ISSUES
IN NURSING

42. Answering
difficult
questions
Balancin
g science
and
morality
Health
care
decisions
Ethical
decision
making
•What is safe care?
•What does it mean to be ill or well?
•What is the proper balance between
science/technology and the good of humans?
•Where do we find balance when science will allow
us to experiment with the basic origins of life?
•Nurses must examine life and its origins, as
well as its worth, usefulness, and
importance
•Nurses must determine their own values
and seek to understand the values of others
•Decisions are made with the patient, family,
other nurses, and other health care providers
•Nurses must develop a reasoned thought process
and sound judgment in all situations that take
place within the nurse-patient relationship

43. Values formation and
moral development
Examining
value
systems
Learning
right and
wrong
Under
standing
moral
developmen
t theory
Moving
towards
moral
maturity

44. Ethical theory
• A system of principles by which a person can
determine what ought and ought not to be done.
• Rooted in the assumption that an action or practice
is right if it leads to the greatest possible balance of
good consequences, or to the fewest possible bad
consequences
• Strongest approach for bioethical decision
making—which action will lead to the greatest
ratio of benefit to harm for all persons involved?
Utilitarianism
• Rooted in the assumption that humans are rational
and act out of principles that are consistent and
objective, and compel them to do what is right
• A decision is right only if it conforms to an
overriding moral duty and wrong only if it violates
that moral duty
• All decisions are made in such a way that the
decision could become universal law
Deontology

45. Ethical principles
Autonomy
Non-
maleficence
Beneficence
Veracity

46. Ethical decision-making
model
Situation
assessment
procedure
Identify and
analyze
available
alternatives
for action
Select one
alternative
Justify the
selection
Identify the
ethical issues
and problems

47. Bioethical dilemmas: life, death
and dilemmas in between
• Definition
• Dilemmas that pose a choice between
perplexing alternatives in the delivery
of health care because of the lack of a
clear sense of right or wrong
• Nurses should consider the dilemmas
that might arise in a given practice
setting

48. Bioethical dilemmas: life, death
and dilemmas in between
Life
• Bioethical abortion issue
•When does life begin?
•Nurses serving in women’s and children’s health settings must be prepared to face this
morally laden issue
• Reproduction issue: influenced by genetic screening, genetic engineering, and cloning
Death
• Quality of life and definition of death issues: With advances in health care, what
is usual and what is heroic care has become unclear
• Euthanasia and assisted suicide present new ethical questions
• Nurses in every setting must be prepared to consider end-of-life questions
Dilemmas
• Right to health care
•Health care system more selective in the amount and type of treatment offered as a result
of managed care
•Is each person entitled to the same health care package?
•Does ability to pay affect specific level of entitlement?
•How ethical is gatekeeping in the new managed care system?
•Access to health care and respect for human dignity are at the core of nursing practice

49. Ethical challenges
• The challenge of veracity
Issues of alternative treatments and acknowledgment of
uncertainty test truth-telling
Which treatment among two or more is best for the
patient?
Which of the new drugs should be used?
Should every patient be subjected to every possible form
of diagnostic treatment?
Should patient be made aware of questions and various
options surrounding care?
Is disclosure of uncertainty beneficial or detrimental?
• The challenge of paternalism
Provider tries to act on behalf of the patient and believes
that his or her actions are justified because of a
commitment to act in the best interest of the patient
Interferes with a patient’s right to self-determination

50. Ethical challenges contd.,
• The challenge of autonomy
Makes way for the crucial legal step of informed consent
When are patients competent to make informed consent
decisions? Can family members or surrogates make decisions
by proxy?
Questions about informed consent are raised for minors,
confused older adults, mentally compromised, imprisoned,
inebriated, unconscious, and those in emergency situations
Nurses also must take responsibility for understanding and
educating people about advance directives
• The challenge of accountability
Nurses have an obligation to uphold the highest standards
of practice, to assume full and professional responsibility for
every action, and to commit to maintaining quality in the
skills and knowledge base of the profession
Obligation to denounce a harmful action or potentially
threatening situation may fall to a fellow member of the
profession; to remain silent is to consent to the action of the
threatening situation

51. JOURNAL
REFERENCE

52. Robotic surgery: Bioethical
aspects
• The use of robotic surgery has been increasing
common today, allowing the emergence of
numerous bioethical issues in this area. The
overall result of the citations obtained from
the selected 17 articles, which ever used for the
preparation of the article. It contains brief
presentation on robotics, its inclusion in health
and bioethical aspects, and the use of robots in
surgery.

53. Bioethical issues in conducting
Pediatric Dentistry clinical
research
• Pediatric clinical research on new drugs and
biomaterials involves children in order to create
valid and generalizable knowledge. Research on
vulnerable population, such as children, is necessary
but only admissible when researchers strictly follow
methodological and ethical standards, together with
the respective human rights; and very especially
when the investigation can’t be conducted with
other population or when the potential benefits are
specifically for that age group. Clinical research in
pediatric dentistry is not an exception. The aim of
the present article was to provide the bioethical
principles and recommendations including informed
consent, research ethics committees, conflict of
interest and the “EQUIPOISE concept”.

54. CONCLUSION

55. BIBLIOGRAPHY

56. Book reference
• Potter, Perry. Fundamentals of Nursing.
Elsevier publications. 7th ed. 2009. 1328-30.
• Berry, Kohn. Operating Room Technique.
11th ed. Elsevier publications: 2007; 21,
369-84.
• Ghaiath M. Bioethical issues in patient’s
safety practice and research. Ehtics of pt.
safety. 2008; 4: 5-40
• Sutradhar M. bioethics. J Plant Biotech.
2014: 55-78

57. Journal reference
• Siqueira-Batista R et al. Robotic surgery:
Bioethical ascepts. Arq Bras Cir Dig. 2016; 21:
56-9
• Garrocho-Rangel A et al. Bioethical issues in
conducting Pediatric Dentistry clinical research.
J Clin Pediatr Dent. 2017; 10: 20-8