3. TUSKEGEE STUDY
Syphilis is a chronic, contagious bacterial disease that
is most often sexually transmitted but is sometimes
congenital. Since about 1946, the disease has been
successfully treated with antibiotics. Prior to 1946,
individuals with the disease had an inevitable
progress through its sequelae, from the primary
lesion and chancre to rash, fever, and swollen lymph
nodes to the final stage of nervous system and
circulatory problems and finally death. The progress
of the disease is often thirty to forty years.
4. Around 1929 there were several countries in the South
with a high incidence of syphilis. The US Public
Health Service (USPHS) began a demonstration
project to treat those afflicted with the disease in
Macon Country, Alabama, home of the famous
Tuskegee Institute. With the great Depression,
funding for the project to treat the men became an
opportunity for a study in nature. A study in nature
means that that the researchers were not to treat the
patients but rather were to observe the natural
progression of the disease.
5. To conduct this study in nature, the USPHS selected
399 African American men who had never received
treatment. The research group was told essentially
that they had “bad blood”, and as they had been
selected for special free treatment. Except for an
African-American nurse, Eunice Rivers, there was
very little continuity with staffing of the experiment,
as the federal doctors would come every few years to
check the progress of the disease. To induce the
participants, they were promised free transportation,
free hot lunches, free medicines (for everything
except for syhilis), and free burials.
6. Although antibiotics were available in adequate supply by
1946, the study subjects were never treated. In fact, the
local draft board was provided their names so that they
could not enter the army, where they would have been
treated as a matter of course. The local members of the
Country Medical Society were also provided their names
and were asked not to provide them with antibiotics.
In July 1972, Peter Buxtun of the USPHS, who had been
criticizing the study since 1966, told the story to an
Associated Press reporter, and the research became
headline across the nation. In 1997, President Clinton
officially apologized to the remaining study participants
on behalf of the United States government.
9. The practice of doing acts of goodness,
kindness, and charity that directly benefit the
patient.
10.
11.
12. Patient’s Bill of Rights
8. Be informed of business relationship among the hospital ,
educational institution, health care providers that may
influece the patient’s treatment and care.
9. Consent or decline to participate in experimental research
affecting his care.
10. Reasonable continuity of care when appropriate and be
informed of other care options when hospital care is no longer
appropriate
11. Be informed of the hospital policies and practices that relate
to patient care.
13. “ Apply measures for the benefit of the
sick”
- Hippocratic Oath
“The nurse’s primary commitment is to the
health, welfare, and safety of the client”
-Pledge of the American Nurses Association
14. The Nightingale Pledge
I solemnly pledge before God
And in the presence of this assembly
To pass my life in purity
And to practice my profession faithfully.
I will abstain from whatever is deleterious
and mischievous,
And will not take nor administer
any harmful drug
I will do all in my power
To elevate the standards of my profession
And will hold in confidence
All personal matters committed to my keeping
And all family affairs coming to my knowledge
In the practice of my profession
With loyalty will I endeavor to aid
the health team in their work
And devote myself to the welfare of those
committed to my care
So help me God
Formulated in 1893 by a Committee headed by Mrs. Lystra E. Gretter RN
15. Is the restoration of life appears
to have no value to the
individual, beneficence?
Are the staggering fiscal and
emotional costs justifiable?
16. If a fetus is detected to be
deformed or defective
through a process, known
amniocentesis, would you be
doing it more good than harm
by aborting it?
17. This marks the significance of individual autonomy
which mandates a strong sense of personal
responsibility for one’s own life.
Responsibility
FREEDOM
Last arbiter
of moral
decision
18. ⁺
A form of personal liberty , where the individual is
free to choose and implement her own decisions, free
from deceit, duress, constraint, or coercion.
Self
determination
22. PATERNALISM
Is the intentional limitationof the autonomy of one
person by another, in which the person who limits
autonomy appeals exclusivelyto grounds of benefit to the
other person.
FIDUCIARY RELATIONSHIP
23.
24.
25. The American Hospital Association’s
The Patient Care Partnership
:Understanding Expectations, Rights and
Responsibilities.
Discussing your treatment plan: When you
enter the hospital you sign a general consent
to treatment. In some cases , such as surgery
or experimental treatment, you may be asked
to confirm in writing that you understand what
is planned and agree to it. This process
protects your right to consent or to refuse a
treatment. Your doctor will explain the
medical consequences of refusing
recommended treatment. It also protects your
right to decide if you want to participate in a
research study.
26. The right to refuse medical treatment
and to die with dignity
27. The rendering of what is due or merited;
likewise, that which is due or merited.
This also refers to the right to demand to be
treated justly, fairly and equally.
28. Refers to a principle of equity which
prescribes fairness and impartiality
regarding equal access to health care and
the allocation of scarce medical resources.
32. VS
Hospital has to put triage schemes to
determine who should be served first.
1. Assess the medical prognosis
or medical utility or who among the
patients is most likely to survive.
2.Social utility or social value or
worth, ability to pay, or first-
come-first-served basis.
34. Article XIII of the Philippine Constitution
The state shall adopt an integrated and comprehensive
approach to health development an shall endeavor to make
essential goods, health and social services available to
at affordable cost. There shall be priority for the
needs of the underprivileged, the sick, the elderly and
the disabled, the women and children. The state shall
endeavor to provide free medical care to paupers, establish and
maintain an effective food and drug regulatory system, and
undertake appropriate health manpower development and research
responsive to the country’s health needs and
problems. It shall be establish a special agency for disabled
persons for their rehabilitation.
35. “a state of complete physical, mental, and social
well being , and not merely the absence of
disease.”-WHO
41. FIDUCIARY RELATIONSHIP
The patient has the right to expect
a higher level of truthfulness from
us than other whom they deal.
Dealer of a used Car Healthcare practitioner
42. BENEVOLENT DECEPTION
The idea of not telling the truth to the patient.
The suggestion is that the individual is not
strong enough to tolerate the truth or more time
needed to prepare the patient for unpleasant
fact.
Slipper
y slope
43. BENEVOLENT DECEPTION
Several cases are therein cited:
1. A young married male who was diagnosed to
have AIDS requests the doctor not to tell
his diagnosis to his wife.
2. The children of an aged grandmother
suffering from metastatic cancer request
the doctor not to tell their mother her
diagnosis and instead to proceed with the
chemotherapy.
44. What tormented Ivan Ilyich most
was the deception, the lie, which
for some reason they all
accepted he was no dying but
simply ill … what tormented Ivan
Ilyich was that no one pitied him
as he wished to be pitied . At
certain moments after
prolonged suffering , he wished
most of all (although he was
ashamed to confess it) for
someone to pity him as a sick
child is pitied. He longed to be
petted and comforted.
45. The Justification of Paternalism
(by not telling the truth)
by Gert and Culver
The lie benefits the person lied to; the lie prevents more
evil than it causes for that particular person.
It must be possible to describe the greater good that
occurs.
The individual should want to be lied to. If the evil avoided by
the lie is greater than the evil caused by it, a person would be
irrational not to want to be lied to.
Assuming equal circumstances, we should always be willing to
allow the violation of veracity.
46.
47.
48. Beneficenc
e
Nonmaleficence
One ought to prevent evil or
harm
One ought to remove evil or
harm
One ought to do or promote
good
One ought not to inflict
evil or harm
50. The double effect
principle
The principle applies to a situation in
which a good effect and an evil
effect will result from good cause.
51. A woman who is three
months pregnant and is
found to have cancerous
uterus. To save the
woman’s life, her uterus
must be remove at the
earliest possible time; but
to do so, the life of the fetus
would be sacrificed.
52. Should a dying person in
pain be given a sedative,
when the health
practitioner knows it would
cause respiratory
depression or arrest?
53.
54.
55. The American Hospital Association’s
The Patient Care Partnership:
Understanding Expectations, Rights
and Responsibilities.
We respect the confidentiality of your relationship with your
doctor and other caregivers, and the sensitive information
about your health and health care that are part of that
relationship. State and Federal laws and hospital operating
policies protect the privacy of your medical information. You
will receive Notice of Privacy Practices that describes the ways
that we use, disclose, and safeguard patient information from
our records about your care.
64. is demonstrated through the practice
of justice, respect for autonomy,
compassion, veracity, fidelity, and
confidentiality
generosity and hospitality
Compatriots / Indebt ness or
gratitude – perpetuated
66. is the solid bank one can rely on where
withdrawal of help and support is endless
and the recourse is never
In the Visayan dialect, the parents are
regarded as the source of everything,
hence the term “ ginikanan” meaning the
source
69. “What I may see or hear in the course of the
treatment or even outside of the treatment in
regard to life of men, which on no account one must
spread abroad, I will keep to myself, holding such
things shameful to be spoken about. “
-Hippocratic Oath
70. Pizza 2010
Operator: Thank You for calling City Pizza, May I have your…..
Customer: Hi, I’d like to order….
Operator: May I have your NIDN, first sir?
Customer: My National ID Number, yeah, hold on, eh, it’s 609 609 906 609
Operator: Thank you, Mr Jones. I see you live at 1742 Block lane, and your phone
number is 492-6332. Your office number is 492-5288, ext 091.
Which number are you calling from, sir?
Customer: Huh? I’m at home. Where d’ya get all this information?
Operator: We’re wire into the system, sir.
Customer(sighs): Oh well, I’d like to order a couple of your all-meat specials.
Operator: I don’t think that’s a good idea sir.
Customer: Whaddya mean?
71. Operator: Sir, your medical records indicate that you’ve got very high blood
pressure and extremely high cholesterol. Your national health care
provider won’t allow such unhealthy choice.
Customer: What do you recommend then?
Operator: You might try our new low-fat soybean yogurt pizza. I’m sure
you’ll like it.
Customer: What makes you think I’d like something like that?
Operator: Well, you checked out Gourmet Soybean Recipes from the
library last week, sir. That’s why I made the suggestion.
Customer: All right, all right. Give me two family sized ones.
Operator: Will there be anything sir?
Customer: No, nothing. Oh yeah, don’t forget the two free liters of Coke
your ad says I get with the pizzas.
Operator: I’m sorry. Sir, but our ad’s exclusionary clause prevents us from
offering free soda to diabetics….
72. Health Privacy Project of Georgetown
University
Although she had received a positive review and raise, Terrie Sergeant, a
North Carolina resident, was fired from her job after being diagnosed with a
genetic disorder that require expensive treatment.
An Atlanta truck driver lost his job in early 1998 after his employer learned
from his insurance company that he had sought treatment for a drinking
problem.
The thirteen-year-old daughter of a hospital employee took a list of patients’
name and phone numbers from the hospital while visiting her mother. As a
joke, she contacted the patients and told them they had been diagnosed with
HIV.
73. Health Privacy Project of Georgetown
University
A banker who served on his country’s health board cross-referenced
customer accounts with patient information and called due mortgages of
anyone with cancer.
A doctor’s laptop was stolen at a medical conference. The computer
contained the names and medical histories of his patients.
Documents referring to over 125 psychiatric patients of Rapid City Regional
Hospital were found in a convenience store trash can. A fourth year medical
student had taken the papers from the hospital and dumped them in the
trash.
74. Teleological Ethics Duty-Oriented Ethics
Chilling effect to the
truth telling
relationship.
Personal-privacy is a basic right
Lost confidence
Severely limited
quality of care
Autonomous right to
the control personal
information
Person’s right
Professional’s
duty
76. A young man by the name of Prosenjit Poddar confided to his clinical psychologist that he
intended to kill a young woman he readily identified as Tatiana. The psychologist,
understanding that his patient presented a real danger to the young woman, decided that
Prosenjit should be committed for seventy-two hours to allow further evaluation, and he notified
security to assist in securing the patient’s confinement. The patient, however, convinced the
security officers that he was rational , and he was released following his promise to stay away
from the young woman. The health care providers rescinded to place Prosenjit in confinement
for evaluation, and no efforts were made to warn Tatiana or her family of potential danger.
Within the weeks of these events, Prosenjit murdered the young woman.
Tarasoff Case
Tarasoff CaseTarasoff Case
77. To whom do the
caregivers owe
their duty?
To their real
patient?
To the potential
victim?
78.
79. Code of Medical Ethics:
Current Opinions of the American
Medical Association
The obligation to safeguard patient confidence is subject to
certain exceptions, which are ethically and legally justified
because of overriding social considerations. Where a patient
threatens to inflict bodily harm to another person or to
himself or herself and there is a reasonable probability that
the patient may carry out the threat, the physician should
take reasonable precautions for the protection of the
intended victim, including notification of law enforcement.
80. Harm Principle
This principle requires that health care providers refrain from acts
or omissions that would forseeably result in harm to others,
especially in cases in which the individuals are particularly
vulnerable to the risk.
Sissela Bok
Child abuse
Contagious diseases
Sexually Transmitted
Diseases
Wounds caused by guns or
knife
82. The practitioner's observance of
the principle of confidentiality must
always be balanced by the need to
protect other’s from foreseeable
harm, especially if the other
individual is particularly vulnerable
to that harm
83. MEDICAL RECORD
Medical records
Personal data of financial and social nature
Patient Attending physician Authorized
representative
Hospital staff members with
legitimate interest
•Health care
practitioners
•Professional education
•Administrative function
•Auditing functions
•Research
•Public health reporting
•Criminal law
requirements
84. GUIDELINES TO
PROTECT THE
SECURITY OF
MEDICAL RECORDS
Competent medical
records or risk
management personnel
Original Medical Records
No patient nor
representative
85. 85% → Physician
80% → allied health and nursing professions
Insurance company – because they pay the bills
Public health agencies – monitoring and investigating
disease outbreak pattern
Employers – assess job-related injuries
Government – develop health care plan and allocate
resources
Attorneys and law enforcement agencies – evidence to
settle civil and criminal matters
Media – report hazarda nd report medical research
development
87. A Young woman who
states she has just been
raped comes into the
emergency room
requesting a pelvic
examination and a
morning –after pill but
insists that the staff not to
call the police. The staff
reports the incident.
88. A young father brings his
child into the emergency
room for treatment of an arm
injury. The family has
brought the child in several
times for similar injuries
with the same excuse that
she is somewhat clumsy and
is having difficulty learning
to ride her bike. The child
shows no fear of the parent
89. You are a nursing
student on the
pediatrics rotation
within the hospital ,
and you notice that
the neighbor of
your parents has
been admitted to
the surgery unit.
90. In the course of caring
for a patient, a school
bus driver, the
physician notes that
she is at risk for
having a heart attack
and recommends that
she cease driving, since
she may be placing the
children at risk. The
driver asks the
93. Is there a Duty to Lie?
Barbara Gonzales is a special procedure nurse at a medium-sized
community hospital . She enjoys her position as it allows her to spend
additional time with the patients who have come in for cardiac stress
tests. In fact, she enjoys almost all aspects of her job with the
exception of dealing with Dr. Jones, who is invariably late for
procedure appointments. Barbara understands that physicians have
full schedules and often takes additional time with some patients,
which makes them late for all other appointments that day. However,
in this case, it is not a professional problem that is delaying the
physician but rather a personal one. It is widely known among the
hospital staff that he is having an affair with a nurse from the critical
care unit. Barbara does not care who Dr. Jones is having an affair
with and feels that it is not her business to judge. However, she
resents being brought into matter, as the doctor has directed her to
tell his waiting patients that he is being held up in an emergency.
94. Is nurse Gonzales making a big
deal over a small matter?
Does she have a duty to
protect her colleague?
How would you address this
issue?
95. Gatekeeping
One looks out for the interests of the profession or
of others in a similar practice, comes as a result of
our professional obligations and training, this leads
us to a strong sense of collegiality with others in our
practice.
We are not only responsible for our actions in regard
to the patient but we are also charged with the duty
to ensure that the rest of the health team is
practicing appropriate care.
97. Professional Code of Ethics
-Set a series of ethical rules for the members.
- it symbolizes that this group of professionals is
differentiating itself from the broader group of
occupations and technical careers.
-To affirm that the professional is an autonomous,
responsible decision maker, not someone who just follow
orders.
102. The Hard-Working Therapist
Sheryl is a respiratory therapy
technician in a small town in Michigan.
The town has a small hospital and a
small durable medical supply company.
Sheryl is known locally as an
entrepreneur ball of fire and has manage
d to become both the head of the
hospital respiratory care department and
the owner of the small durable medical
supply company.
103. In the most of the
referrals from Sheryl’s
department for home
care equipment are to
Sheryl’s home care
business, does this
present a conflict of
interest?
What should Sheryl do?
108. Ethical Decision Making in Nursing Administration
Mary C. Silva
Gather the facts.
Identify the dilemma concrete
terms.
Explore all the options and rules or
principles governing each option.
Make a decision, and be prepared
to reflect on the decision.
109.
110. Who is the patient?
In a recent pediatric case presentation, a physician described a situation in
which a fourteen-year-old boy is brought to the clinic. The teenager is
described by the physician as having one of the most severe cases of
attention deficit disorder (ADD) that he had seen in practice. During the
session , the boy fidget, did not stop hand gestures, and did leg swinging
and tapping. According to the mother, the boy would not pay attention to
any adult attempting to engage him and was in jeopardy of flunking ninth
grade. The mother wants the physician to write a prescription for Ritalin.
Given the boy’s condition, the request seems reasonable although not
without some potential side effects, such as tics and sleep disturbances.
The boy however, does not want the medication, stating that when “ I take
that stuff, I zone out. I’m like a log. Ritalin ruins my life!” He describes
life without the medication as being in a room in which all the newest
videos are playing and try to watch them all. When he is not on
medication, he feels that he is more alive, that he can crack great jokes,
and fellow students like him. Given the adolescence is the time when we
want young people to find out who they are, is it right to medicate him
and not allow him to express what he sees as being his true self? It is
114. A author who contracts a terminal disease.
His physician knows of a drug that, if taken, will
extend the author’s life by ten years. Following
the physician’s recommendation , the author
takes the medication and starts what he
anticipates will be his greatest work.
Unfortunately, the medication leaves his mind
clouded, and he losses his ability to write., He
faced with the problem of taking the medication
and extending his life to ten rather cloudy,
noncreative years or not taking the medication
and shortening his life by seven or eight years.
Without the drug however, during his remaining
two to three years he would be clear minded,
115. The Code of Ethics of the American Medical
Association (1848)
The obedience of a patient to the prescriptions of
the physician should be prompt and implicit. He
should never permit his own crude opinions.
The Patient’s Bill of Rights
The patient has the right to refuse treatment to
the extent permitted by law and to be informed
of the medical consequences of his action.
116. PATERNALISM
- It is consist of acting in a way that is
believed to protect and advance the interests
of another even though the actions may be
against the desires, or may in fact limit the
freedom of action, of the individual.
BENEFICENCE
VS
AUTONOMY
124. CONTRACTUAL
MODEL
This is a shared decision-making model
in which the patient is accorded the
right to make decisions and to have
control over his life whenever
significant decisions are to be made.
OBLIGATIONS and
EXPECTED
BENEFITS
126. INFORMED CONSENT
This is a moral and legal doctrine, a product of
the last half of the twentieth century as judges
have sought to protect the patient’s right to
greater freedom of choice.
This binds the physician to an adequate
disclosure and explanation of the treatment and
the various options and consequences.
127. The Elements of Informed Consent
Disclosure
Understanding
Voluntariness
Competence
Consent
128. Disclosure
The nature of the
condition
The various options
Potential risks
The professional’s
recommendations
Nature of consent as
an act of authorization
133. Locked-In Syndrome and Informed
Consent
Some patients following a massive
cerebrovascular accident (stroke)
survive the loss of function within
their brain stem and suffer a
condition known as locked-in
syndrome. Paralyzed from head to
toe, they are locked in their body
and unable to move , but their mind
remains intact. In this particular
case the only means the patient had
to communicate was by blinking the
left eye. Unable to effectively clear
secretions, these patients often are
subject to life threatening
134. Can this patient be
considered competent
to make the decision?
Can informed consent
be given with a blink
of an eye?
136. ORAL CONSENT
Is as binding as written consent
as there is no general legal rule
that consent must be provided
in written form.
Requires collaboration.
Difficult to prove.
137. IMPLIED CONSENT
Is often used in cases in
which immediate action is
required to save the
patient from death or
permanent impairment of
health.
138. WRITTEN CONSENT
Is preferred form of consent.
This provides legal, visible
proof of the patient’s
intentions in the matter.
The obligation of gaining the
consent should not be
delegated on others on the
health care team,
instead the PHYSICIAN.
139. GENERAL CONSENT
These general statements are
worded in such a way as to
permit the health care
providers to perform almost
any medical or surgical
procedure that is deemed
medically necessary in the
patient’s best interest.
Do not provide a unit with
carte blanche authority.
140. SPECIAL CONSENT
Use in specific high-risk
procedures or
treatments that expose
the patient to an
unusual risk.
142. Professional Community Standard
The practitioner and
patient were bound in a
special fiduciary
relationship in which the
difference in levels of
information and patient
trust binds the professional
to act in the patient’s behalf
Based on
Physician’s
standard of
practice.
143. Reasonable Patient Standard
This standard is that
the type and amount of
information needed
must be at the patient’s
level if he is truly to be
autonomous as a
decision maker.
144. Patient-Centered Standard
This relies on the unique
nature and abilities of
the individual patient to
determine the amount of
disclosure needed to
satisfy the requirements
145. Is a legal exemption to the rule of informed consent
In which it allows the caregiver to proceed with care
without consent in cases of:
“E”
Incompetence
Depression
Instability
146. Refusal of Lifesaving Therapy
A thirty-five-year-old pregnant woman was
taken to the hospital following an accident in
the home. At the hospital , it was determine
that the near-term fetus was not getting
sufficient oxygenation. According to medical
opinion, both the mother and child needed a
blood transfusion. The woman, a member of the
Jehovah's Witness faith , refused the blood on
the basis of her religion.
It is clear that the woman had the right to
refuse the blood for herself, but the situation
is complicated by the fact that her choice
adversely affected the child, who was delivered
by cesarean section. After the birth, the
father refused a blood transfusion for the
147.
148. What then, is the basis of the
medical judgment that
overcomes and limits patient
autonomy?
149. COMPETENCY
DETERMINATIONDoes the patient understand the nature
of the illness and the consequences of
the various options that maybe
chosen?
Is the decision based on the
rational reasoning?
151. In January 1990, an eighty-five –year-old woman was taken from a nursing home to a
medical center for emergency care. Helga Wangele required emergency intubation and was place
in a ventilator. During weaning attempt, the patient suffered a cardiac arrest and had to be
resuscitated. Following the arrest and resuscitation event, the patient was in a persistent
vegetative state. The attending physicians concluded that nothing further could be done and that
the continuation of life support was futile in that no treatment could reverse the underlying
disease processes or restore the woman to a state of acceptable function. Although continued
treatment was continued futile, the patient was not brain dead.
The physician approached her husband in regard to removing the ventilator from his
wife. During the conversation , he informed them that although his wife had not given her
opinion regarding the matter, he wanted everything done and that the physician could not play
God. It was the husband’s opinion that his wife was not better off dead and that removing the
ventilator was just another sign of the decay within the culture.
It seemed to the health care staff that the request was entirely consistent with rational
health care and the need for cost containment. Although the costs for the continued care of Mrs.
Wangele were being borne by Medicare, the physician felt the=at the case had already consumed
a fair share of the resources that had been pooled for the benefit of the community.
Helga Wangele Story
152. Helga’s Story
On July 1, 1991, the court
agreed with the husband
and appointed him to
represent his wife’s
interests.
Three days later the
patient died of
153. Medical Futility
Refers to medical care
that prolongs suffering,
does not improve the
quality of life, or fails to
achieve good outcome
for the patient.
155. Quantitative Futility - based on
consideration of reported empirical data
(such as treatment has been found useless
in the last 100 cases), or similar personal
experience, or experiences shared with
colleagues.
Qualitative Futility – based on
the assessment that the
treatment will merely preserve
biological life such as
permanent unconsciousness or
a treatment that cannot end
dependence on intensive
medical care.
