An Introduction to Health Ethics'

What is Ethics?
Ethics is the study of how human beings treat each other and the natural environment; it is the
systematic examination of the attitudes and behaviors of people. Ethics is about carefully
studying the values that actually do guide our attitudes and behaviors in given contexts, and it is
about exploring what values ought to guide our attitudes and behaviors.

2. Overview of the Ethics in Health Care

Health care ethics are important for each person who provides some aspect of health care, from
the custodian who cleans a clinic's office to the head of surgery at the most prestigious medical
facilities, everyone who provides some aspect of health care needs to understand the ethical
responsibilities and limits. Likewise, each person who interacts with health care, from a single
blood draw at a store front lab to major surgery in an large city medical center, needs to
understand his or her responsibilities and rights in regards to heath car ethics [7], in at-
tempts of answering the following questions to educate the health care professionals on the
basics of health care ethics.

3. The First Question We Have to Answer Is What Is Ethics?

Ethics has a long history in Western philosophy. The word "ethics" comes from the Greek word
Ethika, which is an adjective that itself derives from ethos, the Greek word for character. For
Aristotle, character is of central importance to ethics, and one cannot have a good character
without having formed good ethoi or habits. So ethics is Greek for customs, and morality comes
from mores, which is Latin for customs [8] 19].

3.1. What Then, Is Ethics?

Ethics is a branch of philosophy that seeks to determine how human actions may be judged
right or wrong. When the study of the ethics is applied to a professional field, it becomes
necessary to discuss not only basic ethical positions, but also the nature of the profession and
the conditions under which that profession operates [10]. Ethics also, is understood as a
philosophical study of morality [11]; morality refers to human conduct and values whereas ethics
refers to the study of those. The two terms are used interchangeably however, morals may be
perceived as prescriptions or rules to guide our actions and behavior whereas ethics may be
perceived as a set of analytical tools or a process that helps to identify right conduct and
determine appropriate behavior. In one sense morality is what we ideally aim for whereas ethics
is a process that has a theoretical reflective and normative element that helps to achieve the
aim. In other words the use of moral or ethical theory can be applied to help resolve dilemmas
[12].

The terms bioethics and healthcare ethics sometimes are used interchangeably. Bioethics, born
out of the rapidly expanding technical environment of the 1900s, is a specific domain of ethics
focused on moral issues in the field of health care (see Box 2-1). During World War II President
Franklin D. Roosevelt assembled a committee to improve medical scientists' coordination in
addressing the medical needs of the military (Jonsen, 2000). As often happens with wartime
research and advancements, the work aimed at addressing military needs also affected civilian
sectors, such as the field of medicine.

Definitions of Ethics
The word ethics has Greek roots:
+ Ta ethika, referring to philosophical inquiry into good and evil
+ Ethos, meaning personal character
Purpose
The purpose of Ethics and the Healthcare Professional is to provide healthcare professionals
with information about ethics, ethical principles, and Codes of Ethics, and to explore the ethical
aspects of situations that healthcare professionals commonly encounter in practice.

Bioethics As Applied Ethics

1.4
This book is an applied ethics. Etymologically, "bioethics" (from the Greek bios life') means
"ethics of life" (Shannon and Digiacomo 1979: 1-5; Varga 1980: ix-x). Broadly considered, it is
the ethics of medical care though it is not the same as medical ethics which is primarily geared
to the morally legitimate practice of the medical profession. Strictly speaking, however,
bioethics' is the branch of applied ethics which investigates practices and developments in the
life sciences and/or biomedical fields (Pahl:2, Beauchamp and Childress 1979: vi-vii). It is, in
other words, an applied study of ethical issues and values not only in medicine and biology but
also in the behavioral sciences. The primary and major predicaments with which bioethics as an
applied ethics deals are those concerning life, health, and death that have resulted from modern
biological technology (e.g., biomedical engineering and genetic therapy), particularly the way
they have affected human values. The "bio" part of bioethics leads us to examine new findings
and data from the physical and natural sciences. In this way, we take seriously the scientific
knowledge derived from the disciplines and we evaluate them in the light of the ethical theories
(Shannh and Digiacomc? 2).

Medical ethics. Known as the oldest phase of bioethical exploration is medical ethics which is a
fomulation of ethical norms for the conduct of health care professionals in the treatment of
patients (Pahl: 2; The Hippocratic Oath: 242). The physician-patient relationship is no different
from other human relationships in which duties and rights are involved. Respect for these rights
and acting by one's duties will be for the good of both the physician and the patient, whereas
any infraction thereof is detrimental to the relationship. Thus, codes of ethics were written by
and for physicians as early as the 3rd century B.C.

One of the oldest known formulations of medical ethics is the Hippocratic Oath, named after
Hippocrates (460-357 B.C.), who was recognized by many scholars as the Father of Medicine.
He was a native of Thessaly, Greece but practiced and taught medicine in Athens. A cursory
glance at the oath will reveal that it is a theocentric pledge made by the physician to both Apollo
and Asclepius, the father-and-son gods of medicine in Greek mythology. It underscores the
physician's all-out concern for the patient to be kept from harm and injustice. The physician
should not prescribe a fatal drug to anyone even if asked do so; nor should
the physician suggest that fatal drugs be taken (a clear reference to euthanasia during those
times). The oath rules out any form of abortifacient (another obvious reference to the practice of
abortion as early as 500 B.C.) and sexual relations between doctors and patients, be they male
or female, rich or poor, free or slaves. Likewise enshrined in the pledge is the moral significance
of confidentiality, otherwise known as medical secrecy. Fulfillment of the oath is believed to
bring about honor, fame, and joy in medical practice; while its transgression brings about
dishonor and infamy among all for every generation to come.

Research ethics. The second phase in the development of bioethical study is research ethics
in the biomedical fields (hence it is likewise called biomedical research) (Pahl). This refers to the
use of humans as experimental specimens., e.g.. prisoners, poor patients, childrern, and
fetuses. Undertakings along this line were surreptitiously perfomed on concentration camp
inmates in Germany during the dictatorial regime of Adolf Hitler -this period is also known as the
Third Reich (covering the years 1933 to 1945). The Nazi fascist was tremendously influenced by
Friedrich Nietzsche's philosophy of will to power (supposedly Hitler's favorite bedtime reading).
Nietzsche's superman concept as the culmination of the will to power inherent in every
individual strengthened Hitler's strong conviction that the German race is superior to others. He
agreed with the "superman” philosopher that real progress could be attained not by the
emancipation of the masses from poverty but by the cultivation of the superior race of humans.
And he thought the Germans could become the super race.

Public policy. This is the third stage in the development of bioethical inquiry. It accentuates the
participatory aspect of decision-making in a democratic set-up with regard to the formulation of
public policies for the benefit of all. This phase refers to the people's efforts or involvement in
formulating public guidelines for both clinical cases and biomedical research (Pahi: 3). This is
done by consulting the people through surveys, meetings, conferences, convocations about
their opinions and views on particular bioethical issues (e.g., human experimentation,
abortifacient contraceptives, allocation of scarce medical resources). Experts and authors from
various disciplines are asked to give their suggestions and recommendations. Public discussion
is encouraged and conducted in order to give everyone an opportunity to participate in the
consultative process.

Applied ethics does not only apply general moral concepts and principles, but also specifies
the particular situations in life in which they are valid and legitimate; hence it is also known as
special ethics. In an attempt to resolve specific moral problems, general ethical precepts are
applied (hence the name). Professional ethics is an applied type of ethics insofar as it deals with
certain moral precepts or rules by which persons behave and act in the exercise of their calling
or profession. Likewise, there is legal ethics for lawyers in the practice of law, a teachers' code
of ethics for educators, and nursing ethics, among others.

Traditionally, therefore, ethics may be divided into general and applied. General ethics refers to
all the diverse ethical formulations of general and universal concepts and principles which serve
as the foundation of morality (Bittle: 309). It raises the problem of moral norms and attempts to
formulate and defend a system of fundamental ethical perceptions that settle which acts are
good and which are evil. For every moral theory these ethical principles are presumed to be
valid (hence to be followed) for everyone. Consequently, inasmuch as general ethics deals
with the issue of the norm of morality, it is sometimes called normative

1.1 Moral Philosophy.

Ethics is a practical and normative science, based on reason, which studies human acts and
provides norms for their goodness or badness. It is likewise known as moral philosophy, insofar
as it deals with morality. Moral rectitude or the rightness and wrongness of human acts. As a
practical science, ethics deals with a systematized body of knowledge that can be used,
practiced, and applied to human action. It considers the usefulness, practicality and application
of human knowledge to one's experience, as distinguished from theoretical knowledge, which is
simply interested in truth for its own sake, without any bearing on action and experience. As a
normative science, ethics establishes norms or standards for the direction and regulation of
human actions. How can one determine whether one is acting rightly or wrongly? Is there a
norm of good and evil? Ethics attempts to resolve these questions. Ethical studies are based on
reason, insofar as all proofs of ethical science must find their source in the native power of
reason alone.

Ethical studies are based on reason, insofar as all proofs of ethical science must find their
source in the native power of reason alone. Ethics investigates the facts, analyzes them and
draws from them practical applications to particular actions. Ethics does not subscribe to, nor
will it rely on, so-called "divine revelation" for the final answers or resolutions of certain moral
issues. Divine revelation refers allegedly to certain know edge revealed by God to humans--
knowledge which we cannot fully understand, but which we have to accept as true because God
said so, and because we know that God can neither deceive us nor be deceived by us.
This makes ethics different from religion, for the latter subscribes to "divine revelation." Here lies
the disparity between two claims: The religionist contends that there can be no morality without
God, whereas the ethician maintains that morality remains possible even without God. This
means that one can still determine the goodness or badness of one's behavior even if one does
not believe in God. A non-believer can still be good. This apparently controversial, religious and
philosophical issue is a part of every Individual's continuous search for meaning.

Ethics deals only with human acts insofar as they are performed with intellectual deliberation
and freedom. Personal responsibility presupposes knowledge and volition. This explains why
the acts of irrational animals (e.g., cats, dogs, etc.) and insane persons are devoid of moral
significance; they are amoral beings performing nonmoral acts. Let us pursue this point further:
Is one to be held morally responsible for all one's acts? This leads to the distinction between
human acts and acts of man. (Aquinas 1947; Bittle 1950: 24-33). The former are those which
are done with knowledge and full consent of the will. One knows what one is doing and one
does it freely and willingly. The latter refers to those which are performed in the absence of
either or both of the two conditions (of a human act).
Types of Ethics
Descriptive Ethics
The aim of descriptive ethics is to depict and clarity moral opinions and practices, and to
explicitly articulate the concepts and assumptions implicit in these. For example, "What does
group X think about the morality of abortion?" is a question of descriptive ethics.

Nomative Ethics
Nomative cthics concerns making moral judgrments about what is right and wrong. good
and bad etc. It also involves developing action guides to direct ethical behaviour. For
example, "Is abortinga fetus ethically justifiable?" is a normative question.

Meta-Ethics
The discussion here is not about what particular people think ethics is or what ought or
ought not to be considered ethical. Rather, meta-ethics involves analyses of the language,
concepts, and methods of reasoning in health care. For example, "What does 'ethically
justifiable mean? is a meta-ethical question.

What is Health Ethics?

Health ethics is the branch of ethics that deals with ethical issues in health, health care,
medicine and science. It involves discussions about treatment choices and care options that
individuals, families, and health care providers must face. It requires a critical reflection upon
the relationships betwecen health care professionals and those they serve, as well as the
programmes, systems, and structures developed to improve the hcalth of a population.
Health ethics involves deliberating about the allocation of resources, and reflecting on the
complex moral choices arising from ongoing health care restructuring and advancing
technology. It also entails a critical, political, and ethical analysis of the definition and the
determinants of health.

Preliminary
In this rapidly changing world, healthcare professionals face multiple changes involving
ethical dilemmas Ethical dilemma refers situations in which one's values conflict with that of
the other. These are situations in which two or more moral principles conflict with one another.
Ethical dilemmas occur when there is a difficult choice to be made between two or more
options, neither of which resolves the situation in a manner that is consistent with accepted
ethical guidelines. Ethical dilemma is a conflict between alternatives, where no matter what a
person does, some ethical principle wll be compromised.

Classes of Ethical theories

DEONTOLOGY
States that people should adhere to duties and obligations when engaged in decision
making when ethics are in play. A person will follow his/her obligations to another individual or
society because upholding one's duty is what is considered ethically correct. A person who
adheres to deontological theory will produce very consistent decisions since they will be based
on the individual's set of duties.
ETHICAL RELATIVISM
- Also known as
+ Moral relativism
+ Relativist ethics
+ Relativist morality
- It is the opposite of Moral Absolutism
A theory that holds that morality is relative to the norms of one's culture, that is, whether an
action is right or wrong depends on the moral norms of the society in which it is practiced. An
action may be morally right in one society but be morally wrong for another.

+ It considers a range of practices considered morally acceptable in some societies but

condemned in others (descriptive moral relativism). Such difference may lead us to the
question whether there are any universal moral principles or whether morality is merely a
matter of "cultural taste." Thus, moral standards are culturally defined.
+ Culture differs widely in their moral practices. Different societies have different customs.
Each society develops standards that are used by people within it to distinguish
acceptable from unacceptable behavior, and every judgment of right and wrong
presupposes one or another of these standards.
+ Moral relativism is the idea that there is no universal or absolute set of moral principles.
For ethical relativist, there are no universal moral standards-standards that can be
universally applied to all people at all times. There are no absolute truths in ethics and
that what is morally right or wrong varies from one person to person or from society to
society.
+ There are no objective grounds for preferring the moral values of one culture over the
other. One may think that his own society's customs are the best but in reality there is no
set of social customs is really better or worse than any other (meta-ethical moral
relativism). No standpoint is uniquely privileged over all others.
+ Thus, all societies should accept each other's differing moral values, given that there are
no universal moral principles. It promotes tolerance (normative moral relativism). lf, from
an objective point of view, one's own value and the values of one's society have no
special standing, then an attitude of "live and let live" toward other peoples values
seems appropriate.

SITUATION ETHICS (Situational Ethics or Situationism)

In ethics and theology. the position that moral decision-making is contextual or dependent on a
set of circumstances. In situation ethics, right and wrong depend upon the situation. Thus, it
takes into account the particular context of an act when evaluating it ethically, rather than
judging it according to absolute moral standards. Situational ethics is a teleological or
consequential theory, in that it is primarily concerned with the outcome or consequence of an
action, the end. It is directed at the consequences that will determine whether an action is right
or wrong. Situational ethics is a form of consequentialism that focuses on creating the greatest
amount of love, unlike in utilitarianism which aims the "greatest good for the greatest number."
 + Situation ethics can be outlined in ten principles which is divided into six fundamental
principles and four working principles: the six principles are:
1. Only one thing is intrinsically good, namely, love: nothing else
- Love means desiring and acting to promote well-being of people.
- An action is god only insofar as it bring about agape.
- It is based on doing good because it teaches that right acts are those motivated by the
wish to promote the well-being of people.
2 The ruling norm of Christian decision is love, nothing else
- The most important commandment is to love God and love thy neighbor."
- Love has a technical meaning which pertains to agape. Love is not the feeling we might
have towards friends of family members (filial) nor is it the erotic desire we might feel
towards others (erotic).
- Love is an attitude and not a feeling at all, one which does not expect anything in return
and does not give any special considerations to anyone.

3. Love "wills the neighbor's good" [desires the best for aur neighbors] whether we like
them or not
- Agape is in the business of loving the unlovable and we should always do the most
loving thing in any situation.
4. Love and justice are the same, for justice is love distributed, nothing else
- To act justy or fairly is precisely to act in love. Love is justice, justice is love.
5. Only the ends justify the means, nothing else
6. Love's decisions are made situationally, not prescriptively
- No decision can be taken before considering the situation.

The 4 working principles of situationism

1. Pragmatism
- The course of action must be practical and workable; an action someone makes should
be judged according to love influenced in it, so the user must always ask: what is the
most loving thing to do?
2. Relativism
- There should be no fixed rules; it is just appeal for people to stop trying to lay down the
law for all people in all contexts; what is right or wrong is related to the situation we are
in.
3. Positivism
- The person freely chooses to believe in agape love as described by Christianity.
4. Personalism
- Love is something that is experienced by people. So if we are to maximize love we need
to consider the person in a situation

Situation ethics was originally devised in a Christian context, but it can easily be applied in a
non-religious way. It is based on the general Christian norm of brotherly love, which is
expressed in different ways in different situations. In forming ethical system based an "love," this
is best expressed in the notion of love thy neighbor, which Jesus Christ
taught in the Gospels of the New Testament of the Bible. Although there is clothing of religion in
this type of ethics, it uses the religious term such as "agape" but it has nothing special to do with
theological faith. (Agape means absolute, universal, unchanging and unconditional love for all
people.) It is based on the golden rule "love your neighbor as you love your self" and altruism
which is putting other before yourself and showing agape towards everyone.

In the Bible story in Mark 3:1-6, Jesus healed a man with a withered hand in the Jewish temple,
an act which one would consider to demonstrate Jesus's love for all. However, the Pharisees
tell him off because he has performed this healing on the Sabbath day and the Jewish law says
that no one can work on the Sabbath. This act of Jesus is an attempt to show how acts can be
morally acceptable even if they go against the so-called moral laws. Jesus's act is morally
acceptable despite going against the Jewish law -because he acted to bring about the most
love.

PRAGMATISM (Pragmatic Ethics)

- It means thinking of or dealing with problems in a practical way. For pragramatists,
thematter of ethics is approached practically.
- It is epistemological (the idea that knowledge must be tested by its usefulness) by nature
but can be applied to ethics. As an epistemological doctrine, pragmatism hold the belief
that the true and meaningful form of knowledge is one that is practical,
workable,beneficial and useful.
- According to pragmatism, an idea is practical if it produces good results, workable if it
can be put to work, beneficial if it benefits people, and useful if it can be used to attain
good result

2.4 Utilitarianism
Found in the writings of two English philosophers, Jeremy Bentham (1748-1832) and John
Stuart Mill (1806-1873), this ethical doctrine states that the rightness or wrongness of actions is
determined by the goodness and badness of their consequences. It claims that there is one and
only one moral principle-that is, the principle of utility formulated by Mill: "Actions are good
insofar as they tend to promote happiness, bad as they tend to produce unhappiness" (Pahl:
20-21; Mill 1961). How are we to determine, it may be asked, whether an action tends to
promote happiness or tends to produce pain? By means of its consequences or results rather
than by means of some features of the action itself. The utility or usefulness of an action is
happiness: An action is good (right) insofar as it produces the greatest happiness for the
greatest number of people; bad (wrong) insofar as it produces more harm than benefit for the
greatest number of individuals (Pahl 21-23; Albert and others 1984:219-238). Faced with a
moral decision, one should not just consider one's happiness or benefit, or the happiness of a
particular person or group of persons, but the overall balance of the greatest benefits for the
greatest number of people. It seems that the principle of equity is implied in the alternative
formulation: Equal benefits or happiness for the greatest number of individuals concerned.

The utility or usefulness of an action is determined by the extent to which it promotes happiness
rather than its reverse. No action seems to be either intrinsically right or intrinsically wrong; nor
does the goodness or badness of an act depend upon the motive, intention, or past action of the
doer. Consequences effects, results, and outcomes are most important. Bearing the principle in
mind, we should consider the possible effects of each action or moral decision. We ought to
choose the action (among many other possible ones) that produces the most benefits (comfort
or happiness) at the least cost of pain or unhappiness. Some unhappiness may possibly result
from the action we take, but what matters is the greatest possible balance of happiness over
unhappiness for all individuals affected. Physicians, for instance, should minimize the cost of
suffering of their patients. Whenever there is a choice between various but equally effective
methods of medical treatment, patients' benefits should be maximized and the costs and risks
minimized. To use an expensive method at the expense of the patient (i.e., for pecuniary
reasons) when an inexpensive one may be sufficient would be rightly regarded as an unethical
practice.

Happiness, for both Bentham and Mill, is an intrinsic good, or something good per se, good for
its own sake. By happiness is meant intended pleasure and the absence of pain; by
unhappiness, pain, the privation of pleasure. Whereas Bentham suggested a "calculus of pleas-

Bentham and Mill, bent on getting rid of any strain of individualism and subjectivism, gave an
alternative formulation of the utilitarian utility principle, known as the principle of the greatest.

3.1 Kant's Ethlcs

Immanuel Kant (1724-1804), a brilliant German thinker of great Immanuel Kant renown, laid the
foundations for his ethics in his short but influential Groundwork of the Metaphysic of Morals,
translated into English by L. W. Beck as Foundations of the Metaphysics of Morals (in Critique
of Practical Reason and Other Writings in Moral Philosophy, Chicago 1949) (Kant 1949:; 1950).
His ethical view is sometimes called: deontologism for its emphasis on duty or obligaluon i.e.,
deontos in Greek). Others regard it as a form of intuitionism precisely because of its claim that
morality is exclusively within the human personality what is morally right or wrong is solely a
matter of intent, motive and will. Intuition here means internal motive or intention; hence
Is a motivist theory, too.

Likewise, a doctor who performs his/her job out of the mere desire to do so, or inclines towards
it rather than something else, is not acting morally or doing a moral act. It is only when a doctor
recognizes the duty to cure a patient that he/she is genuinely a moral person, acting morally,
and doing a distinctively moral act. Duty in this context is that which an individual ought to do,
despite the inclination to do otherwise. Hence, doing one's duty is doing what one is obliged to
do. That is why duty is also known as obligation.

Kant maintains that one acts morally (1.e.. performs a moral act) if and only if one does
whatever one is obliged to do. But what is that act which an individual is obliged to do? It is one
that is performed or done from a sense of duty or obligation. Thus, what makes an act
moral is its being done out of duty as distinguished from acts done for other reasons. Anyone,
for example, who does something merely because one feels like doing it (e.g, out of inclination)
is not acting morally, is not a moral person, nor is he/she performing a moral act.
3.1.2 Categorical imperative. Kant's categorical imperative mandates an action without any
conditions whatsoever, and without regard to the consequences that such an action may yield

It is a command or maxim that joins a person to do such and such an act without qualification; it
thus lays down a universal rule which, if followed, will ensure that the person is acting from a
sense of duty. Therefore, such an act or moral decision is morally legitimate and just. A
categorical imperative is distinguished from a hypothetical imperative, which is a command with
a corresponding condition or limitation. It is a directive to the effect that if you wish to achieve
such and such an end, you must act in such and such a manner. Kant says that a hypothetical
imperative is concerned with prudential action, which is performed from a sense of prudence.

8.1.3 Formulations of the categorical imperative:

"Act only on that maxim which you can at the same time will to become a universal law (Paton
1948). To illustrate, let's take the example of stealing, applying the test of the categorical
imperative, to steal or not to steal. Let the maxim or precept be: "Everybody else should steal."
That is, my father, mother, brother, sister, cousin, and all others should steal. The maxim must
be binding on everyone at all times and in all places; it must become a universal law mandating
everybody else to steal. Of course, since you cannot will the said maxim (i.., "Everybody else
should steal") to become a universal principle, then you should not steal. You now recognize
that it is your sense of duty not to steal. Hence, the moral dictate of the categorical imperative
forbids lying, stealing, killing, breaking of promises, etc, under any and all circumstances. By
simply invoking the first.

Another formulation is: (2) "Always act so as to treat humanity, either yourself or others, as an
end and never as only a means. This is Kant's principle of justice, which has important
consequences lor democracy. This is interpreted to mean that no individual should be
discriminated against before the law. It is another way of stating Confucius's Chung: "Do unto
others what you wish yourself," or as the Filipinos put it: "Gawin mo sa iyong kapwa ang nais
mong gawin nila sa iyo. " In your medical practice, for example, would you wish yourself to be
treated as efficiently and expediently as you should be treating a patient under your care? Or,
could you care less about how you should be treated by your own physician when you yourself
get sick? One can readily discern here the humane element of the golden rule as it is applied in
the medical context. Let's go back to Kant. Every individual must be counted as being of equal
value. Irrespective of one's gender, race, creed, social or financial status, no one should be
discriminated against. Everyone must be treated as equally as all others, be it in the legal or
moral realm of life. Rationality, in Kant's view, confers upon every person an intrinsic worth and
human dignity. very human being, therefore, because he/she is a rational creature, has an
inherent value and dignity which is not determined by one's profession, upbringing, or financial
capability: This explains why Kant holds that no one should be treated as only a means but
always as an end. In this light, seduction, abduction, exploitation, oppression, or kidnapping with
ransom are all acts whereby others are used as means for purely selfish ends, Rape is another
instance in which the victim is treated simply as a means for the sexual satisfaction of the rapist
be it a male or a female). And prostitution best exemplifies what Kant, in the second formulation
of the categorical imperative, means by treating ourselves as only a means rather as an end.
For a prostitute

Another formulation is: (2) "Always act so as to treat humanly, either yourself or others, as an
end and never as only a means." This is Kant's principle of justice, which has important
consequences for democracy. This is interpreted to mean that no individual should be
discriminated against before the law. It is another way of stating Confucius's Chung: "Do unto
others what you wish yourself," or as the Filipinos put it: "Gawin mo sa iyong kapwa ang nais
mong gawin nila sa iyo." In your medical practice, for example, would you wish yourself to be
treated as efficiently and expediently as you should be treating a patient under your care? Or,
could you care less about how....

Let's go back to Kant. Every individual must be counted as being of equal value. Irrespective of
one's gender, race, creed, social or financial status, no one should be discriminated against.
Everyone must be treated as equally as all others, be it in the legal or moral realm of life.
Rationality, in Kant's view, confers upon every person an intrinsic worth and human dignity.
Every human being, therefore, because he/she is a rational creature, has an inherent value and
dignity which is not determined by one's profession, upbringing, or financial capability: This
explains why Kant holds that no one should be treated as only a means but always as an end.

3.1.5 Autonomous, self-regulating will. Kant's concept of the will as autonomous and sell-
regulating has contributed a great deal to our understanding of autonomy as freedom of action
(Munson 1979). Autonomy means governing, regulating, restraining oneself, including one's
own choices or courses of action, in accord with moral principles which are one's own and which
are binding on everyone (i.e., universalizable). When we therefore say that an individual has
an autonomous, self-regulating will, we refer to his/her independence, self-reliance, and self-
contained capacity to make moral decisions by and for herself/himself. This means that the
reasons and justifications for one's decisions are one's own. To respect an autonomous agent,
therefore, is to recognize one's own considered value judgment, even if the latter is believed to
be mistaken or incorrect. To respect one's….

3.1.4 Two types of duties. Kant makes a distinction between two types of duties: the perfect
and imperfect (Munson 1979; Palht 31-32). The former is one which we must always observe,
irrespective of time and place or circumstances. That I should not harm or inflict injury upon
others is a perfect duty. The latter is one which we must observe only on some occasions. That
I should show love and compassion occasionally to others, based on my own choice, is an
imperfect duty. You will observe that the categorical imperative according to Kant, is the voice of
duty, the sense of oughtness; it is a priori in so far as it is derived from reason itself. This voice
of duty through the categorical imperative is the only thing in the calm of morals that is definite
in a relative and changing world.
Specifically for Kant, however, respecting autonomy is bound to his notion that every person
has worth and dignity, precisely because persons are ends in themselves and are capable of
making their own moral decisions. They are not to be treated merely as means. It goes
without saying then that to treat an individual merely as a means is an infraction of Kant's
concept of autonomy, because one is being treated in a way one does not want to be. Not to
respect an autonomous agent is either to reject that person's own judgment or to deny him the
freedom to choose and act on that judgment. For Kant, mutual respect for autonomy between
persons in moral relation is the basis of justice; its violation would be a form of injustice.

Third, an action is right and legitimate insofar as it satisfies the categorical imperative. Good
results never make an action morally right. The welfare of the great majority of people at large
may not justify the harm, deception, or injustice done or imposed upon an individual just
because he is poor, a criminal, or a handicapped person.

3.2 Ross's Ethics

William David Ross (b. 1877), a British Aristotelian scholar and moral philosopher presented a
rule-deontological theory in his book The Right and the Good. Though influenced by rule
utilitarianism, Ross has rejected the utilitarian precept that and action is validated as right by its
consequences. The outcomes of an act, however beneficial and pleasant they may be for many
individuals, may not determine its rightness. And though he was a deontologist himself like
Kant, Ross considers the latter's absolute principles to be too rigid. He perceives that not only
do such principles fail to demonstrate sensitivity with regard to the complexities of actual
situations, but they also conflict with one another in some instances. Is it morally justified,

3.2.1 Rules and moral properties.

Despite Kant's absolutism, however, Ross has perceived the ethical significance of rules in the
medical context, although moral rules should not be so absolute and inflexible that there are no
exceptions whatsoever (Pahl 1981; Munson 1979). Moral rules serve as moral guidelines insuch
a way that they must be adjusted or modified, if not set aside in some Situations, depending
upon our perception of what is right and good.

In the light of these problems, Ross has recognized that there are exceptions for every rule, and
in some situations the latter must be set aside. Absolute rules are often insensitive to the
consequences of an act; at times, not only are they in conflict with one another but they are also
so inflexible that they become irrelevant to ever-changing situations. "Always tell the truth." But
suppose the truth kills the patient, or at least hastens his death?

3.2.2 Actual duty and prima facie duty.

If and when moral rules come into conflict in particular situations, how are we to determine
which one applies? To resolve this question, Ross makes a distinction between an actual duty
and a prima facie duty (Pahl, 1981). The former is one's real duty in a given situation. It is the
action one ought to choose from among many other actions. The latter (which in Latin means
"at first view," or so far as it appears) 1s one that directs or commands what one ought to
perform when other elevant factors are not taken into account. More often than not,
Let us illustrate: I have promised to lend money to a friend in dire need. It is thus my prima facie
duty to hand over the money on the day agreed upon. But suppose, for instance, that before I
do so, I find that I need the money because my mother has suffered from an attack of chronic
asthma, and needs to be hospitalized. Faced with two conflicting prima facie duties, I must now
decide on which one is my actual duty in such a situation. According to Ross, "Do whichever
act is more of a duty." In other words, my actual duty in the situation is determined by an
examination of the weight of both prima facie duties in conflict. Which one is the stronger of the
two? Here one can see that the prima facie duty of promise-keeping (as I have done for
my friend) is not absolute, for it can be overridden by a stronger prima facie duty under some
conditions (such as my duty to an ailing mother in serious condition).

Sir David Ross (as his colleagues in the academe often call him) offers us two principles by
which to resolve cases of conflicting duties. First, act in accordance with the stronger, more
stringent or more severe prima facie duty. Second, act in accordance with the prima facie duty,
which has a greater balance of rightness over wrongness compared to other prima facie duties.
How am I to determine my actual duty in a given situation when there are conflicting prima facie
duties? If a terminally ill patient asks "Am I going to die?" I have a prima facie duty to tell him the
truth. But I also have a prima faci duty to give him comfort, peace of mind and to spare him from
needless suffering.

Ross holds that (a) one and only one of these two prima lacie duties is my actual duty; (b) I
know cach of them to be a prima lacie duty; and (c) I can have only an opinion (a personal
conviction or perception to the best of my knowledge) about which is "more of a duty" (more
crucial, more serious) and therefore my actual duty. So, if I can save a person from killing
himself by lying to him, then my prima facie duty to lie in order to save him is my actual duty; my
prima facie duty to lie is more stringent than my prima facie duty to tell him the truth and allow
him to kill himself.

Two conflicting duties. For Ross, we have to rely on our moral intuitions (hence, his view is
also known as intuitionism) as the ultimate guide in particular cases. What to do then in such a
situation would be: (1) Learn and discern the facts in the case; (2) Consider the possible
consequences of our actions; (3) Reflect on our prima facie duties; then (4) Decide on the best
course of action under the circumstances.

Ross has listed down seven types of prima facie duties: (1) duty of fidelity, (2) the duty of
reparation, (3) the duty of gratitude, (4) the duty of justice, (5) the duty of beneficence, (6) the
duty of self-improvement, and (7) the duty of non-maleficence (i.e., non-infliction
of harm). Duty of fidelity. We should be faith full to our duties, obligations, vows, or pledges; this
likewise refers to one's loyalty to a worthy cause, telling the truth as the situation demands it,
keeping actual and implicit promises, and not representing fiction as truth. Treachery, deception,
hypocrisy, trickery, double-dealing, insincerity, betrayal, lying, duplicity, cunning or craftiness are
infractions against the duty of fidelity.
Duty of reparation. A Filipino saying underscores the great significance of this duty: "Kung
nakagawa ka ng masama, gumawa ka naman g mabuti. " So we have a duty to make amends
lor injury that we have inflicted on others, This is an act of making amends, righting the wrongs
we have done to others. Asking for the other person's forgiveness is insufficient. We have to do
that person good to atone for our wrongdoing. It is casy to say "I am sorry," or "Please, forgive
me for what I've done." This duty lurther enjoins us to do good to make up for or repair the
damage done; hence it is also knownas the duty of compensation. You should not only say "I'm
really……. (Way sumpay)

Duty of gratitude. We have a duty to appreciate and recognize the services others have done
for us, which may be either a favor, kindness, good fortune, a great help., or saving one's life.
The cultural grip of one's duty of gratitude to one's parents among Fillpinos is very strong. In
fact, this is an essential element of their value system, their philosophy of life, by which they
gauge the rightness or wrongness of their moral decisions.

Duty of beneficence. This type of duty enjoins us not only to bring about what is good for
others but also to help them better their conditions with respect to virtue, intelligence, or comfort.
We should contribute in whatever small way we can to their health and well- being. Our duty to
confer benefits and to prevent and remove harm is important in biomedical and behavioral
contexts. Equally important is the duty to balance the good that our decision may yield against
the harm that may result from doing or not doing what we honestly believe to be beneficial to the
patient. In short, this duty requires the provision of benefits and balancing of benefits and harm
for all people concerned in a given circumstance.

Duty of self-improvement. As we have a duty to help others better themselves, so we also

have a duty to improve and develop ourselves with respect to virtue, intelligence, and
happiness. This type of duty should go hand-in-hand with other duties, for unless
one performs or carries out one's duty to oneself, the fulfillment of one's other duties would be
less effective. Having done my duty of self-improvement-morally, intellectually, and physically -I
would be in a better position to fulfill my duties to others. On Kantian precept, I should treat
myself also as an end and never only as a means for the benefit of others. In other words, I
must be just to prevented.

Duty of nonmaleficence. Ross views "not injuring others" as synonymous with nonmaleficence
(Bcauchamp and Childress: 97-131). We ought to avoid inflicting evil, injury or harm upon others
as we would avoid doing so to ourselves. We ought to prevent evil or harm, which encompasses
pain, suffering, disability, and death. For instance, we have a duty not to push someone who
cannot swim into deep water. Culpable negligence, which includes the failure to guard against
risks of harm to others and to oneself, is an infraction of this duty. A physician who assumes the
treatment and care of a patient, yet lacks the qualifications of his profession, and does not
possess the skill, care, and diligence required for treating such a patient, would actually be
exposing this patient to danger.
3.3 Rawls's Theory of Justice
In his book entitled A Theory of Justice (1971), John Rawls, a noted Harvard philosopher, has
attempted a brilliant synthesis of the strengths of utilitarianism and of the deontological views of
Kant and Ross. While avoiding the apparent lack of justice in utilitarianism, he has built on both
Kant's and Ross's fundamental notion of the ultimate dignity of human beings his concept of
social morality, which serves as the basis of social justice.

3.3.1 Theory of justice. Every individual is inviolable. This inviolability, which is founded on
justice, is so sacrosanct that not even the general welfare of society can override and
supersede it (Rawls 1971; Albert and others: 364-381; Munson 1979; Pahl: 43- 48;
Beauchamps and Walters 1978:44-46). The greater good to be shared by all members, for
example, should not be used to justify the loss of freedom of others. Or the larger sum of
advantages which is Supposedly to be enjoyed by the many should not outweigh the sacrifices
or inconveniences to be imposed on a few. In other words, one may not exploit or oppress one
individual or a particular group of citizens in the name of modernism and industrial progress.

Another feature of Rawls's concept of justice is that an erroneous theory is tolerable in the
absence of a good one. As much as possible, when given two erroneous laws, one should
choose the better and the less erroneous one. An act of injustice, for instance, can be tolerated
if and only if it is necessary to avoid an even greater act of injustice. It must be borne in mind
though, that in the case of a tolerable erroneous theory it is the only one available at hand, so
reason dictates that it must be carried out for the sake of those who are supposedly benefited or
affected by it. It's like saying a wrong or an unjust law is better than no law at all. St. Thomas
Aquinas, in his political theory, seems .......

A third aspect of Rawls's concept of justice is: Individual liberties should be restricted in order to
maintain equality of opportunity. Liberties of equal citizenship are of paramount importance in a
Just society. Individual rights are not subject to political bargaining or compromise. Walang
palakasan. Hence, restrictions of individual liberties serve as safeguards against abuses and
misuses of one's freedom against others. Pagbibigayan ang kailangan. Walang lamangan.
Without constraints, some over-ambitious people may use their power, money, and influence
against their fellowmen. Restrictions, therefore, are intended not to destroy but to preserve
freedom; and amidst these restrictions, equality of opportunity among the citizens to develop
themselves will best be served.

3.3.2 Principles of justice. Rawls speaks ofa two-fold principle of justice: First, equal access
to the basic human rights and liberties (Pahl: 44-46). This principle defines and secures
equal liberties of citizenship. Our basic rights and liberties include the right to vote and to be
eligible for public office, freedom of speech and peaceable assembly, liberty of conscience,
freedom of thought, right of ownership (that is, freedom to hold property), and freedom from
arbitrary arrest and seizure as defined by the concept of the rule of law, and not of man. As it
appears, the first principle guarantees a system of equal rights and liberties for every citizen; it
prohibits the
bartering away of liberty for social or monetary considerations. No citizen, for example, may sell
his/her right to vote.

The second principle is: Fair cquality of opportunity and the equal distribution of socio-
economic inequalities. As much as the availability of resources will allow, everyone should be
given an opportunity for self-development or to receive medical treatment. This principle deals
more with the distribution of social goods and/ or medical resources than with liberty. Rawls
admits that some individuals are born more affluent than others, and they enjoy advantageous
social positions. Such socio-economic differences are neither just nor unjust per se. He
maintains, however, that in a just society, such differences are tolerable only when they can be
shown to benefit everyone, including those who have the fewest advantages.

3.3.3 Justice in human relations. Aware of the need for principles that bind and guide
individuals in making moral decisions, Rawls cites four.types of duties: (1) fairness in our
dealings with others, (2) fidelity, (3) respect for persons, and (4) beneficence. In addition,
he also mentions what he calls "natural duties": (1) the duty of justice, (2) the duty of helping
others in need or in jeopardy, (3) the duty not to harm or injure others, and (4) the duty to keep
our promises.

3.4 Natural Law Ethics

This ethical doctrine assumes many names by virtue of its historical development. Some call it
Thomistic ethics, after St. Thomas Aquinas (1225-1274), a profound Italian philosopher and the
collegian, who gave the doctrine its most influential formulation and articulation in the thirteenth
century. Others label it as Scholastic ethics after the brilliant, moral teachings of a group of
scholars, known as Scholastics or Schoolmen, headed by St. Thomas Aquinas himself, in the
University of Paris during the Middle Ages. Still others identity it as Christian ethics and/or
Roman Catholic ethics insofar as the church's contemporary versions of the theory are mostly
elaborations and Interpretations of St. Thomas's basic ethical precepts. Lastly, it 1sS often
known as natural law ethics, precisely because it claims 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.

In Aquinas's view, the source of the moral law is reason it (Aquinas: 94; Pegis 1915; Aquinas
1923-1929). The latter directs towards the good as the goal of our action, and that good is
discoverable within our nature. In its operation, reason recognizes the basic principles "Do
good, avoid evil." He used the term synderesis to describe inherent capacity of every individual,
lettered or unlettered, to distinguish the good from the bad. This is the basis of Aquinas
argument that certain moral principles are objective and can be found in the nature of things
through reason and reflection.

3.4.1 Voice of right reason or voice of conscience. Interpreters of St. Thomas's moral
doctrine regard right reason or the voice of reason as the moral norm, insofar as an individual's
natural capacity to determine what is right from what is wrong (synderesis) is no less than the
manifestation of the moral law. In short, the moral law is the dictate of the voice of reason; and
this dictate is expressed in the moral principle "The good must be done, and evil, avoided"
(Aquinas: 94; Stumpf: 198-200; Reyes: 51-53). How are we to determine whether we are acting
rightly or wrongly? We know we are acting rightly if we heed or follow the voice of reason; we
know we are acting wrongly if we act against it. Other Thomists would view the voice of reason
as the voice of conscience.

3.4.2 Man's threefold natural inclination. What is theg ood? St. Thomas asserts that human
good is that which is suitable to or proper for human nature. Thus, whenever an act is suitable
to human nature as such (as being endowed with reason and free will), then it is good and it
must be done; whenever it is not proper for human nature, however, then it is evil and it must be
avoided. (You will notice how it is again related to the voice of reason, as mentioned earlier.) In
other words, how does one know that a particular act is or is not suitable to human nature as
such? By means of whether one is following and obeying the voice of reason (conscience) or
acting contrary to it. Hence, it is for this reason, too, that other Thomists human nature as the
proximate norm of morality.

In St. Thomas's view, the good is built into human nature, and it is that to which we are directed
by our natural inclinations as both physical and rational creatures (Munson 1979; Pahl: 50-51;
Stump: 198-199). We have three natural inclinations: (1) sell-preservation, (2) just dealings with
others, and (3) propagation of our species. We are naturally inclined to preserve our life. Self-
destruction, firstly, is unnatural as far as St. Thomas is concerned. This natural inclination urges
us to care for our health, not to kill ourselves or put ourselves in danger. Thus, any act that
violates this basic inclination is wrong; it contradicts human nature as the Creator intended to
be.

3.4.3 Three determinants of moral action. On St. Thomas's ethical principles, there are three
factors which determine the rightness or wrongness of a concrete individual human act: (1) the
object, (2) the circumstances, and (3) the end of the agent (Pegis 1945; Bittle: 83-90; Reyes:
149-151). For a given act to be truly morally good, it must be good in all its three elements. A
defect in any of these three determinants will make an act morally wrong.

The Object. That which the will intends directly and primarily is the object of the moral act; it
may be either a thing (for example, money) or an action (such as surgical operation). The very
act of operating on a patient for a particular disease, say, a tumor or cyst, is directly and
primarily intended by the physician. The circumstance and the end are also intended, but not as
directly and primarily as the object. Another example is the physician's act of injecting a drug
into an ailing patient in which case the act is primarily intended by the doctor. The physician
here is moved to action specifically and primarily by the object rather than by the circumstances
of the act or the end of the agent.

The Circumstances. There are conditions which, when superadded to the nature of the moral
act, will affect its morality. They are called the circumstances. "Will affect its morality" means
that a given circumstance or a set of circumstances will either mitigate or aggravate the
goodness or badness of a particular act; an act whose object is morally good may further be
judged as good because of some circumstance; likewise, an act whose object is morally wrong
may further be judged as wrong because of some circumstance. Let us examine the seven
circumstances cited by St. Thomas.

Who? This circumstance has something to do with the special quality, prestige, rank, or
excellence of the person involved in the moral act. It is morally bad to rape a woman but even
worse to rape one's own daughter. The worst is to rape one's own grand daughter.The act of a
physician who treats a hospital patient entrusted to him is morally good, but that of one who
extends medical assistance to an indigent unable to afford confinement is even better and more
commendable. To mistreat one's own patient is bad in itself, but to mistreat him, and take
advantage of his ignorance, is even worse.

What? This circumstance refers to the quantity or quality of the moral object. The very act of
surgical operation on a sick person who needs it is good in itself but to perform the act as
excellently as a skilled surgeon is capable of heightens the goodness of the said action. The
former may be done simply as a daily routinely function of a resident surgeon on duty, whereas
the latter is performed with a sense of service, dedication, and concern for the well-being of the
patient, irrespective of his socio-economic status in life. Let's consider

Where This circumstance denotes the place where the act Occurs, lt makes a big difference, for
example, when a doctor extends medica assistance to someone brought to the emergency
room for stab wounds, and when a doctor selflessly goes out of his way to take the wounded
victim to his clinic or to a nearby hospital. The former a perfunctory role, while the latter is the
act of a "Good Samaritan. lo abuse a patient maliciously is a corrupt medical practice, but to
assault her or him sexually in one's own clinic is even more heinous and outrageous. It likewise
makes a difference if an assassin kills his victim in a restaurant, or inside a church while mass is
being said.

By what means? This refers to the means used in carrying out the act. To take advantage of
one's weakness is bad enough; but to deceive and seduce someone in order to take advantage
of that person makes matters much worse. Let s take another example: To extend medical help
to an indigent patient is good; but to give him/her the money needed for his/her medication
makes the goodness of the act much greater. Carnapping, on the other hand, is in itself bad; but
to use the proceeds from the sale of the carnapped vehicle to hire an assassin to kill the car's
owner makes the act even more horrendous and inhuman.

Why? The end or purpose is considered as a Circumstance adlecting the goodness or badness
of the action, If the act itself is bad and is still carried out with a bad purpose, the said act
becomes much worse. To seduce a destitute girl is in itself bad; but to do so with the intenton of
making her one's querida or number two makes the act of seduction doubly, evil, so to speak.
On the other hand, helping this girl to finish a vocational course is in itself good; and doing so
with the intent of employing her later in one's garment factory, enabling her to help her own
family, makes the act even "more" legitimate and righteous.
How? This circumstance indicates the manner in which the action is done. When facing death
through starvation, for example, the famished or starving individual may take surplus goods
from the famis another in order to avoid death. In a case of extreme necessity, the another
ordinary right to private property no longer holds. Similarly, in the case of unjust aggression, it is
legitimate to kill the aggressor who unjustly attacks and attempts to kill another person. It makes
a difference whether a resident physician has been inadvertently remiss in his hospital duties
due to a hectic schedule or other unforeseen causes, or he has been advertently remiss in bad
faith due to personal indifference to his medical function. Has he committed an error in

When? This circumstance refers to the time clement involved in the performance of an action,
not only with regard to quantity but to quality as well. To commit rape under the cover of
darkness is even worse than when it is done in broad daylight. To abuse one's patient under
sedation is much worse than mere seduction. It makes a difference whether one commits a
crime in the church when the mass is being said or when there is no mass at all.

8.4.4 The double effect principle. The principle applies to a situation in which a good effect
and an evil effect will result from good cause (Pahl: 51-52; Bittle: 44-50; Reyes: 151-155;
Shannon 98/ 67). We may have a good action which will yield two effects, a good one and an
evil one, How are we to resolve this question According to the principle, under certain
conditions, some evil etfect voluntary in cause-may be permitted to occur The classic example
1.The action directly intended must be good in itscll, or at lcast morally indifferent. First of all, thc
moral action must be in tself good, otherwise it is evil at the very outset. In the case cited above,
the surgical operation on the woman's uterus is good per se because of the condition
mentioned. 2. The good effect must follow from the action at least as immediately as the evil
effect; or the evil effect may follow from the good effect. In other words, either both the good 3.
The foreseen evil effect may not be intended or approved. but merely permitted to occur In other
words, the killing of the unborn child must not be directly intended, but considered only as
indirectly intended and as the secondary effect of the operation. Ifit is directly intended, then it
becomes the direct and primary object of the operation, and hence it is evil. But Since it is only
indirectly intended, it becomes the secondary object of the operation, and hence it is morally
permissible. 4. There must be proportionate and sufficient reason for allowing the evil effect to
occur while performing the action at stake.

3.4.5 The principle of totality. An individual has the right to cut oft, mutilate, or remove any
defective or worn-out non-functioning part of his body; to dispose of his organs or to destroy l
their capacity to function "only insofar as the general well-being of the whole body requires it"
(Pahl: 52). Under natural law ethics, we have a natural obligation not only to preserve our lives,
but also to preserve the integrity of our bodies. Accordingly, a diseased organ may be
amputated or excised for the good of the whole organism. A gangrenous leg or arm or any other
organ that is beyond cure and threatens the whole organism may be mutilated to save the
person life. Healthy organs, however, may not be cut off, as this would weaken a person's
health. The principle of stewardship declares that human life comes from God, and no individual
is the master of his/her own body. Humans are only mere stewards or caretakers, with the
responsibility of protecting and cultivating spiritual and bodily functions. We are obliged to take
good care of ourselves, to maintain a sound mind and body, band to safeguard our dignity.

The principle of the inviolability of life states that life is God's and has been loaned to us;
hence, it is inviolable and sacred. It is only God who has complete control and dominion over
life; our duty is to take care of it until God takes it back from us. The principle of sexuality and
procreation underscores a twofold purpose of sexual union: (1) the procreation and nurturing of
children: band (2) the expression of loving union and companionship. Both purposes must be
achieved only within the conjugal bond. Human procreation requires responsible collaboration
on the part of the spouses with the fruitful love of God; the gift of human life must be actualized
in marriage through the specific and exclusive acts of husband and wife, in accordance with the
laws inscribed in their persons and in their union.

The Moral Issues of Paternalism and Truth-telling

In ancient China, a Confucianist thinker named Meng Tze or Mencius (ca. 371-289 B.C.) stated
that there are "four beginnings" that differentiate man from the beasts; hence they should be
developed, because it is only through their development that man becomes truly human (Fung
Yu Lan 1948: 68-70): (1) The feeling of helpfulness and commiseration, which is the beginning
of human- heartedness; (2) the feeling of shame and dislike, which is the beginning of
righteousness; (3) the feeling of modesty and yielding, which is the beginning of propriety; and
(4) the sense of right and wrong, which is the beginning of wisdom." According to Mencius,
these "four beginnings," if fully developed, become the four constant virtues: human-
heartedness, righteousness, propriety, and wisdom.

Our point of departure in this chapter is Mencius's concept of human-heartedness or the feeling
of helpfulness and commiseration. “All men," explains Mencius, "have a mind which cannot bear
to see the suffering of others.... If now men suddenly see a child about to fall into a well, they
will without exception experience a feeling of alarm and distress" (Fung Yu Lan: 69-70). What
Mencius is telling us here refers to what psychologists claim lies deep within the human psyche-
it is the desire to help others, the feeling of benevolence or good will, a sense of compassion
with the desire to help, to be of service, to give assistance whenever it is needed.

The biblical story of the Good Samaritan best exemplifies and supports this dimension of human
nature. For Mencius, this sense of helpfulness or human-heartedness consists in loving others.
We desire to help because we love others. Christians refer to this as a sense of charity,
kindness, or benevolence, which reflects what we earlier considered to be the principle of
benevolence and/or non-maleficence.

On the other hand, the principle of autonomy-otherwise known as the right of self-determination
—affirms that an individual is autonomous. Hence he has the right to act and decide by and for
himself. He can choose who he wishes to be, and take responsibility for such a choice. It seems
that respect for an individual's autonomy and right of self-determination presupposes
noninterference and nonintervention with his choice or plan of action and moral decision.
Generally speaking, however, paternalism involves some sort of interference with the
individual's freedom of action. This is the moral issue of paternalism

8.1 Definition and Types of Patarmalism

From the Latin pater father' or paternus 'fatherly paternalism means the act of being fatherly to
someone, as if the latter were one's own offspring. Strictly speaking, it consists in acting like a
father to a person for the latter's own good and interest. This is in keeping with the principle of
nonmaleficence and with Mencius's sense of human- heartedness. It is argued that a
paternalistic act is believed and intended to protect or advance the interest of its recipient,
although such an act may go against the latter's own immediate desires or may limit his
freedom of choice (Pahl: 213-214). Is a paternalistic act, therefore, morally legitimate? Will it not
circumvent and undermine the recipient's right of self-determination or autonomy?

1.With regard to the recipient's welfare, paternalism may be either pure or impure (Childress
1982; Shannon 1987:13- 14,16). Pure paternalism justifies intervention into a life for the sole
welfare of that person. For example, a child is told by his parents to eat vegetables because it
good for his health. Impure paternalism, on the other hand justifies interference with another
person not only for that person's welfare but also for the welfare of another. Some argue, for
example, that the parent of a Jehovah's Witness should have a blood transfusion not only for
his/her own good but also for the good of his/her children (i.e., "alang alang man lamang sa
iyong mga anak na maiiwan kung ikaw ay mamamatay").

2. With regard to the recipient's defect and safety, paternalism may be either restricted or
extended. Restricted paternalism supports intervention which overrides an individual's action
because of some defect or weakness in that individual. One may prohibit a child from doing
something, for example, because of chronological or psychological incompetence (hence the
Filipino will say, "Anak, huwag mong gawin iyan, hindi mo pa kaya"). Extended paternalism, on
the contrary, is one in which an individual is restrained from doing something because it is too
risky or dangerous. For instance, riding motorcycles without wearing helmets is not encouraged
(i.e., it is unlawful) because of the imminent danger it incurs. Hence, the Filipino will say,
“Huwag kang magbibisikleta sa kalye, anak, mababangga ka ng mga sasakyan."

3. With regard to the promotion of good and prevention of harm, paternalism may be either
positive or negative. An example of the former is when a patient is forced into a rehabilitation
program to promote his/her own good; an example of the latter is when cigarettes or weapons
are taken away from an individual to prevent that individual from any harm or violence. (Hence,
the Filipino will say “Kaya dinala ka namin dito sa rehabilitation center, anak, para magamot at
pagkatapos ay magbagong buhay ka na sana" as an indication of positive paternalism and
“Itinapon ko na ang lahat ng iyong biniling sigarilyo sa hangarin kong hahaba pa ang iyong
buhay" as an indication of negative paternalism.)

4. With regard to the patient's sense of values, paternalism may be either soft or hard. In a soft
paternalistic act, the patient's values are used to justify the intervention with his possible action
or decision. An unconscious or comatose patient, for example, is usually detached from life-
support machinesbbecause he/she earlier signified such preference if ever he/shebwould be put
in such a situation. (Hence, a Filipino wouldbsay "Kapag ako'y nag-aagaw buhay na, huwag na
ninyo akong ikabit sa artificial respirator."
In hard paternalism, on the other hand, the patient'svalues are not the ones used to justify a
paternalistic act. For example, someone who supposedly knows what is good for a patient
directs the latter with regard to what is to be done, or directs someone else to do this for the
patient. Hence the Filipino physician would tell a patient, “Mas mabuti para sa iyo kung
magpaopera ka na ngayon,” or a husband would tell his wife's attendant physician: “Doc, mabuti
pa kaya'y gawin nang Caesarean ang panganganak ng misis ko."

5. With regard to the recipient of the benefit, paternalism may be either direct or indirect
(Childress: 14). In the case of the former, the individual who should receive the supposed
benefit is the one whose values are overridden or disregarded for his own good. The
motorcyclist, for example, who is forced by law to wear the helmet is the one who will benefit in
case of an accident. In the case of indirect paternalism, a particular individual will be benefited,
if one person is restrained from doing something. A good example is child abuse, in which
parents are restrained by law in some way to protect the child.

9.2 In the Medical Context

We can speak of personal and state paternalism in its application in the medical context (Pahl:
214-217): (1) On the basis of a (2) Personal paternalism is one in which an individual decides
on the basis of one's best knowledge of what is good for another person. State paternalism, on
the other hand, refers to the control exerted by the legislature, an agency, or other
governmental bodies over particular kinds of practices and procedures in medicine. Such
control is exercised through the compliance with certain laws, licensing requirements,
operational guidelines and regulations in medical practice. All behavioral therapists for instance,
must be either licensed psychologists or psychiatrists; all practicing doctors must pass the
medical board examination.

9.3 Justincations for Personal Paternalism

(1) The recipient of the paternalistic act is sick and consults the physician seeking medical
expertise and assistance; (2) the recipient of the paternalistic act has some incapacity which
prevents him/her from making a decision. Or, the person is under undue stress, suffers a
nervous breakdown, is a minor, or his/her judgment is impaired in one way or the other; (3) to
the best of one's knowledge and training, there is the probability of harm unless a paternal
decision is made; here one needs to determine if all harms are equal (e.g., physical, mental,
and social); (4) the probable benefit of paternal intervention outweighs the probable risk of harm
from noninterference; (5) the physician has an obligation to act in the best interest of the patient;
band (6) the patient, upon consulting the physician, voluntarily transfers part of his/her
autonomy to the latter based on faith in the physician(Pahl: 216-217; Shannon 1987: 14).

9.4 Justifications for State Paternalism

(1) To improve the good quality of medical education (e.g., issuing a set of policies or practices);
(2) to upgrade a high standard of medical care (rigorous standards and strictly enforced laws,
for example, have done much to improve medical practice); and (3) to control drug addiction,
other drug abuses, or the spread of AIDS and other sex-related diseases (Pahl: 214-216).

9.5 Application of Ethical Theories

Natural law ethics endorses both kinds of paternalism in the medical context: personal and state
paternalism (Pahl: 222-224) While the patient knows what is good and bad for himself, he does
not know everything. Since the physician has superior knowledge about human pathologies or
diseases, he is in a better position to perceive what action or decision should be made in the
best interest of the patient. Likewise, individuals possess inherent worth and have the freedom
to make moral decisions by and for themselves. Individuals, however, may not have the
pertinent information, the sufficient knowledge, and the intellectual capacities needed to
determine what is really in their best interest Sometimes, individuals are just moved by
momentary pastors and unforeseen circumstances to make haphazard decisions. Lt is lor such
reasons that the state is organized to bring about such natural benefits as health, medical
practices, and laws that promote the common good; hence, state paternalism is morally right.
The state may act so that people are protected from their own weaknesses, shortcomings, and
random decisions; yet their genuine desires and ends are satisfied or achieved. State
paternalism, while restore and corrective, protects individual freedom. Unrestricted freedom may
lead to chaos and anarchy, whereas restrained liberty individual a necessary condition for
peace and order.

Considering Kant's concept of a person as a rational and autonomous agent, it seems that he
might be against paternalism. paternalistic act may be taken as an interference with an
individual's autonomy and sell-regulating will. It can be argued, however, that in the medical
context, Kant's position may become untenable if and when an individual lapses into
unconsciousness, in which case the attending physician must act in order to save the patient's
life as much as possible. For the physician to simply stand by and watch the unconscious
patient die without doing anything is somewhat contrary to the dictates of right reason. Moreover
it will be in keeping with
Kant's precept of not treating any person as a means but always as an end, if the attending
physician performs a paternalistic act for and on behalf of the unconscious patient.

Rawls's theory of social and political morality is compatible with state paternalism. Society
might decide to institute a set of medical practices and policies that would promote common
interests and general welfare. With regard to Ross's moral principles, on the other hand, each
person has a moral right to be treated as an autonomous agent who has to make decisions by
and for oneself. It is possible to imagine, however, certain circumstances in which intervention
or interference with an individual's autonomy would be legitimate. As an example, a person who
might be mentally Incompetent to make a decision would need paternalistic assistance.

Ulitarianism endorses paternalism insofar as state laws and policies are justified by the
principle of utility. Restricted individual liberty may promote the greatest benefits for the greatest
number For the utilitarian, individual freedom has no absolute value, it can be restrained or
restricted for the sake of the many.
28 Truth-telling
When a patient agrees to place himself under the care of a doctor by virtue of the fact that the
former consults the latter for medical care, the power of the physician over the patient cannot be
absolute; that is, the patient does not become a helpless slave or creature to the physician.
Thus, the physician-patient relationship involves the moral issue of truth-telling and
confidentiality Is it justifiable for a doctor to deceive his/her patient How much autonomy must
be given up by the patient? What are the limits of paternalism that can be legitimately exercised
by the doctor?

Two approaches to the truth-telling issue maybe cited: the person-centered and the
problem-centered. The former lends Importance to the patient as a person, while the latter
stresses the nature of the problem or the degree and severity of the patient's illness (Fletcher
1954). In other words, the person-oriented approach considers the patient as a person with a
problem, but not as a problem

Himself/herself. The patient is a person with feelings of hope and despair, with purpose and
defeat. As such, one has the right to know the nature of one's disease and the physician is
morally obligated to respect that right. The physician owes the patient the truth, just as the latter
owes the doctor skill and technical powers. Moreover, caring for a person is a moral relationship
in which the physician's attitude should be an utmost concern for the patient.

The problem-fomented approach, on the other hand, considers the patient's problem, illness,
or condition. The physician may not tell the truth when it is in the best interest of the patient;
after all the physician is fallible and makes mistakes. Thus, if only for the best interest of the
patient's failing or worsening condition, the physician may withhold the truth from the patient.
This approach is usually appealed to by those who endorse the legitimacy of the use of
placebos (Latin placebo, I shall please') in medical therapy. Patients who are seriously ill will
oftentimes show improvement when they are given placebos for treatment. This can happen
even when the medication is irrelevant to their condition.

Joseph Fletcher compares the twofold approach to truth-telling with what Martin Buber defines
as two types of relationship: the 1 it and the I-thou (Fletcher 1954). The "I-it" relationship
describes a person's relationship with things, objects, or "its"; hence, an it or man-object,
subject-object relationship, This kind of relationship is determined by our attitude to what is
other than Ourselves. My relationships with my books, cars, eyeglasses, shoes clothes, and
other possessions typify the "I-it" or subject-objectrelationship. Insofar as these things are my
possessions or personal

I-thou relationship, on the other hand, delineates our relationship with Other persons, like
ourselves, other subjects, 1's, thou's or you's; hence, "I-thou," or "I-I," subject-subject, person-
person relationships. Insofar as the other person is a fellow human being, a thou or someone
with integrity and a moral quality of his/her own, I cannot manipulate or use him/her without
degrading or dehumanizing him/her at the same time. For persons, like myself, are not things or
objects which are usable and manipulable by other persons.
In the medical context, the physician-patient relationship exemplifies an -thou" or person-
person relationship, inasmuch as both are persons, both are "I's." This type of relationship is a
moral experience because persons can respond, i.e., they are responsible; unlike things they
can say "yes" or "no"; they can make decisions. In short, they have sights, especially the right to
say "yes" or "no" in response to any course of action: the right to self-determination, the right to
be themselves, to choose to be a "you" rather than an "it." In FletcherS view, if a patient simply
becomes an object of medical treatment, who submits himself to a physician, without any
knowledge of his condition and its prognosis, that patient has ceased to be a "thou and has
become an "it." He is being used and manipulated as If he were a thing or object; he is no
longer accredited as a person, and hence is deprived of personal responsibility and moral
status.

27 Justifications for Truth-telling

(1.)It 1s argued that our human and moral quality as persons is taken away from us if we are
denied whatever knowledge is available about our condition as patient, as the case may be;

(2) AS patients, We have entrusted to the physician any knowledge he has about Ourselves, so
the facts (i.e., his findings) are ours and not his-hence to deny them to us is to steal from us;

(3) The highest conception of the physician-patient relationship is a personalistic one which is
based on mutual confidence and respect for each other's rights; and

(4) To deny a patient pertinent knowledge about himself, especially in a life-and-death situation,
is to deprive him the ample time to prepare for his own death or to carry out responsibilities that
are based solely on his decisions or actions (Fletcher 1954; Pahl: 217-220).

9.8 Confidentiality
Confidentiality (from the Latin confidene 'to trust) refers here to medical or professional secrecy
in which certain information (1.e., secret finding) is committed to a physician in an official
capacity for the sake of medical assistance (Pahl: 220-221; Walters 1987: 169- 175). This is in
conjunction with one provision of the Hippocratic Oath: "Whatever I see or hear, professionally
or privately, which ought not to be divulged, I will keep secret and tell no one." The practical
function of confidentiality in a physician-patient relationship underscores the confidence and
trust that the patient has for the physician. With this feeling of confidence, the patient is not
reluctant but cooperative in giving personal information to the physician. The moral issue of
confidentiality arises if and when there is a conflict between individual interest (i.e., patient's
interest) and the interest of society (i.c., the common good). The physician is placed in the
middle of a conflict between the interest of the individual and the interest of society. Doctors, for
example, are required by law to reveal certain information about their patients. This legal
obligation enjoins them to report the names of patients who are carriers of communicable
diseases (e.g., AIDS, syphilis, T.B.) to health departments. If the physician acts to protect the
patient's trust, then he is acting contrary to law; if he acts in accordance with the law, he violates
the confidence of his patient. It is argued, however, that confidentiality is not absolute. Under
certain conditions, it is better to violate it than to preserve it. Confidentiality can be violated if it is
necessary to produce conditions which will bring about happiness and well-being. Let us
consider these instances: If someone's life is in great danger, then confidentiality loses its
binding power Or, if the testimony of a physician is nervous to help establish the innocence of
someone who is being tried for the crime he did not commit, then charity demands that the
innocent party be protected and the secret be divulged. Physicians, it must oe

Four conditions may be cited to justify the violation of confidentiality:

(1) when keeping the secret would be detrimental to the common good;
(2) when the subject of the secret intends to inflict grave injury upon an innocent third party;
(3) when it is necessary for the subject of the secret to avert grave injury; and
(4) when it iS necessary for the one keeping the secret to avoid grave injury (Pahl;
Walters 170-173; Bittle: 360-R66).

9.9 Application of Ethical Theories

Natural law ethics maintains that each individual has an inherent worth, and so is entitled to
know the truth about himself or herself It recognizes, however, the superior knowledge of the
physician, who may perceive the best interest of the patient better than the patient himself.
Thus, natural law ethics considers the necessity of withholding information from the patient on
certain occasions for the patient's well-being (Pahl: 222-224). With regard to the issue of
confidentiality, natural law ethics perceives that the relationship between physician and patient
is one of trust and confidence. A physician therefore has a duty not to betray the confidence of
his/her patient. Such a relationship, however, is not sacred, and such a duty not absolute. If in
the physician's perception a greater wrong or evil will be committed by not divulging what the
patient has confided, then by all means the physician has a duty to break that confidence. To
illustrate, the physician's testimony is needed to acquit the patient from a heinous crime he/she
did not commit; it is the physician's duty to make his/her testimony available, even if by doing so
the patient's secrets will be divulged. With respect to Ross's ethical principles, it would seem
that between two conflicting prima facie duties-the physician's duty to the patient and to the
state-the latter appears to be more stringent than the former. Hence, it becomes the physician's
duty to preserve the interest of society or to protect the common good. The same holds true for
truth-telling. If the physician honestly believes that withholding the information would be in the
best interest and well-being of a particular patient, then it becomes the physician's actual duty to
withhold the information. Kantian ethical precepts regard truth-telling and confidentiality as
absolute. In the physician-patient relationship, the former is under obligation to preserve
confidentiality because keeping promises is an absolute duty. In the matter of truth telling, the
categorical imperative rules out lying; a patient is a person who is entitled to receive information
about his/her condition, no matter how painful it may be.

Under the moral principles of situationism, one should consider the circumstances prevailing
in a particular situation. Whatever these circumstances are, however, one should make one's
decision in the name of agapeic love or concern for the welfare of the patient. Would it do the
patient more good than harm? Then, the expediency of the given situation should be one's
guide in making a decision.
The Moral Issue of Patients' Rights
Rights are necessary because every individual lives in a community of persons in relation. "No
man is an island," so the saying goes (Merton 1967: 9-17). Man is a being-with-others in the
world. For this reason, human life is more meaningful and worth living only in the presence and
help of others, in communion with others, and for the benefit of others. This holds true for all
kinds of human relationships, including physician-patient relationships. A patient, like the
physician, is an individual human being endowed with reason and freedom. As such, he/she
enjoys natural and inalienable rights, such as the right to life and the right to privacy, among
others.

10.1 Meaning of Patients' Rights

What is meant by patient's right? In the medical context, a patient's right means the moral
and inviolable power vested in him as a person to do, hold, or demand something as his own
(Bittle: 276, 303; Feinberg: 38-44; Shannon and Digiacomo: 145-153). By nature, every person
enjoys a moral and inviolable power (i.e., right) to do, hold, enjoy, and exact those things proper
to one's whole being. Every right in one individual involves a corresponding duty in others to
respect this right and not to violate it. As the patient enjoys some rights, for example, so the
doctor must respect these rights. Duty, therefore, is the correlative of right. A right is something
mine or yours, something that belongs to a person by nature; it is sometimes, but not always,
reinforced by law. Hence, everyone ought to respect another person's right. The moral
oughtness (or obligation) to do or omit something in favor of another according to the demands
of strict justice is known as duty (Bittle: 277; Shannon 1987: 14-16). From the foregoing, the
patient has the right to do, hold, or demand something, it is the duty of the physician not to
interfere with this right; rather, he has the obligation to perform or omit an action corresponding
to the patient's right. This obligation arises from strict justice-i.e., giving the patient his own due
by nature. Only in this way can equality between one person and another—which is the essence
of justice-be realized and established.

10.2 Types of Patients' Rights

The right to self-determination (also known as the principle of autonomy) mentioned in
Chapter One as one of the major themes in bioethical literature, is the central element in the
moral issue of patients' rights. The patient, as an individual person, has the moral right to
determine what is good for himself. This right is an important consideration in the discussion of
patients' rights in the medical context (Beauchamp and Childress 1979:62-94; Varga: 102-103;
Beauchamp and Walter: 134-137; Pahl:240-264):
(1) right to informed consent;
(2) right to informed decision;
(3) right to informed choice; and
(4)right to refusal of treatment.

Right to informed consent. The patient has the right to receive all necessary information
concerning diagnosis and treatment in order to be able to give consent based on his/her value
system, "Informed consent" refers to the knowledge or information about and the consent to a
particular form of medical treatment, before that treatment is administered. The information
should include the risks and advantages of any medical treatment that concerns the patient.

Right to informed decision. Information and understanding are necessary for genuine
deliberation. The patient cannot make a moral decision unless these two important elements are
present. "Informed decision" refers to the necessary information of and decision on a medical
treatment before the latter is carried out. The patient must be informed about the whole process
and must understand what this information pertains to so that an appropriate moral
decisionmcan be arrived at.

Right to informed choice. "Informed choice” refers to the necessary information a patient
should know about a medical treatment or experiment so that a moral choice can be made. The
patient has the right to be informed about all possible alternative courses of action to be taken,
together with the possible consequences. In reality, however, “informed consent, decision and
choice" go together in moral decision-making. As soon as the patient has been informed about
what the process involves and has understood it, he/ she will either consent to it or will not.
Whichever is the case, a decision is made, and whatever decision arrived at becomes the
patient's moral choice. In short, as the patient consents to undergo treatment, he/she decides
on it, as the patient makes a decision, he/she makes a choice between two or more alternatives.
Thus, the emphasis on informed consent" involves the information and agreement or
disagreement, consent or non-consent; "informed decision," the information and the decision
made; and informed choice," the information and the choice taken from among several
alternatives.

Right to refusal of treatment, In conjunction with the "Statement on a Patient's Bill of Rights"
presented by the American Hospital Association, 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"
(Beauchamp and Walters: 140; Beauchamp and Childress: 82-84). In many instances, a patient
may refuse medical treatment because their religious convictions prohibit them from doing so
(e.g., a patient who is a member of a particular set may refuse to undergo blood transfusion).
Many regard this right

10.3 Four Major Elements of Informed Consent

1. Competence. This refers to a patient's capacity for decision- making (Shannon: 1013; Beau
champs and Childress: 66-82). One is considered competent when (a) one has made a decision
(i.e., one can choose between alternatives); (b) one has the capacity to justify one's choice (i.e.,
give reasons for one's choice)—competence here requires some process of deliberation,
justification, and an articulation of why one has made this particular choice; (c) one does not
only justify one's choice but does so in a reasonable manner.

2. Disclosure. This refers to the content of what a patient is told or informed about during the
consent negotiation. The patient must be informed and must understand the information
concerning medical treatment to be undertaken, so that a moral decision can be made. The
disclosure of the information must be conducted in such a way that the patient understands the
whole process and is aware of the possible outcomes of his/her moral choice. Should there be a
language barrier between the physician and the patient, an interpreter might be consulted to
communicate the pertinent information.

3. Comprehension. This refers to whether the information given has been understood. The
disclosure of information is not enough; equally important is the comprehension of that
information. If the patient does not understand what he/she has been told, then information has
not been relayed at all. Health care professionals have a professional language and so they are
expected to translate their jargon so that it will be intelligible to their patients. They must be
sensitive to their patients' needs.

4. Voluntariness. This means that consent must be voluntary. The patient must of his own free
will agree to become a research subject, as the case maybe. He/she must make a choice
without being unduly pressured by anyone else. Being free in making a decision means that the
patient owns the decision, that the decision is the patient's alone, that the patient has chosen
the option based on the information disclosed to him/her.

104 Limitations of a Patient's Rights

1. Patients' rights do not include the right to be allowed to die (Hegland 1981: 266-272). Under
the concept of personal paternalism, the physician may make the moral decision for and in
behalf of the patient who can no longer decide by and for himself, as in the case of a comatose
patient. It is the sworn duty of the attending physician to do whatever is medically possible to
save the patient's life.

2. A patient in a moribund condition does not possess the necessary mental or emotional
stability to make an informed choice. A dying patient, or one who lapses into unconsciousness,
becomes mentally incompetent to make a decision. In such a situation, the attending physician
may perform a paternalistic act for the well-being of the patient.

3. Patients' rights are not absolute. Paternalistic concern limits the competent adult patient's
freedom of choice (e.g., refusal of treatment) for his/her own good in order to prevent harm from
befalling that patient. This precept is enshrined in the Hippocratic Oath: "I will apply dietetic
measures for the benefit of the sick according to my ability and judgment; I will keep them from
hain and injustice" (Beauchamp and Walters: 138).

10.5 In the Medical Context

In actual medical practice in the Philippines, there are two methods of obtaining informed
consent: First is a written consent, which is a consent form to be filled up and signed by a
patient as he/ she checks in for admission in a hospital. This practice, by all indications, appears
to be only perfunctory, because the clerk or admission personnel does not bother to explain the
content of the consent form to the patient. Usually, the latter will just sign it. The second is a
verbal consent. Whenever the patient verbally signifies
In emergency cases, however, the following types of patients need not require informed
consent:
(1) comatose or obtunded patients; (2) blind or illiterate patients; (3) underaged patients or
those unable to understand the circumstances; and (4) language-barrier patients.

In principle, the parents, immediate relatives, guardians, or next of kin should be informed when
the patient is comatose, blind or illiterate, underage or unable to understand the language of the
physician. In actual experience, however, the expediency of the situation may be such that the
physician, exerting a Solomon-like judgment, may not have time to consult the patient's next of
kin. In emergency situations, for instance, time is of the essence. An instant decision is a matter
of life and death. A physician's delayed action may be fatal to a particular patient

The Rights of Patients

Following are twelve rights of patients as they are documented in the American Hospital
Association's (AHA) "Statement on a Patient's Bill of Rights" (Beauchamp and Walters:
140-141; Pahl: . 244-245).

1. The patient has the right to considerate and respectful care.

2. The patient has the right to obtain from his physician complete current information concerning
his diagnosis, treatment, and prognosis in terms that the patient can be reasonably expected to
understand.
3. The patient has the right to receive from his physician information necessary to give informed
consent prior to the start of any procedure and/or treatment.
4. 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.
5. The patient has the right to every consideration of his privacy concerning his own medical
care program. (The issue here is one of privacy and simple courtesy.)
6. The patient has the right to expect that all communications and records pertaining to his care
should be treated as confidential
7. The patient has the right to expect that, within its capacity, the hospital must provide a
reasonable response to his/her request for services.
8. The patient has the right to obtain information regarding any relationship of his hospital to
other health care and educational instructions insofar as his care is concerned.
9. The patient has the right to be advised if the hospital proposes to engage in or perform
human experimentation affecting his/her care or treatment. The patient has the right to refuse to
participate in such research projects.
10. The patient has the right to expect reasonable continuity of care. (The patient has the right
to know in advance what appointment schedules and physicians are available and where.)
11. The patient has the right to examine and receive an explanation of the hospital bill,
regardless of source of payment.
12. The patient has the right to know what hospital rules and regulations apply to his/her
conduct as a patient.
107 Application of Ethical Theories
Natural law ethics regards the right to informed consent as morally legitimate Should a patient
decide to give his/her consent, it must be given freely and not the consequence of intimidation,
deception, or coercion. Under the principle of stewardship and the inviolability of life, natural law
ethics seems to be against the patient's right to refusal of treatment if the latter means an act of
commission and/or an act of omission which results in self-killing (suicide) or euthanasia.
Rawls's principles of justice do not allow medical treatments or experiments that violate freedom
which a patient is entitled to by virtue of being a member of society. All experiments and medical
treatments that make use of coercion and deception are ruled out. In as much as a patient has a
right to dec de what risks he/she is willing to undergo, voluntary informed consent is required of
all subjects of research. With Kant's ethical principle that we must always be treated as ends
and never only as means, patients must not be deceived by their physicians, no matter how
good their intentions may be. As rational and autonomous individuals, patients have a right to
be told what they are getting into so that they can decide whether they want to go through with it
or not.

Utilitarianism's principle of utility requires health care professionals to design medical treatment
in a way that minimizes suffering and harm. As far as informed consent is concerned.
utilitarianism does not seem to require it. If more social good is to be gained by making patients
research subjects without receiving their consent, then it is morally legitimate.