NURSING PRACTICE
(An attempt to explore the moral implications, responsibilities and values of the provision in section 28, article VI of RA 9173 which governs the practice of nursing in the Philippines - WN)
Scope of Nursing Practice (Section 28, Article VI)A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established; (b) establish linkages with community resources and coordination with the health team; (c) Provide health education to individuals, families and communities; (d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and (e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice; Provided, That this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization: Provided, finally, That the program and activity for the continuing professional education shall be submitted to and approved by the Board.” “A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age.” Comments: 1. Place of Republic Act No. 9173 to Nursing Profession a.) Every aspect of the practice of a profession is interwoven directly or indirectly with legal rules and sanctions. The examination and registration of applicants for the practice of a profession, the professional conduct of registered practitioners, the maintenance of ethical and technical standards of the profession, the illegal practice of unregistered persons are all governed by specific provisions of law. Every one is conclusively presumed to know the law and that ignorance of the law excuses no one from compliance therewith. (Civil Code of the Philippines, Article 3) b.) A professional practitioner must be required to know not only the general laws of the land but also the special law governing his profession. c.) A professional practitioner is considered above the ordinary citizen, both in the enjoyment of privileges and in the scope of his legal, social and moral responsibilities. d.) Nurses shall perform their professional duties in conformity with existing laws and generally accepted principles of moral conduct and proper decorum. (Amended Code of Ethics for Nurses as adopted by the PNA House of Delegates in 1982 and amended by the Board of Nursing in its Resolution No. 1955, series of 1989, approved by the General Assembly of Nurses on October 25, 1990) 2. Practice of Nursing initiates and performs nursing services to individuals, families and communities in any health care setting. a.) The Practice of Nursing is a not a money-making trade or a business but a profession dedicated to the ideal of service. b.) The Amended Code of Ethics for Nurses as adopted by the PNA House of Delegates in 1982 and amended by the Board of Nursing in its Resolution No. 1955, series of 1989, approved by the General Assembly of Nurses on October 25, 1990 enumerated the following guidelines which distinguish the Nursing profession from business: b.1) Solicitation and advertisement shall not be allowed for personal gains and other purposes that would be detrimental to the profession; b.2) They shall not demand and receive any commission, fee or any emolument for recommending or referring a patient to a physician, a co-nurse or another health care worker; neither shall they pay any commission, fee or other compensations to one referring or recommending a patient to them for nursing care. c.) Nursing Profession is a duty of public service, of which the emolument is a byproduct, and in which one may attain the highest eminence without making much money. 3. License to practice nursing a.) The license to practice nursing is never a vested right (RA 7164, sec. 13); it is but a privilege conferred by the State to persons of given qualifications and as such it may be withdrawn if the best interest of the government and its people so demands. b.) In the guidelines set by the Board of Nursing, Registered Nurses are required: b.1) to know the definition and scope of nursing practice which are in the provisions of R. A. No. 9173, known as the “Philippine Nursing Act of 2002” and Board Res. No. 425, Series of 2003, the “Rules and Regulations Implementing the Philippine Nursing Act. of 2002”, (the IRR); and b.2) to be aware of their duties and responsibilities in the practice of their profession as defined in the “Philippine Nursing Act of 2002” and the IRR. 4. Nursing Practice is a Noble Profession a.) God has entrusted to the nursing profession the noble mission to practice, protect, promote, safeguard, and enhance the quality of life … from the moment of conception to the moment of death and the nurses must carry it out in a manner worthy of their profession. This is mandated by their Code of Ethics, Republic Act 9173 section 28 and their Oath. b.) Profession has been defined in a general way as “a calling in which its members profess to have acquired special knowledge, by training or by experience or by both, so that they may guide or advice or serve others in that special field.” (Harold H. Titus, Ethics for Today, p. 296) 5. Nursing Practice includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age.” a.) Definition of Nursing Care (Section 28 (a), Article VI, Republic Act No. 9173) b.) Caring b.1) Caring is considered by many nurses to be an essential aspect of nursing practice. Madeleine Leininger (1984) states that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing. She says that there can be no cure without caring, but that there may be caring without curing. b.2.) Jean Watson (1985) described caring as the moral ideal of nursing; it involves the will to care and the intent to care. b.3.) Caring validates the humanness of both the care giver and the cared for. The practice of caring is central to nursing; it is grounded in a set of universal human values: b.3.1) compassion Compassion means literally to “suffer with.” Nurses are asked to go where it hurts, to enter the places where people suffer (during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age) and experience their pain and anguish. Compassion is not a purely human virtue, but rather a gift from God. Being compassionate remains the ethical foundation of all Christian behavior and most importantly of all nurses, “be compassionate as your Father is compassionate” (Lk. 6:36). Our God is a God WITH US. He is a God who wants to be with us in our pain, miseries, loneliness, and anguish. He wants to console and comfort us with His unpretentious presence. The mystery of God’s compassion has been revealed to us in the person of Jesus of Nazareth. All the actions and deeds Jesus performed were done out of compassion. The Hebrew word ‘splangchna’, used to describe Jesus’ feeling compassionate, refers to the entrails of the body, the guts, the place where our most intimate and intense emotions are located. The word comes from the Hebrew word “rachamin,” which means a movement of the womb of God, the center of his being (Proclaiming His Kingdom, John Fuellenbach, SVD, p. 111) The Nursing Profession, among other professions, is the best venue to follow the compassionate Lord. They offer people comfort and consolation in moments of illness, of real suffering, of mental anguish, of distress and loneliness. They stay, serve and care for people from all walks of life even if they do not know them; they suffer with them in their predicaments without accusing them, or without moralizing anyone; and they are just there simply as companions … as friends. Question: In the performance of your duty in the hospital or in your COPAR, did you ever try to enter into other people’s experience of joy, success, pain, suffering or struggle? How does it feel? b.3.2) Altruism. It is a concern for the welfare and well-being of others. In Nursing Practice, altruism is reflected by the nurse’s concern for the welfare of patients, other nurses, and other health care providers. b.3.3) Autonomy. It is the right to self-determination. Nursing Practice reflects autonomy when the nurse respects patients’ rights to make decisions about their health care. b.3.4) Human Dignity. It is respect for the inherent worth and uniqueness of individuals and populations. In Nursing Practice, human dignity is reflected when the nurse values and respects all patients and colleagues. b.3.5) Integrity. It is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is reflected in Nursing Practice when the nurse is honest and provides care based on an ethical framework that is accepted within the scope of nursing practice. b.3.6) Social justice. It is upholding moral, legal, and humanistic principles. This value is reflected in Nursing Practice when the nurse works to ensure equal treatment under the law and equal access to quality health care. c.) Conception c.1.) Questions: c.1.1) As nursing student, what do you understand by conception? c.1.2) As nursing student, how do you exercise nursing care during conception? c.1.3) What method of family planning do you promote? If artificial method, do you educate the users of its ill-effects and damaging consequences? c.1.4) If the method that Ateneo de Davao University is promoting or if the method you believe should be promoted is contradicting the method of the government, which of the two should prevail? c.2) Definition: c.2.1) Medical Definition: It is the act of becoming pregnant. Pregnancy, in Medical definition, occurs upon conception and before implantation of the embryo into the uterus (not after implantation) c.2.2) Civil Code Art. 283: “The civil personality of the child shall commence from the time of his conception. Its computation is from the birth of the child, and by counting backwards if the last sexual intercourse occurred within the period which is the first 120 days of the 300 days immediately preceding the birth.” c.2.3) Catholic Church: It is the union of egg and sperm cells. c.3.) During conception, two basic principles come into conflict: c.3.1) value of life principle = relation of the unborn life to the life of the Mother; c.3.2) Principle of individual freedom = Mother’s right over her own body, procreativity and life. Pro-Life. The conceptus has an absolute right to life from the moment of conception onward; Pro-Choice. Women have absolute rights over their own bodies. “As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death.” Comments: A. Questions: 1. Why should nurses promote health and prevent illness of people? 2. How should nurses treat patients in a “vegetative state”? 3. How can nurses restore health, alleviate suffering of patients, and provide peaceful death to the dying? 4. Is the withdrawal of nutrition and hydration an act of providing peaceful death to the patient? Why? B. Catholic Church Teaching for Health Care Services 1. Well-being of the whole person a. Christ's redemption and saving grace embrace the whole person, especially in his or her illness, suffering, and death. The Catholic health care ministry faces the reality of death with the confidence of faith. In the face of death—for many, a time when hope seems lost—the Church witnesses to her belief that God has created each person for eternal life. Above all, as a witness to its faith, a Catholic health care institution will be a community of respect, love, and support to patients or residents and their families as they face the reality of death. What is hardest to face is the process of dying itself, especially the dependency, the helplessness, and the pain that so often accompany terminal illness. One of the primary purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it. Effective management of pain in all its forms is critical in the appropriate care of the dying. b. The truth that life is a precious gift from God has profound implications for the question of stewardship over human life. We are not the owners of our lives and, hence, do not have absolute power over life. We have a duty to preserve our life and to use it for the glory of God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome. c. Suicide and euthanasia are never morally acceptable options. The task of medicine is to care even when it cannot cure. The use of life-sustaining technology is judged in light of the Christian meaning of life, suffering, and death. Only in this way are two extremes avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death. d. While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community. e. The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology. Therapeutic procedures that are likely to cause harm or undesirable side-effects can be justified only by a proportionate benefit to the patient. 2. Moral obligation of a Person a. A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community. b. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community. c. “A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.” (See Directives 32 and 58 of the Ethical and Religious Directives of Catholic Health Services, at http://www.nccbuscc.org/bishops/directives.htm and http://www.embracingourdying.com/articles/departures.html) 3. Person in “Vegetative State” (excerpted from the Allocution of the late John Paul II on Nutrition and Hydration) a. With deep esteem and sincere hope, the Church encourages the efforts of men and women of science who, sometimes at great sacrifice, daily dedicate their task of study and research to the improvement of the diagnostic, therapeutic, prognostic and rehabilitative possibilities confronting those patients who rely completely on those who care for and assist them. The person in a vegetative state, in fact, shows no evident sign of self-awareness or of awareness of the environment, and seems unable to interact with others or to react to specific stimuli. b. The term permanent vegetative state has been coined to indicate the condition of those patients whose "vegetative state" continues for over a year. Actually, there is no different diagnosis that corresponds to such a definition, but only a conventional prognostic judgment, relative to the fact that the recovery of patients, statistically speaking, is ever more difficult as the condition of vegetative state is prolonged in time. However, we must neither forget nor underestimate that there are well-documented cases of at least partial recovery even after many years; we can thus state that medical science, up until now, is still unable to predict with certainty who among patients in this condition will recover and who will not. c. The adjective "vegetative" (whose use is now solidly established) as applied to the sick as such, actually demeaning their value and personal dignity. In this sense, it must be noted that this term, even when confined to the clinical context, is certainly not the most felicitous when applied to human beings. In opposition to such trends of thought, I feel the duty to reaffirm strongly that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a "vegetable" or an "animal". Even our brothers and sisters who find themselves in the clinical condition of a "vegetative state" retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help. d. The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery. e. I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering. f. The obligation to provide the "normal care due to the sick in such cases" (Congregation for the Doctrine of the Faith, Iura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical Council "Cor Unum", Dans le Cadre, 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, n. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission. g. In this regard, I recall what I wrote in the Encyclical Evangelium Vitae, making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (n. 65). h. Considerations about the "quality of life", often actually dictated by psychological, social and economic pressures, cannot take precedence over general principles. First of all, no evaluation of costs can outweigh the value of the fundamental good which we are trying to protect, that of human life. However, it is not enough to reaffirm the general principle according to which the value of a man's life cannot be made subordinate to any judgment of its quality expressed by other men; it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients i. It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition. In these situations, then, spiritual counselling and pastoral aid are particularly important as help for recovering the deepest meaning of an apparently desperate condition. j. Distinguished Ladies and Gentlemen, in conclusion I exhort you, as men and women of science responsible for the dignity of the medical profession, to guard jealously the principle according to which the true task of medicine is "to cure if possible, always to care". As a pledge and support of this, your authentic humanitarian mission to give comfort and support to your suffering brothers and sisters, I remind you of the words of Jesus: "Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me" (Mt 25: 40). In this light, I invoke upon you the assistance of him, whom a meaningful saying of the Church Fathers describes as Christus medicus, and in entrusting your work to the protection of Mary, Consoler of the sick and Comforter of the dying, I lovingly bestow on all of you a special Apostolic Blessing. (ADDRESS OF JOHN PAUL II TO THE PARTICIPANTS IN THE INTERNATIONAL CONGRESS ON "LIFE-SUSTAINING TREATMENTS AND VEGETATIVE STATE: SCIENTIFIC ADVANCES AND ETHICAL DILEMMAS", Saturday, 20 March 2004) C. Church Teaching On the Duty to Preserve Life, Forgoing Nutrition and Hydration, and Euthanasia 1. The Duty to Preserve Life a. In the Roman Catholic tradition, human life is regarded as sacred from the moment of conception until natural death because it is created and given to us by God. For this reason, we have a duty to protect and preserve our lives. Yet this duty is not absolutely binding under all circumstances because we know that our ultimate end lies in eternal life with God. In the well known words of Pope Pius XII: "A more strict obligation would be too burdensome for most people and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends" ("The Prolongation of Life," November 24, 1957). Similarly, Pope John Paul II in Evangelium Vitae (1995) observes that "it is precisely this supernatural calling which highlights the relative character of each individual's earthly life. After all, life on earth is not an 'ultimate' but a 'penultimate' reality" (Introduction, Section 2). b. In light of this belief, it has been widely accepted among Catholic moralists from the sixteenth century onward that one need only employ "ordinary" means of preserving life, but not those deemed "extraordinary," by which is meant measures that fail to offer a proportionate hope of benefit or impose excessive burdens. This teaching is affirmed in the Catechism of the Catholic Church (1994): "Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of 'over-zealous' treatment. Here one does not will to cause death; one's inability to impede it is merely accepted" (#2278). 2. Proportionate and Disproportionate Means a. When assessing which means are "ordinary" and which are "extraordinary" (or "proportionate" and "disproportionate," which is the language most often used today) the focus, according to traditional moralists, is not on how basic, simple, usual, or easily available the means are, but rather on what effect the means have, primarily on the patient, but also on the patient's family and on the community. b. The most basic and simple means can be extraordinary or disproportionate if they offer no hope of benefit to, or impose excessive burdens upon, the given patient. In other words, no means can be considered proportionate or disproportionate in themselves, but only in relation to the condition of the patient, holistically considered. c. In the Vatican Declaration on Euthanasia (1980) we read: "It will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources." d. The late Pope John Paul II states in his 1995 encyclical letter Evangelium Vitae: "Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement." (See also the United States Conference of Catholic Bishops' Ethical and Religious Directives for Catholic Health Care Services (2001), directives 56 and 57.) e. In the Catholic tradition, it is morally permissible to take into account the effects of treatment upon family members and the community. For example, the Vatican Declaration on Euthanasia states: "This rejection of a remedy is not to be compared to suicide; it is more justly to be regarded as a simple acceptance of the human condition or a desire to avoid the application of medical techniques that are disproportionate to the value of the anticipated results or, finally, a desire not to put a heavy burden on the family or the community." (See also the Ethical and Religious Directives, directives 56 and 57). 3. Nutrition and Hydration a. Although the traditional moralists did not have to contend with questions about feeding tubes, they did consider the moral obligation one has to preserve one's life with food and fluids. It is not surprising that even ordinary food and fluids could be forgone if they failed to provide a proportionate hope of benefit or imposed excessive burdens. Dominican moralist Francisco De Vitoria (1486-1546) makes this clear when he argues that "if the depression of spirit is so low and there is present such consternation in the appetitive power that only with the greatest of effort and as though by means of a certain torture, can the sick man take food, right away that is reckoned a certain impossibility, and therefore he is excused, at least from mortal sin, especially where there is little hope of life or none at all." b. De Vitoria's views were not unique. They were held by moralists down through the centuries as well as by contemporary moralists. c. It should be noted here, however, that since the 1980 Vatican Declaration on Euthanasia, a debate has ensued within the church regarding how to consider artificial nutrition and hydration. Some propose that artificial nutrition and hydration are basic care and, therefore, ordinary and morally obligatory as long as they can be assimilated by the body and bring comfort to the person who is imminently dying. (See, for example, the Pontifical Council on Health Affairs, "Questions of Ethics Regarding the Fatally Ill and Dying," 1981; the Pontifical Academy of Sciences, "Report of the Pontifical Academy of Sciences on the Artificial Prolongation of Life," 1985; the New Jersey Catholic Conference, "Providing Food and Fluids to Severely Brain Damaged Patients," 1987; the Pennsylvania Catholic Conference, "Nutrition and Hydration: Moral Considerations," 1992; United States Conference of Catholic Bishops Committee on Pro-Life Activities, "Nutrition and Hydration: Moral and Pastoral Reflections," 1992.) 4. Euthanasia a. The traditional moralists made a clear distinction between allowing to die (i.e., forgoing extraordinary or disproportionate means where death is foreseen but not directly intended) and direct killing or euthanasia. The former is morally permissible; the latter is not. John Paul II reiterates the distinction in Evangelium Vitae, echoing the Declaration on Euthanasia b. Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering. "Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used. Euthanasia must be distinguished from the decision to forego so-called "aggressive medical treatment," in other words, medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family (section 65). Moral Values and Responsibilities of a Nurse (Section 28, Article VI RA 9173) A student nurse who desires to become a professional nurse must constantly be of good moral character. The moral character she/he displayed when she/he was in college and when she/he applied for admission to take board exam must be maintained incessantly. Otherwise, her/his privilege to practice nursing may be withdrawn from her/him. Its continued possession is also essential for remaining in the nursing practice. Morality: “Morality is that quality of a human act towards the objective last end of human action. It consists in the relation existing between human acts and the norm of morality” (Ethics, Paul Glenn, 1965 Ed., P. 100) Norm of Morality: “The norm of Morality is, remotely and ultimately (but primarily), the Eternal Law; while proximately (but secondly) it is conscience. In reality, then, there are not two norms but only one; for conscience is the judgment of human reason recognizing and applying the Eternal Law in individual human acts.” “A human act, to be a morally good act, must be found in agreement with the Norm of Morality on all three points, i.e./ it must be good in itself or objectively, in its end, and in its circumstances. A human act is evil if it fails to conform with the Norm of Morality in any one of the points or determinants, viz (a) the act itself (i.e. the object); (b) the end of the agent; (c) the circumstances other than the end of the agent.” (Ethics, Paul Glenn, 1965 Ed., P. 103) Instances when Moral conduct is absent: 1. Moral Turpitude. The term “turpitude” means everything done contrary to justice, honesty, modesty, or good morals. (Henry Campbell Black, Black’s Law Dictionary, 4th ed., p. 1686). The term “moral turpitude” may be defined as “an act of baseness, vileness or depravity in the private and social duties which a man owes to his fellow men, or to society in general; an act contrary to the accepted and customary rule of right and duty between man and man.” (Ibid., p. 1160) 2. Immoral Conduct. An immoral conduct is a personal behavior that is contrary to good morals or inconsistent with the rules and principles of morality; it is a behavior or deportment which is harmful to the public welfare according to the standards of the community. (Black, p. 885) 3. Dishonorable Conduct. A dishonorable conduct is a personal behavior that is disreputable, discreditable, disgraceful, shameful, or scandalous. It is that conduct of a person which stains his character or lessens his reputation. (Webster’s Universal Dictionary, Vol. p. 488) Application to Nursing Act: The nursing act provides that the registration certificate of a registered nurse may be revoked by the Board if he/she is guilty of immoral or dishonorable conduct. (RA, no. 7164, sections 20 and 21) Does the term, immoral conduct, is referring only to immoral conduct committed by a nurse in the exercise of her/his profession, or to immorality in general? The “immoral conduct” mentioned in section 20 is likewise one of the grounds included in section 21 of the act for the revocation of a certificate of registration of a nurse. It is evident, therefore, that the immoral conduct contemplated by law as a ground for the revocation of a nurse registration certificate is one committed by the nurse prior to her registration as such, that is, an immorality committed by him or her not in connection with the practice of nursing. Moreover neither section 20 nor 21 of RA 7164 provides that such immoral conduct must be one committed by a nurse in the course of his/her professional practice. By necessary implication, it follows that the immoral conduct contemplated by the Nursing Act as ground for revocation or suspension of a nurse certificate is immorality in general. Moral Frameworks: Moral theories provide different frameworks through which nurses can view and clarify disturbing client care situations. Nurses can use moral theories in developing explanations for their moral decisions and actions and in discussing problem situations with others. Three types of moral theories are widely used, and they can be differentiated by their emphasis on either of the following: consequences, principles and duties, or relationships. 1. Consequence-based theories (Teleological). These look to the consequences of an action in judging whether that action is right or wrong. Utilitarianism, one form of consequentialist theory, views a good act as one that brings the most good and the least harm for the greatest number of people. This is called the principle of utility. This approach is often used in making decisions about the funding and delivery of health care. 2. Principle-based theories (deontological). These emphasize individual rights, duties and obligations. The morality of an action is determined not by its consequences but by whether it is one according to an impartial, objective principle. 3. Relationship-based Theories (Caring). These stress courage, generosity, commitment and the need to nurture and maintain relationships. Unlike the two preceding theories, which frame problems in terms of justice (fairness) and formal reasoning, caring theories (Watson, 1997) judge actions according to a perspective of caring and responsibility. Principles-based theories stress individual rights, but caring theories promote the common good or the welfare of the group. Caring is a central force in the client-nurse relationship, and a force for protecting and enhancing client dignity. For example, guided by this framework, nurses use touch and truth telling to affirm clients as persons, not objects, and to help them make choices and find meaning in their illness experiences. I firmly believe that caring is the central goal for nursing practice as well as a basis for nursing morality. A moral framework guides moral decisions, but it does not determine the outcome. Application: A frail, elderly client has insisted that he does not want further surgery, but the family and surgeon insist. Three nurses have each decided that they will not help with the preparations for surgery and that they will work through proper channels to try to prevent it. Using consequence-based reasoning, Nurse A thinks, “Surgery will cause him more suffering; he probably will not survive it anyway; and the family may even feel guilty later.” Using principles-based reasoning, Nurse B thinks, “This violates the principle of autonomy. This man has a right to decide what happens to his body.” Using caring-based reasoning, Nurse C thinks, ”My relationship to this client commits me to protecting him and meeting his needs; and I feel such compassion for him. I must try to help the family understand that he needs their support.” Moral Responsibilities: Nursing students and professional nurses have the moral responsibility to examine the values they hold about life, death, health, and illness. 1. One strategy for gaining awareness of personal values is to consider whether one’s attitude about specific issues such as abortion or euthanasia is in consonance with the teaching of the Scripture and of the Church. 2. Another strategy to clarify one’s values was developed by Raths, Harmin and Simon in 1978 (p. 47). They described a “valuing process” of thinking, feeling and behavior that they termed “choosing, prizing, and acting.” a. choosing (cognitive) – beliefs are freely chosen without outside pressure from among alternatives after reflecting and considering consequences. b. Prizing (affective) – chosen beliefs are prized and cherished c. Acting (behavioural) – chosen beliefs are affirmed to others, incorporated into one’s behavior, and repeated consistently in one’s life Application: To perform effective Nursing Practice and Care, nursing students and professional nurses should need to identify clients’ values as they influence and relate to a particular health problem. When clients hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as an intervention. The following process may help the nurse clarify the values of his/her client: 1. List Alternatives. Make sure that the client is aware of all alternative actions. Question to ask, are you considering other courses of action? 2. Possible Consequences of the Choice. Make sure the client has examined or thought about possible results of each action. Question to ask, what do you think you will gain from doing that? Or what benefits do you foresee from doing that? 3. Choose freely. Determine whether the client choose freely. Question to ask, Did you have any say in that decision? Or Do you have a choice? 4. Feeling about the choice. Determine how the client feels because some clients may not feel satisfied with their decision. Question to ask, How do you feel about the decision or action? 5. Act on the choice. Determine whether the client is prepared to act on the decision. Question to ask, will it be difficult to tell your wife about this? 6. Act with a pattern. Determine whether the client consistently behaves in a certain way. Question to ask, how many times have you done that before? Or would you act that way again? When implementing these steps to clarify clients values the nurse assists the client to think each question through, but does not impose his/her personal values. The nurse offers an opinion only when the client asks for it. |
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