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The place of principles in bioethics In the realm of health care it is difficult to hold rules or principles that are absolute.

This is due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several principles that seem to be applicable in many situations. Even though they are not considered absolute, these rules and principles serve as powerful action guides in clinical medicine. Over the years, these moral principles have won a general acceptance as applicable in the moral analysis of ethical issues in medicine. How do principles "apply" to a certain case? Principles in current usage in health care ethics seem to be of self-evident value. For example, the notion that the physician "ought not to harm" any patient appears to be convincing to rational persons. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must indicate a willingness to accept the proposed treatment, if the patient is cognitively capable of doing so. Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness. One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery. In other words, we have a "prima facie" duty to both benefit the patient and to "avoid harming" the patient. However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher W.D. Ross claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's actual duty is determined by weighing and balancing all competingprima facie duties in any particular case. What are the major principles of medical ethics? The commonly accepted principles of health care ethics include: 1. 2. 3. 4. the the the the principle principle principle principle of of of of respect for autonomy, nonmaleficence, beneficence, and justice.

1. Respect for Autonomy

Any notion of moral decision making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, mean that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding health care. (See also Informed Consent.) Illustrative Cases 2. The Principle of Nonmaleficence The principle of nonmaleficence requires of us that we not intentionally create a needless harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligence if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well. In a professional model of care one may be morally and legally blameworthy if one fails to meet the standards of due care. The legal criteria for determiningnegligence are as follows: 1. 2. 3. 4. the the the the professional must have a duty to the affected party professional must breach that duty affected party must experience a harm; and harm must be caused by the breach of duty.

This principle affirms the need for medical competence. It is clear that medical mistakes occur, however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm. Illustrative Cases 3. The Principle of Beneficence The ordinary meaning of this principle is the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as self-evident and are widely accepted as the proper goals of medicine. These goals are applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large. It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual. Whereas, beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, the physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.

Illustrative Cases 4. The Principle of Justice Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined. It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as a criteria for distributive justice, including the following: 1. 2. 3. 4. 5. 6. to to to to to to each each each each each each person person person person person person an equal share according to need according to effort according to contribution according to merit according to free-market exchanges

John Rawls and others claim that many of the inequalities we experience are a result of a "natural lottery" or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay.

A theory of biomedical ethics I take to be a comprehensive, systematic account of a general approach to addressing ethical questions in the medical or biological sphere. It may be from a religious tradition or a secular world view; it may be articulated by health professionals or by medical lay people. It may be limited to the medical sphere (as the Hippocratic ethic seems to be) or, more plausibly embedded in a more general ethical theory (such as Kantianism, utilitarianism, or Talmudic ethics). If this is true, then medical or biomedical ethical theories are not limited to those articulated by physicians. Some medical ethical theories may be the exclusive province of physician groups--as the Hippocratic and World Medical Association's are--if one can call these approaches "systematic theories." Others go beyond theories generated by professional physician groups in several ways. First, not all medicine is practiced by physicians. "Medicine," taken in its broad sense, involves other professions-nursing, pharmacy, dentistry, and, especially in some non-Western cultures, shamans, "medicine men," or faith healers. A true biomedical ethic systematically addresses the norms of character and conduct for these other medical professional roles. Beyond that, we must recognize that most medical decisions in

any culture are made by lay people: individuals concerned about their own health, lay surrogates, spiritual advisors, and public policy-makers such as judges and legislators. From this perspective professionally-articulated physician codes are one sub-species of professionally articulated theories of biomedical ethics, which are, in turn, a species of the genus of theories of biomedical ethics. The most powerful and complete biomedical ethical theories have often been layarticulated, derivative from larger, more coherent systems of ethical thought--religious or secular. Thus, to mention just one example, Roman Catholic moral theology presents a comprehensive ethical system for Catholic lay decision-making as well as health professional behavior articulated by a group of theological professionals who are medical lay persons. They draw on a more comprehensive epistemological and normative framework of Catholicism (1). Likewise, the Caraka Samhita presents the outlines of a comprehensive system grounded in the Vedic belief system and concepts (2). Secular philosophical systems also have the potential of articulating a bioethical component to their theories. Secular Western liberalism has produced what is probably the most aggressive and successful challenge to Hippocratism as a bioethical theory (3). It includes concepts such as autonomy, equality of human worth, and respect for the individual that are absent from traditional professionally-articulated bioethical theories. Other secular thought systems including Marxism (4), libertarianism (5), and feminist thought (6) also have the potential for generating bioethical theories. When I published A Theory of Medical Ethics in 1981 (7), I hoped to stimulate a movement among biomedical ethical theorists to articulate descriptions of these comprehensive theories. I admit that one of my chief purposes was to make clear to all--especially to physicians--that the old Pythagorean/Hippocratic ethical theory was only one among many competing theories and that it was, indeed, an anemic, implausible, and even dangerous ethical position, which modern human beings ought to find indefensible and offensive when compared to the richer, more complete, and more sophisticated ethical theories available. Any general bioethical theory must address five key questions. Therefore, any theorist must speak to when providing a full and systematic account of a particular theoretical approach to bioethics. Since this paper was first presented as part of a program focusing on the theme "Is Bioethics Love of Life?" I will illustrate how these elements of theory are relevant to the concept of "love" attempting to show how the concept of "love" functions as an ethical category and how it might fit into a general bioethical theory. Five Central Questions for Bioethical Theories As long ago as the mid-1970s I suggested that any comprehensive bioethical theory ought to address five critical questions (8). Let me put these forth as a guide for future theorizing. At the same time, I shall comment on what I believe are the prospects for international and cross-cultural agreement on the answers to these questions. What Is the Metaethic of the Theory? First, any theory must have a metaethical framework for understanding the meaning of the terms it uses and for explicating how one can have ethical knowledge. Religious bioethical theories have a metaethic that comes pre-formulated. The major world religions provide something of a cosmology, a metaphysics, and a way of knowing. They all provide definitive sacred texts and theories of authority. Protestantism, for example, has a theological framework and, most importantly for modern medical ethics, a doctrine of the "priesthood of all believers" that affirms that every lay person has the capacity to know, understand, and interpret the moral norms without relying on a priestly authority (9). It also hold that the key texts belong in the hands of the lay person. I think it is quite clear that modern Western medical ethics--both religious and secular--is heavily dependent on these metaethical premises. The patient's rights movement

is little more than Protestant metaethics secularized and applied to medicine. Other theories incorporate other metaethics: Soviet era medical ethics with its reliance on the authority of the state and Confucianism with its emphasis on the wisdom of the great teachers are other examples (10). Many secular philosophical theories also provide metaethical systems that can be appropriated for a medical ethic: Kantianism's reliance on reason and the British empiricist tradition reliance on experience are two examples. Stoicism's turn to natural law theory is another. Even Hippocratism has its own metaethic. It traditionally has considered only the professional group to be capable of understanding and articulating the norms for physician conduct, a view compatible with the Hippocratic tradition's Pythagorean origins, but incomprehensible either by modern democratic theories of knowledge or by religious authoritarian epistemologies (11). Hippocratism is also characterized by the view that only medical professionals are capable of adjudicating disputes about physician conduct--what most of us would see as naive at best and simple in-group self-serving protection, at worst. These metaethical, metaphysical, and epistemological disputes have existed throughout history. I see no real hope that these questions will be resolved soon. Fortunately, it appears that it may be possible to reach convergence on the some other four great questions in ethical theory even if the metaethical issues are intractable. Normative Theory I: What Is the Axiology (Theory of Value)? Next come three core questions of any systematic bioethical theory--all at the level of normative ethics. These three questions spell out the content of the character and conduct that the theory requires. The first two may be as intractable as the metaethics. The third may turn out to be our best hope for crosscultural agreement. The first of the normative questions has to do with what is considered intrinsically valuable. It is the question of axiology. Almost all normative theories pay at least some attention to striving to produce good outcomes (12). Utilitarianism, for example, strives to maximize the aggregate net good; Thomistic Catholicism seeks to do good and avoid evil. Hippocratism commits the physician to maximizing the patient's welfare. This radical limitation of the good to that of the individual patient is unique in Hippocratic theory and extraordinarily controversial, especially in these days of managed care and health resource rationing. It would not only permit the individual physician to "game" the system by lying to an insurer, it would make such lying morally required (if it were necessary to benefit the patient). It would ban all systematic research conducted for the good of society. It would even proscribe public health efforts, especially those that came at the expense of a physician's patient--such as reporting a positive HIV diagnosis. Whatever version of the pursuit of the good that a theory commits to, it must have a notion of what counts as the good. It must incorporate a version of a desire satisfaction view, a preference theory, or perhaps, as most traditional religions do, an objective theory of the good. One of the great contributions of the modern period was the realization of how difficult it is for someone, especially a specialized professional, to know what will produce overall maximization of the good. Some Hippocratists short-circuit this problem by limiting the physician's attention to the "medical good." That, however, overlooks the fact that rational people are not interested in maximizing their medical good, at least when doing so comes at the expense of their overall good. All rational people will trade off some medical well-being for well-being in other spheres of life. Even more critically, even medical well-being is a complex concept. It includes prolongation of life, cure of disease, relief of suffering, and promotion of health in some mysterious combination. The important cases are those in which maximizing one dimension of medical well-being comes at the expense of another dimension, when relieving suffering

comes at the expense of prolonging life, for example. No rational person would maximize any one of these dimensions of medical well-being in all imaginable circumstances. One of the great contributions of medical ethical theory of the past twenty years has been the convincing demonstration that there is no way that the typical physician in the typical patient-physician relation can be expected to know what will best serve the interest of his or her patient. Thus even if it is morally correct for the physician to hold such a goal, it will be impossible to accomplish in the typical case. There is as little reason to expect international cross- cultural convergence on the theory of the good as there is on the metaethical questions. For those who remain committed to the idea that the physician's moral task is to maximize some entity's welfare, either the patient's or society's, this is a serious problem. For those more committed to patient autonomy and societal democratic decision-making, this may be of more marginal significance. They will see the health professional's moral duty to be the fulfilling of promises, the telling of the truth, or the following of just policy democratically determined rather than pursuing the good. Normative Theory II: What Counts as Virtue? The second major question in theory at the normative level is what should be considered praiseworthy character trait? This is often referred to as the theory of virtue (13). Regardless of what counts as good outcomes and what counts as right behavior, we often want to know what traits of character a theory affirms. For Plato the praiseworthy traits were wisdom, temperance, courage, and justice; for the Christian, Paul, they were faith, hope, and love or charity. But for other ethical systems other character traits predominate. For the "Islamic Code of Medical Professional Ethics," (14) there are seven virtues including kindness, mercy, patience, and tolerance.. For Homer the virtues included proper hatred of the enemy, the opposite of Christian ethics. They also included for women, proper subservience to husbands (15). There is more divergence in bioethical theory regarding the virtues than any other question. There seems to be little hope of resolving the controversy. Fortunately, for much of what an ethical theory is supposed to do--guide proper conduct--agreement on the virtues may be unnecessary. Within close-knit communities--the family, the religious group, or the small town--we rightly worry a great deal about manifesting the proper virtues. We want our children, clergymen, and neighbors to act from praiseworthy motivation, not merely to engage in the right action. However, much of ethics, especially at the crosscultural level, pertains to conduct among strangers. At this level, we are usually much more worried about what the stranger does rather than the disposition from which it is done. At most instilling a virtue becomes a cause to hope that right conduct will come more reliably. Given the enormous diversity over what constitutes the proper virtues from one culture to another, it may be hopeless to strive for international cross-cultural agreement. But it may not matter all that much anyway. Normative Theory III: What are the Principles of Right Conduct? The third question at the normative level of theory is in many ways the most critical. We would like to have some general norms for right conduct, norms that govern individual actions or rules that in turn govern actions. These norms are often called principles. When used in this technical way, a principle is not a value and it is not a virtue. It is a norm of right action, not an intrinsic good or a praiseworthy trait of character. Contrary to what some believe, there is no rule that there must be four principles. I favor seven in my theory (16); others support one (17), two (18), three (19), or five (20). It is at this point that bioethical theory comes much closer to convergence at the international level. Almost all medical ethical theories make room some place for doing good for patients and preventing harm to them (what in the jargon are called the principles of beneficence and nonmaleficence). Most theories also make room for some non-consequence-maximizing principles such as veracity, fidelity to

promises, and avoidance of killing of humans. Theories as diverse as the Islamic Code, Buddhist ethics, Talmudic law, and Engelhardtian libertarianism all make room for veracity or truth-telling. Most modern theories also include the principle of respect for autonomy. Different theories may get these principles into their system using different mechanisms. Some utilitarians, for example, do so through the use of rule-utilitarianism-a device that generates consequence-based rules regarding truth-telling, promisekeeping, and the like. Kantians may group several of these principles under the heading of respect for persons. Most theories also have some account of the way goods and harms should be distributed. This will appear under the rubric of the principle of justice. There is room for considerable disagreement at the cross-cultural level in exactly how these variables enter a normative theory of right action. Utilitarians may find most of them derivative from the principle of utility; the Dartmouth theorists derive them from nonmaleficence--the "do-no-harm-without-goodreason" principle." Some, express these in the language of human rights rather than as principles. One way or another, however, the content at the level of norms for right action is remarkably similar from one medical ethical system to another. Of course, there will continue to be differences at the margin, even some very important margins. Whether to make an exception to the avoidance of killing norm when the patient is suffering and voluntarily asks to be put out of his misery is one current controversy. What constitutes the proper pattern of distribution of the good in a theory of justice is another. However, we at least seem to have enough of a common vocabulary and an agreement on norms to be able to talk to one another and identify those marginal areas where we continue to disagree. The task seems much less formidable than trying to agree on the theory of the good or the theory of the virtues. To the extent that love is a virtue rather than an action norm, this will have important implications its place in theories of bioethics. What Is the Relation Between Principles and Cases? The fifth and final critical question in a bioethical theory is how the principles, the norms for right conduct, relate to individual instances of behavior. Here we are at the level of casuistry (21). One very popular view among physicians and undergraduate college students is that the principles, as abstract general action guides, must be brought to bear on each moral situation making a bold, independent judgment about what is the right action without having the principles mediated through rules that are binding at the level of individual instances of action. This view, sometimes called situationalism, evolved as a backlash to what many perceived as an excessively rigid conversion of the principles into rules of conduct. This is a device for handling potential conflict among duties, for example, when one has promised to tell a lie or when knows that speaking the truth will result in a killing. A variant of this approach is seen among some principlists including my colleagues at the Kennedy Institute, Tom Beauchamp and Jim Childress, who hold that when the principles conflict, there must be a balancing of the weightiness of the competing claims (22). The result may be an act-utilitarianism or act-deontology. Some who balance competing claims nevertheless give rules more status than mere guidelines. It can lead to a rule-utilitarianism or rule-deontology. Still others claim that these balancing approaches, even the approach that generates rules for a specific domain--sometimes called specification (23) --still permits too much bending of morality to the whim of the powerful. They claim that it would permit terribly offensive research using human subjects and grossly inequitable allocation of health resources, for example, if only the consequences to the society as a whole were good enough. A full theory of bioethics will have to provide an account of how to move from principles to cases (or perhaps from cases to principles and back again). On this final question, once again we have nothing like agreement internationally. We do not even have agreement domestically. There was a time when liberals

supported more situational approaches as a hedge against legalistic application of moral rules. More recently, the critics of establishment medicine from the radical left have turned hostile to act-utilitarian and act-deontological theories and specificationism, in favor of more old-fashioned rigid rule following, perhaps dressed in the respectable garb of the name given by philosopher John Rawls--the rules-ofpractice view (24). They fear that situationalism opens the door too wide for those in authority--such as physicians--to impose their tailor-made judgments on the powerless and weak to use them as research subjects, withhold the truth from them, and divert resources rightfully theirs to others of higher status who treatment can be deemed more useful to society. The case can be made that more rigorous commitment to the rules is really the more radical view. Only recently have we seen another potential reversal in this oscillation between the rule-followers and the case-by-case decision-makers as the contemporary feminist bioethicists have moved once-again for a more "relationship-oriented" derivation of what counts as morally right conduct. The Place of Love In Bioethical Theory I shall close with some final comments on how the concept of love fits into bioethics at the theoretical level. It is hard to imagine how love would play a role in any of the metaethical issues. Love does not tell us anything about the source or grounding of ethics. Nor does it provide an epistemology. Likewise, only by a stretch is love relevant to understanding the relation of principles to cases. Joseph Fletcher the onetime Anglican ethicist who developed a 1960s version of situationalism claimed that love could guide an individual to move directly from the principle of beneficence to the right action in the individual case (25). He led the charge against rule-based ethics. He seemed never to grasp that love could also push people to inappropriate, irrational action. The real issue is where love might fit among the three central questions of normative ethics. Does it have a role in value theory, virtue theory, or the theory of right action? Love is an ambiguous term. People can show love of things. They can love a food, a painting, or knowledge. Among the intrinsic values are pleasure, beauty, and knowledge. Here love seems to function merely as a synonym for "value" or "desire." When love is applied to a thing, it means nothing more than one places very high value on the thing. It is part of value theory. I think this applies to the idea of "love or life." (26) Love also relates to the way an individual interacts with another human. It describes a disposition, a character trait. We have already seen that one interpretation of it (the Greek agape) functions in Christian ethics as a virtue, indeed the most important virtue. The issue, however, is whether it plays a similar role in the virtue theory of other ethics. We have seen it was not on Plato's list of virtues. It is not a key virtue in the code of the International Organization of Islamic Medicine (27) and is not even mentioned in the Oath of the Islamic Medical Association of the USA and Canada (28). It is not in Confucian ethics; that tradition generally mentions humaneness, compassion, and sometimes filial piety (29). Buddhist or Hindu ethics do not include it either. It is not mentioned in any physician-generated medical ethic. The Hippocratic Oath mentions purity and holiness; The Percivalian Code, tenderness, steadiness, condescension, and authority; the World Medical Association, "conscience and dignity" (whatever those might mean). The Nazi physicians went so far as to berate Christian ethics, claiming that love of the genetically afflicted would contaminate the gene pool by preserving the lives of the unfit. New, feminist bioethical theory often emphasizes the virtue of "care." (30) A first question for us to address is whether the Christian virtue of love can be related to this virtue of care or to various other virtues such as compassion, benevolence, or humaneness. I do not see how these terms can be considered complete synonyms. If love has meaning for ethical systems other than the Christian ethic, we need to clarify what it could be and why these other virtue terms prevail.

More critically, if love is merely a virtue, it should only tell us what disposition or character trait of an actor is praiseworthy, not what behaviors are morally right or wrong. When Fletcher treated love and utility as synonyms, he was surely incorrect. Producing good outcomes-what is called for by the ethical principle of beneficence or utility-cannot be equated with acting lovingly. We know that because we know that someone can act so as to produce good outcomes in an unloving way. They may do so malevolently or merely because it promotes their own self-interest. They may even produce good outcomes by accident while trying to hurt someone. One may produce good results with evil intention or act in a loving way that results in nothing but harmful outcomes. Beneficence is a principle of right action, as are justice and the other principles. Love is virtue describing the character of the actor. They are logically independent, even if one who is loving may tend to be more inclined to engage in right action. Moreover, to the extent that the physician is a stranger to the patient (and perhaps the patient's culture), merely being loving may leave one without any guide for action because one may not know either what is utility maximizing or how the principle of utility relates to other ethical principles in the ethical system of the patient or the patient's culture. Love may be crucial in certain special medical relations within a Gemeinschaft, a small, closed community. Love in a medical setting among strangers may turn out to leave both physician and patient without action guides. Worse than that, if it gives the actors a sense that moral self-confidence, it could be dangerous. It could leave the actors feeling they need pay less attention to moral principles, rules, and codes, because if they have love, they have everything. ----Love, then, is an ethical concept closely related to only one of the five questions that any ethical theory must address. It is a candidate for the list of virtues. It is one possible answer to the question of what are morally praiseworthy traits or character or virtues? It seems to have little to do with the other four critical question s in bioethical theory. It does not tell us much about the meaning and grounding of ethical claims or how ethical truths can be known (metaethics). It is not an intrinsic good the way knowledge, beauty, holiness, or health might be. It is not a norm for right action. It describes not characteristics of actions that are morally right-making, but rather a trait of human character that, according to some ethical theories, is praiseworthy.

Van Rensselaer Potter's original concept of bioethics as a global integration of biology and values was designed to guide human survival. His attention to the creation of human knowledge and the incorporation of ecological concepts and values into medicine and health remain important, yet largely neglected, contributions deserving of further elaboration. Bioethicists should heed his warnings about unsustainable progress, particularly in health care systems, and work towards changing their behaviors. Incorporating life-affirming spiritual values and extending Potter's global bioethics to a deeper bioethics seem essential. The future of bioethics lies to a considerable degree in its past. The original formulation of bioethics by Van Rensselaer Potter included a profound commitment to the future (Potter 1971) that the world desperately needs bioethicists to rediscover. Our health care systems are unhealthy medically and morally. Bioethicists need to find the courage and wisdom to lead the revolution in organizational change and not be wedded to dysfunctional systems. This paper is a critique of the aspects of contemporary bioethics as a profession and a plea to make our thinking more global. It joins other attempts to revisit the past of bioethics to be constructively but strongly critical of its future, particularly its relationship to medicine and society (Stevens 2000). It also is consistent with those re-examining the future of

environmental ethics (McKim 1997; Sagoff 1991); the social aspects of environment (Marmot 1998); nature-based spirituality in bioethics (Kaebnick 2000); the healing power of nature (Frumkin 2001) and the ethics of public health (McMichael 2000).

The progress that humanity has developed in science, technology and genetic medical treatment during the last two decades of the century and this century have created a gap between the values ethical, legal, human and the same evolution of humanity. In a universal dilemma of ethics and bioethics in humanity, especially in the career of nursing because it carries a set of values in binding regulations, which may perhaps lead to contradictions. Within the power nurse is not free of this situation, since we are the people who remain in direct contact with the user and their needs and potential. Also, the nurse is part of the team research, of teaching and administration, making regulated progress of science, his commitment to humanity, to life with the environment, ie everything. The ethics and bioethics leads to pass to the nurse about the various fields either practical or theoretical, and that is where da-binding code of ethics also entails practice from the race in order to make the nurse faces several problems. 1.2 PRINCIPLES ETHICS To talk of ethics is important to have a vocabulary that can be understood, although some words have different meanings, provide written about ethics in the context where they can understand and discuss the ethical issue. Range: It means the independence of an individual to determine their own destiny in matters of health and disease. The respect for the autonomy of the client is fundamental to the practice of care medical and health professionals, are committed to respect the autonomy of the client. Beneficence: Is making actions positive help to others. It also helps when treatment decisions can be questioned for his risk. Nonmaleficence: It is to prevent injury or damage. Tension health ethics is not only do good but also the commitment to do no harm and in extreme cases strives to do the least damage possible. Justice: It refers to the equity and the task of health professionals to achieve justice in health care. Faithfulness: It is the agreement to keep promises, even in cases of disagreement with the decisions of the client, you must provide the necessary care. 1.3 ETHICAL ASPECTS All people need others throughout life. Dependency levels vary throughout the life cycle and function of living situations. The problems of health often involve higher levels of dependence, and respond to it is a fundamental part of the professional content of the nurses. One characteristic of sick people is that others see in them greater levels of dependency in the life of a person healthy. In turn, the dependence can be interpreted as a deficiency in the ability to make decisions, and empower people who are sick may be restricted, especially in situations of loss of health and contact with health framework. The autonomy of persons is frequently compromised in the life of the person when facing health problems, physical or mental disabilities. This is often compounded by adding see the difficulties of the process of aging. It may seem that decisions must be left in the hands of the family and professionals. To push the responsibility is to look professional care that any decision should have as objective to

preserve, promote and defend the good of the person treated. The human rights in the context of health are shared responsibilities of all professionals, require careful consideration of all those involved in the process of care. Finally be regarded as professional decision-making is highly influenced by the values of personal nurse and the emotions. Knowing your values, identify the emotions arising from the relationship with the patient and his family, is a prerequisite and essential to be able to understand the values and emotions of others. The nurse is professional and wing see is a person that can not forget. Neither can be neglected the stress and / or anxiety that leads to health and relationship decisions. The self-analysis and the analysis in the group help to differentiate the nurse as a person as a professional nurse, and therefore help to better focus on patient needs and not on the needs that the nurse assumes that the patient has. The interpretation of the demand for care and the planning of them must be as patient centered as possible, therefore, identify personal emotions help us be more objective and to listen more readily to the patient and family. Most people are ethical dilemmas, and create conflict between the ways of doing what is right. To be able to resolve an ethical problem, you must first understand the conflict that is occurring between different moral positions. Yet all of these different ethical positions derive from theories that can be based on the result or the duty or obligation, and theories relating to care. This is the framework in which the staff of nursing is faced with clinical dilemmas, such as telling the truth or respect the privacy and confidentiality. The problem with that position should nurses take on if it is an ethical problem to be solved in different ways, resorting to the authority of an official document, taking an individual decision by consensus with the rest of the nursing staff through one dialogue between the profession and the public. Ethical Theories: The theories used for various purposes, an overview is designing the duties and rights of individuals within a given space. To determine the structure of a theory ethics is necessary to define whether certain objectives, duties or rights are basic or subordinates. While providing a framework and general guidelines applicable to our activities and moral doubts, can not give rules specific to be sought by going to the principles that leave the basic underlying theory Theory of consequence: In ethics, it places the good or evil of a share in the outcome of the same (Fundamentals of Nursing, 2003) Utilitarianism It is a formulation of the theory of consequence. Desarrollado por Jeremy Bentham (1748-1832) y Jhon Stuart Mill (1806-1873), Developed by Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873), his proposition is that the good of all those affected by a situation rather than an individual. And from the point of view, the action of saving a life or end it is neutral, ie not specifically good or bad. The will depend on its consequences. Beneficence / paternalism According to this proposition is not just charities do good more than the patient, but it had the voice of nurses does not match that of the one and when the nurses opinion conflicts with the patients welfare paternalism becomes , acts and attitudes paternalistic are those which limit the freedom of the patient for his own good nursing paternalism involves the use of some forms of taxation for the benefit the patient not considered beneficial the outcome you are trying, or not as a good important to remedy suffering to achieve this. Theory of Liability: Any person has the obligation to seek the welfare and reduce suffering in the world scale, these are some of the duties of active nurses. The theory is located on right and wrong of an action on the principles that drive the behavior. Kantianism: A fundamental ethical perspective, called Kantianism. Write Emmanuel Kant (1724-1804):

There are consequences that make an action good or bad if not righteousness that morality depends on the actions you are consistent with a principle whatever consistent results by the concept is fundamental goodwill necessary to assess the overall good of an act, also this theory does recognize the man deserves respect for all this is contrary to what is said in theory result, the obligation to treat the rest as findings in themselves and not as means to an end places the man in the center of moral decision and finally also has a moral obligation to act based on the respect for rights and acceptance of responsibility therefore to meet this mandate is clear and clearly define the principles and responsibilities and follow the moral imperative to act on them. The fundamental ethical principle comes from the perspective of Kantian ethics: respect for autonomy. The nurse takes this respect and makes the patient advocacy through work. Care theory: With a theory based on universal principles and abstract (as defined by Kant and Mill) or nurses or patients are moral agents are only specific individuals and individuals, each one with its own history, opinion and desires. This view of morality contradicts everything that the nurse knows about himself and about his patients as people, within and outside assistance rather than healthy. This framework stresses the importance of morality in practical situations those establishing relationships, care, communication, the desire not to harm others and responsiveness are some very fundamental aspects of ethics. About care, Nel Noddings (1984) states that The theory describes a female carefully distinguishes between caring and worry. Caregiving nurses away from patient and is impersonal and depersonalization . Worrying about is based on emotion, feelings and attitudes. But it ignores the ethical theories assume that only traditional but some moral life richer. Fundamental principles ART.1 .- The code of ethics is constituted by a systematized set of principles, guidelines and standards that guide the financial duties of professional nurses. 1. It is based on moral principles that must be honestly applied by the professionals of nursing practice to ensure an honorable conduct, with justice, solidarity, competence and legality. 2. The holistic concept of health-disease process, they must manage, implement and nursing professionals for the protection of health and life of the population. 3. Nursing is a profession of service so highly human who has chosen this profession must assume a behavior in accordance with the ideals of: solidarity, respect for human life and to be considered in their biodiversity as part and interrelationship with peers and nature 4. The education permanent, having a system of human values and the proper handling of communication allows the nurse or reflect ethical behavior in their relationship with people in their care, with colleagues, team members health and society in general, see what their respectability and recognition assures labor and social. 5. The development scale of the human person demands respect and practice of these human values: justice, freedom, etc.., By both the nurse and the nurse both their personal and professional life should be respected and everyday practices. 6. Health is a right, therefore the nurse and the nurse must respect and work for society and the state to put it into effect. The Professional Practice

ART.2. In practice, the nurse or nurse should be affiliated to their respective school. ART.3. The nurse and the nurse to join the school wing acquire Federation and the responsibility to comply with the laws and ethics governing the practice agreement establishes the legal framework of practice of nurses and nursing, compliance is a serious lack against professional ethics. ART.4. The faults and ethics violations in accordance with this code relate to ethical behavior and will be sanctioned by the respective court of honor. Misconduct is unethical not to report violations against this code, committed by a nurse. It is the duty of any nurse or nurse know and abide by the laws on health lifetimes. ART.5. The nurse and nurse must meet civic duties and participate together with those of more citizens in the promotion and protection of health and life in the individual, family and community ART.6. The nurses are responsible for their performance and to maintain existing professional competence through training and education, consider working with humans and with the rapid changes occurring in science, technology and culture. ART.7. The nurse and nurses must accept or recognize the individual responsibility that they bear in making decisions in their work. ART.8. The nurse and nurse must respect the attitudes, knowledge, and practices of the individual, family and community where these do not harm or be a risk to health. ART.9. In consideration of his prestige and that of the profession, nurses must observe caution when used for professional reasons the media collective. ART.10. The nurses refuse to have their names or people being used for advertising purposes that violate the dignity and human rights. ART.11. every nurse and nurse is free to choose the place where they can practice their profession unless they have contracts that are so determined and accepted. ART.12. The nurse and nurse must provide the individual family and community humanized care, timely, continuous and assured. ART.13. The nurse and nurse should respect the scale of values, ideology and religion of the individual, family and community. ART.14. The nurse and nurse must respect and not do that discriminate by nationality, race, color, religion, etc.. ART.15. The nurse and nurse professional with critical judgment rate the competence of personnel who are required to assign responsibilities. ART.16. The nurses decide the most appropriate for treating a patient when his life is at risk and emergency situations. ART.17. The nurses take into consideration the participation of individuals, families and communities in meeting their needs, applying the principles of treatment and intervention advice and consent.

ART.18. The nurse and nurse, even in cases of urgent necessity, not abandon the patient without having taken measures to ensure continuity of care. ART.19.Comenten grave lack of nurses that promote or engage in acts that threaten the quality of care and health, the person at any stage of life. ART.20. The nurse and nurse may participate in research clinics that do not conflict with ethics and morals and also must obtain the voluntary consent of the person or persons authorized executed, after a detailed explanation of the nature and risk of the same. ART.21. The nurses are required to report to local, national or international practice of torture, physical or mental patients refugees, political or common prisoners, and those who are victims of violence within the family ART.22. The nurse and nurse should respect the rights of all patients, particularly the terminally ill and their families ART.23. The nurse and nurse must be objective and truthful about their reports, statements or testimony. ART.24. The nurse and nurse for the discharge of their functions must wear the uniform in accordance with existing institutional rules, and respect to keep their badges: caps and lamps as part of their identity professional. ART.25. The nurses participate in collective efforts or particular requirements to preserve the human environment from harmful environmental factors and other risks society. ART.26. The nurses are required to provide services in cases of natural disasters, social upheaval, invasions , presenting serious risks for public health. Exercise of teaching and research ART.27. The nurse and nursing students must provide standards of professional and personal morality, through word and example of their daily lives. ART.28.The nurses must have and demonstrate a high scientific training, technical and humanistic training to ensure quality of other professionals. ART.29. The nurse and nurse educators must have the strength to reject impositions flattery and any other action that might induce them to commit irregularities unethical. ART.30. The nurse and nurse involved in the formation of non-professional level of nursing must ensure that educational content corresponding to that level. ART.31. The nurse and nurse to expropriate foreign scientific work, commit a serious lack of ethics. ART.32. The nurse and nurse should communicate and disseminate the product of their research or production science between nursing professionals and encourage the publication of their work. ART.33. The nurse and nurse to be made related to the profession published using a pseudonym, they must communicate their identity to the College Federation.

Relations Art.35. As a member of a multidisciplinary team of health, the nurse and the nurse must have a harmonious relationship with other health team members, based on mutual respect and cooperation to promote improved health of the population, which is their common goal. Art.36. The nurse or health team requires close collaboration, in which the nurse should carry out its functions autonomously, ensuring confidence in the treatment that takes the health team. In cases where risk is in the patient or user, the nurse and the nurse act immediately. Art.37. The relationships between nurses and nurses should be based on harmony and cooperation, particular emphasis should be given to the orientation of new promotions and training of future professionals. Art.38. The nurses in teaching and service should maintain close cooperation, considering the mutual stress leads to a better quality health care to the population and the advancement of the profession. Art.39. The relationships between colleagues will be mutual respect, identity, loyalty and solidarity. Art.40. Have seriously breached professional ethics: A) The nurse and the nurse they cause that libel, slander or infamous to a colleague in a professional or personal life. B) The nurse and the nurse who does not respect lines of authority and try to move a colleague through illegal means or unfair. C) The nurse and the nurse who distort or refuses to provide information relating to the care of patients or families in their care and alter your moral living. Art.41. The nurse and the nurse who has trained to contribute to the professional development of colleagues. Art.42. The nurse and the nursing staff to assess his position to promote their development and progress, acting with justice or equity.

Sarah E. Mendoza BSN-2C