• Ethical decision-making is a systematic, reasoned process for choosing an action when values or duties conflict. It protects clients from decisions based on habit, fear, or personal bias.
• Bioethics applies ethical reasoning to health care, life sciences, and technology — end-of-life care, reproduction, genetics, research, organ donation, and resource allocation.
• Ethical dilemma — a choice between two or more morally justifiable options, each with drawbacks.
• Moral distress — the nurse knows the right action but cannot act on it because of constraints.
• Moral courage — acting on ethical convictions despite risk (e.g., reporting a colleague's unsafe practice).
• Conscientious objection — refusing to take part in an act that violates one's deeply held moral or religious beliefs, while still ensuring the client receives care.
• Surrogate (substitute) decision-maker — a person who decides for a client who lacks decision-making capacity, ideally following the client's known wishes (substituted judgment) or, if unknown, the client's best interests.
• Ethics committee — a multidisciplinary hospital body that advises on difficult cases, policy, and education; it supports but does not replace the clinical team's decision.

A common ethical decision-making model (nursing process style)

1. Identify the problem — is it an ethical issue, a legal issue, a communication problem, or a clinical question? Who is involved?
2. Gather the facts — medical facts, prognosis, the client's wishes and capacity, family views, laws and policies.
3. Clarify values — the client's, family's, nurse's, and profession's values; identify which principles conflict.
4. Identify options — list all alternatives and their likely consequences.
5. Decide and act — choose the option best justified by principles, the Code of Ethics, and law; carry it out.
6. Evaluate — review outcomes and learn for future cases.

Useful tools: an ethics consultation or committee, the Code of Ethics for Registered Nurses, institutional policies, and structured frameworks such as the "four boxes" approach (medical indications, client preferences, quality of life, contextual features).

Assessing decision-making capacity — the client can:

• Understand relevant information
• Appreciate how it applies to their own situation
• Reason about options and consequences
• Communicate a choice

Capacity is decision-specific and can fluctuate. Adults are presumed to have capacity unless shown otherwise. Age of majority in the Philippines is 18.

Key bioethical issues

• Family requests nondisclosure: listen, acknowledge the family's love and fear, find out what the client already knows and wants to know, involve the physician, and arrange a supported disclosure. The nurse does not lie to the client.
• Client wishes to leave against medical advice: first assess the reason (cost, fear, family duties), explain risks clearly, involve the physician, offer alternatives (e.g., social service help), and if the competent client still leaves, obtain a signed waiver per policy and document — without coercion.
• Doubtful consent in research: if a participant did not understand risks, stop and inform the investigator; the participant must be re-informed and may withdraw.
• Surrogate consent for an adult with dementia: confirm the client lacks capacity for this decision, identify the proper legal surrogate under hospital policy, and ensure the surrogate follows what the client would have wanted.
• Colleague delays pain medicine: address it directly if safe, and report to the charge nurse; clients' comfort and safety come before collegial loyalty.
• Patient information left in a public area: secure it immediately; it is both a privacy and an ethical breach.

• Advocate — ensure the client's voice is heard, especially vulnerable clients (children, older adults, persons with disability or mental illness)
• Communicate and coordinate — facilitate family conferences; clarify misunderstandings; bring issues to the physician and ethics committee
• Protect — confidentiality, informed consent, and safety
• Support — families facing end-of-life decisions; colleagues with moral distress
• Participate in ethics committees, policy development, and research ethics
• Know one's own values so that personal beliefs do not override the client's rights; if conscientious objection is raised, it is declared in advance where possible, and care is never abandoned

• The Code of Ethics for Registered Nurses (BON Res. 220, s. 2004) states that human life is inviolable, that the nurse assists toward a peaceful death when cure is no longer possible, and that the nurse is the client's advocate.
• RA 10354 (Responsible Parenthood and Reproductive Health Act of 2012) recognizes that abortion remains illegal and punishable, requires compassionate care for post-abortion complications, and respects conscientious objection except in emergency or serious cases. In Imbong v. Ochoa (2014) the Supreme Court struck down the penalty on non-emergency objectors who do not refer; referral remains an ethical expectation, not an enforceable legal duty.
• RA 11166 (Philippine HIV and AIDS Policy Act, 2018) requires written consent before HIV testing and protects confidentiality of HIV status; minors aged 15 to below 18 may consent to testing themselves (those below 15 who are pregnant or engaged in high-risk behavior may also consent, with counseling).
• RA 10173 (Data Privacy Act) protects genetic and health information as sensitive personal information.
• Refusing emergency care or demanding a deposit before emergency treatment is unlawful under the anti-hospital deposit law (BP 702 as amended by RA 8344 and RA 10932).
• Participating in euthanasia or assisting suicide exposes a nurse to criminal liability and revocation of license.

Case 1. A terminally ill client says, "I want to die now; please give me something."

Correct action: stay with the client, assess pain, depression, and suicide risk, notify the physician, optimize comfort and palliative care, and involve family and spiritual support. Why: the nurse cannot hasten death, but the request signals unrelieved suffering that must be addressed.

Case 2. A competent adult with end-stage kidney disease refuses further hemodialysis after full explanation.

Correct action: confirm understanding of consequences, explore reasons, ensure palliative care, document the informed refusal, and respect it. Why: autonomy of a competent client prevails even if the team disagrees.

Case 3. A nurse with religious objections is assigned to care for a client admitted for bleeding after an induced abortion.

Correct action: provide care — this is treatment of a complication, and it may be an emergency. Why: RA 10354 requires humane, nonjudgmental care for post-abortion complications, and conscientious objection does not apply to emergencies.

Case 4. During a clinical trial, a nurse realizes a participant did not understand the risks before signing.

Correct action: notify the principal investigator (and the ethics review board per protocol) so the participant is properly re-informed. Why: consent must be informed and voluntary.

• Deciding before gathering facts — the model always begins with identifying the problem and collecting facts.
• Treating family wishes as overriding a competent client's decision.
• Equating titrated pain relief with euthanasia — intent and proportionality differ (double effect).
• Assuming conscientious objection lets a nurse refuse all care — it never applies in emergencies, and helping the client reach another provider is expected ethically (the penalty for not referring was struck down).
• Forgetting that a signed consent form is not valid if the client did not understand.
• Believing an ethics committee makes the final decision — it advises.

• Decision steps: identify problem → gather facts → clarify values → options → decide and act → evaluate
• Capacity: understand, appreciate, reason, communicate; presumed in adults; age of majority 18
• Competent client's informed refusal must be respected
• Truth-telling: the competent client's right to know outweighs the family's request for concealment; plan disclosure together
• Euthanasia/assisted suicide: not authorized in the Philippines
• Double effect justifies titrated opioids for comfort
• RA 10354: abortion illegal, post-abortion care humane and nonjudgmental; objection allowed but never in emergencies; referral is good practice (penalty for not referring struck down in Imbong v. Ochoa, 2014)
• RA 11166: written consent for HIV testing; HIV status confidential
• Research: voluntary informed consent; right to withdraw; report concerns to investigator/ethics board
• Allocation of scarce resources: by need and benefit, not ability to pay