Substantive Rules
Rules of truth-telling, confidentiality, privacy, and various rules about forgoing treatment, physician-assisted suicide, informed consent, and the rationing of health care provide more specific guides to action than do abstract principles. Consider a simple example of a rule that sharpens the requirements of the principle of respect for autonomy for certain contexts: “Follow a patient’s advance directive whenever it is clear and relevant. “To indicate how this rule specifies the principles of respect for autonomy, we may state it more fully as: “Respect the autonomy of patients by following all clear and relevant formulations in their advance directives. “This formulation show how the initial norm remains but becomes specified.

Example situation, * In clinical situations nurses respect a patient’s autonomy, where the patient is allowed the freedom of choice regarding treatment, such as in deciding whether he/she wishes to be incubated during an exacerbation of COPD, or deciding when he/she wishes to forgo further dialysis. If a patient lacks capacity for such a decision and has an advance directive, the person who has the durable power of attorney can make the decision.

Authority Rules
That is, rules regarding who may and should perform actions. For example, rules of surrogate authority determine who should serve as surrogate agents in making decisions for incompetent persons, and rules of profesional authority determine who, if anyone, should make decision to override or to accept a patient’s decisions if those decisions are medically damaging and poorly considered. Another example appears in rules of distributional authority that determine who should make decisions about allocating scarce medical resources.
Authority rules do not delineate substantive or criteria for making decisions. However, authority rules and substantive rules do interact. For instance, authority rules are justified , in part, by how well particular authority can be expected to respect and express substantive rules and principles.

Example situation, * Patient has repeatedly voiced fear over receiving a diagnosis of lung cancer, as he believes this is a death sentence. His primary care physician decides not to reveal the diagnosis to the patient after he says he would kill himself if he had lung cancer.

Procedural Rules
We also defend rules that establish procedures to be followed. Procedures for determining eligibility for scarce medical resources and procedures for reporting grievance to higher authorities are typical examples. We often resort to procedural rules when we run out substantive rules and when authority rules are incomplete or inconclusive. For example, if substantive or authority rules are inadequate to determine which patients should receive scare medical resources, we resort to procedural rules such as first-come-first-served, queuing, and lottery.
Example situation, * An example, often used, is female genital circumcision. One side calls it female genital mutilation. Another group may consider this an appropriate cultural rite of passage. The ethical issue discussed—is this a cultural issue or human rights issue. Since it is performed on girls as young as seven years old, the issue of assent, consent, and culture are prominent in ethical discussions.

Reference. * Principles of Biomedical Ethics Book (Tom L. Beauchamp & James F. Childress) -