EditKaidah Dasar Bioetik &

Kaidah Dasar Bioetik &

Prima FacieYuli Budiningsih

Palangkaraya, 24 Oktober 2010

Content:

• Definition• Approached to bioethics• Principles of bioethics / kaidah dasar bioetik• Prima facie

Definition:• THE DISCIPLINE DEALING WITH WHAT IS GOOD AND BAD

AND WITH MORAL DUTY AND OBLIGATION (Webster’s).• ETHICS OFFERS CONCEPTUAL TOOLS TO EVALUATE AND

GUIDE MORAL DECISION MAKING• MEDICAL ETHICS IS A DISCIPLINE / METHODOLOGY FOR

CONSIDERING THE IMPLICATIONS OF MEDICAL TECHNOLOGY / TREATMENT AND WHAT OUGHT TO BE (Univ of Washington School of Medicine)

Ethics can be described as a sub-branch of applied philosophy that seeks ‘what are the right and the wrong, the good and the bad set of behaviours in a given circumstance’

Bioethics is a quasi-social science that offers solutions to the moral conflicts that arise in medical and biological science practice.

The Four Principles of Bioethics in 13th Century Muslim Scholar Maulana’s Teachings,Sahin Aksoy,Faculty of Medicine,Dept Med Ethics & History of Medicine,Turki.

Bioetika:

• Berperan penting dalam menjamin kehormatan harkat dan martabat manusia (respect for human dignity), perlindungan hak-hak asasi manusia dan kebebasan-kebebasan dasar.

• Mencakup dimensi etika, hukum, sosial dan budaya ilmu-ilmu hayati dan juga teknologi yang terkait.

• Rangkuman Pembahasan Kelompok Kerja Komisi Bioetika Nasional 2004-2007.

• Ethics is :the study of morality – careful and systematic reflection on and analysis of moral decisions and behaviour, whether past, present or future.

Morality is : the value dimension of human decision-making and behaviour.

Since ethics deals with all aspects of human behaviour and decision-making, it is a very large and complex field of study with many branches or subdivisions.

Medical ethics is the branch of ethics that

deals with moral issues in medical practice.

Medical ethics is closely related, but not identical to, bioethics (biomedical ethics).

Medical ethics focuses primarily on issues arising out of the practice of medicine.

Bioethics is a very broad subject that is concerned with the moral issues raised by developments in the biological sciences more generally.

• The study of ethics prepares medical students to recognize difficult situations and to deal with them in a rational and principled manner.

• Ethics is also important in physicians’ interactions with society and their colleagues and for the conduct of medical research.

• From Hippocrates came the concept of medicine as a profession, whereby physicians make a public promise that they will place the interests of their patients above their own interests.

In recent times medical ethics has been greatly influenced by developments in human rights.

In a pluralistic and multicultural world, with many

different moral traditions, the major international human rights agreements can provide a foundation for medical ethics that is acceptable across national and cultural boundaries.

• Moreover, physicians frequently have to deal with medical problem resulting from violations of human rights, such as forced migration and torture.

• Medical ethics is also closely related to law.• In most countries there are laws that specify

how physicians are required to deal with ethical issues in patient care and research.

• In addition, the medical licensing and regulatory officials in each country can and do punish physicians for ethical violations.

Different ways of approaching ethical issues:

• Non rational :• 1.obedience• 2.imitation• 3.feeling• 4.intuition• 5.habit

Rational:1.Deontology2.consequentialism3.principlism4.virtue ethics

• Consider the following medical cases, which could have taken place in almost any country :

1. Dr. P, an experienced and skilled surgeon, is about to finish night duty at a medium-sized community hospital. A young woman is brought to the hospital by her mother, who leaves immediately after telling the intake nurse that she has to look after her other children. The patient is bleeding vaginally and is in a great deal of pain. Dr. P examines her and decides that she has had either a miscarriage or a self-induced abortion. He does a quick dilatation and curettage and tells the nurse to ask the patient whether she can afford to stay in the hospital until it is safe for her to be discharged. Dr. Q comes in to replace Dr. P, who goes home without having spoken to the patient.

2. Dr. S is becoming increasingly frustrated with patients who come to her either before or after consulting another health practitioner for the same ailment. She considers this to be a waste of health resources as well as counter-productive for the health of the patients. She decides to tell these patients that she will no longer treat them if they continue to see other practitioners for the same ailment. She intends to approach her national medical association to lobby the government to prevent this form of misallocation of healthcare resources.

3. Dr. C, a newly appointed anaesthetist* in a city hospital, is larmed by the behaviour of the senior surgeon in the operating room. The surgeon uses out-of-date techniques that prolong operations and result in greater post-operative pain and longer recovery times. Moreover, he makes frequent crude jokes about Medical Ethics Manual – Introduction the patients that obviously bother the assisting nurses. As a more junior staff member, Dr. C is reluctant to criticize the surgeon personally or to report him to higher authorities. However, he feels that he must do something to improve the situation.

4. Dr. R, a general practitioner in a small rural town, is approached by a contract research organization (C.R.O.) to participate in a clinical trial of a new non-steroidal anti-inflammatory drug (NSAID) for osteoarthritis. She is offered a sum of money for each patient that she enrols in the trial. The C.R.O. representative assures her that the trial has received all the necessary approvals, including one from an ethics review committee. Dr. R has never participated in a trial before and is pleased to have this opportunity, especially with the extra money. She accepts without inquiring further about the scientific or ethical aspects of the trial.

• Each of these case studies invites ethical reflection. They raise questions about physician behaviour and decision-making – not scientific or technical questions such as how to treat diabetes or how to perform a double bypass, but questions about values, rights and responsibilities. Physicians face these kinds of questions just asoften as scientific and technical ones.

Approached to Bioethics:

• Pendekatan dengan teori etika tradisional: 1. Deontologi. asal kata deon , tidak bersyarat (kategori )

dan tidak bergantung pada tujuan tertentu. Benar tidaknya tindakan bergantung

pada perbuatan atau cara bertindak itu sendiri, bukan pada akibat tindakannya.

Dasarnya kewajiban, mutlak.

Pendekatan dengan teori etika tradisional:

• 2. Teleologi. Bersyarat (hipotetis), benar tidaknya tindakan bergantung pada akibat-akibatnya. Bila akibatnya baik: wajib, bila buruk: haram. Untuk mencapai tujuan kedokteran tertentu tapi tetap dalam bingkai mempertahankan

martabat kemanusiaan (bukan tujuan asal-asalan).

Pendekatan dengan teori etika tradisional:

• 3. Virtue. Keutamaan, benar tidaknya tindakan

tergantung dari norma-norma yang diambil,

meminimalkan norma-norma kemanusiaan yang akan

dikorbankan dengan dasar menghormati norma

kebahagiaan kemanusiaan.

Approached to bioethics:Pendekatan metode etika klinis: 1. Casuistry. metode pengambilan keputusan etik dengan menganalogikan situasi dan kondisi suatu kasus terhadap kasus terdahulu yang sudah ada solusi nya secara konsensus.

2. Moral pluralism. Dikembangkan oleh Jonsen, Siegler dan Winslade.

Metode etika klinis.• 2.Moral pluralism. Melakukan analisis moral terhadap 4 jenis

kategori yaitu: *kategori indikasi medis (medical indications) *pilihan pasien (patient preferences) *kualitas hidup (quality of life) *konteks utama (contextual features)

Appoached to bioethics:Pendekatan etika kedokteran terapan: 1.Principlism. Mementingkan prinsip etik dalam bertindak. *Four principles = kaidah dasar bioetika tokoh: Beauchamp and Childress. *Etika normatif 2.Alternatif Principlism. *Etika komunitarian *Feminist ethics (etika kasih sayang)

Principles of Bioethics = Kaidah Dasar Bioetik:

• Terdiri dari 4 kaidah dasar yaitu: 1. Beneficence 2. Non Maleficence 3. Autonomy 4. Justice Kaidah turunannya : confidentiality, truth

telling, informed consent, privacy, promise keeping, honesty.

1.BENEFICENCE : SIKAP/BERBUAT BAIK (1)

Konteks : tertuju pd pihak ke-2 (individu pasien) pada umumnya, yg stabil (tidak gawat darurat, tidak rentan)

untuk kepentingan pasiennya. Utamakan altruisme Menjamin nilai pokok harkat & martabat manusia

“apa

saja” yang ada, pantas (elok) kita bersikap baik

terhadapnya (apalagi “ada” yang hidup)

1.BENEFICENCE : SIKAP/BERBUAT BAIK (2)

Memandang pasien/keluarga/sesuatu yang tak hanya sejauh menguntungkan dokter

Maksimalisasi akibat baik>buruk Minimalisasi akibat buruk Banyak dianut di Timur (termasuk RI),

paternalisme nyata dan prinsip musyawarah mufakat

2.NON MALEFICENCE : TIDAK MERUGIKAN (1)

Konteks : tertuju pada pihak ke-2 (pasien) yang kesakitan/menderita, gawat darurat, menjelang cacat, distress, rentan, tidak/bukan otonom seperti uzur, terjepit tanpa pilihan, miskin, bodoh.

Sisi komplementer beneficence Primum non nocere (pertama jangan menyakiti) Kewajiban menganut ini berdasarkan hal-hal :

Pasien dalam keadaan amat berbahaya atau beresiko

2.NON MALEFICENCE : TIDAK MERUGIKAN (2)

• Hilangnya sesuatu yang penting Dokter sanggup mencegah bahaya atau

kehilangan tersebut Manfaat bagi pasien > kerugian dokter

(hanya mengalami resiko minimal) Tindakan kedokteran terbukti efektif

3.JUSTICE : KEADILAN (1)

Konteks : tertuju pada pihak ketiga selain individu pasien/klien, wakil/kluster populasi/komunitas; pihak penyandang dana/ikut penanggung jawab, pihak berpotensi dirugikan/paling kurang diuntungkan.

Memberi perlakuan sama kepada pasien untuk kebahagiaan pasien & umat manusia yakni:

Memberi sumbangan relatif sama dengan kebutuhan mereka (kesamaan sumbangan sesuai kebutuhan pasien)

Menuntut pengorbanan mereka secara relatif sama dengan kemampuan mereka (kesamaan beban sesuai dengan kemampuan pasien)

3.JUSTICE : KEADILAN (2)

Tujuan : menjamin nilai tak berhingga dari setiap makhluk (pasien) yang berakal budi (aspek sosial)

Jenis keadilan : Tukar menukar : kebijakan (kebiasaan etis) selalu memberi hak

pasien/yang semestinya harus diterimaDistributif (membagi) : kebajikan dokter/sarkes selalu

membagikan kenikmatan/beban bersama, rata dan merata dengan keselarasan sifat dan tingkat perbedaan jasmani dan rohani.

Social : kebajikan melaksanakan dan memberikan kemakmuran kesejahteraan bersama

Hukum (umum) : bagi dengan hukum (pengaturan untuk kedamaian hidup bersama) mencapai kesejahteraan umum

4.AUTONOMY : SELF DETERMINATION (1)

Konteks : ditujukan pada capable person = individu pasien yg dewasa, sehat, bebas (punya rentang hak pilih atas keputusan dirinya, seperti kondisi pro operasi elektif), sejajar dengan dokternya.

Menghendaki, menyetujui, membenarkan, mendukung, membela, membiarkan pasien demi dirinya sendiri (sebagai makhluk bermartabat)

4.AUTONOMY : SELF DETERMINATION (2)

Pasien = makhluk berakal budi, tidak boleh dijadikan semata-mata alat tetapi tujuan

Wajib menghormati manusia sebagai makhluk pribadi yang otonom

Didewa-dewakan di Anglo-American yang individualismenya tinggi

Erat terkait dengan informed-consent

Prima facie

• Adalah perubahan pemilihan penggunaan prinsip dasar bioetik yang paling tepat atau cocok dalam suatu konteks.

Deductive logic

Beneficence Non Maleficence Autonomy Justice

Combination ofIt’s characteristics = Patient’s Context

Method = Logic Thinking critical analysis

MedicalIndication

Principles-based ethics Prima Facie

T.Beauchamp & Childress (1994) & Veatch (1989)

Beneficence

Non Maleficence

Autonomy

Justice

Contextual featuresQuality of life

Clinical DecisionMaking

Patient’s preference

Medical indicationValue-based medicine

EBM

ENRICHMENT OF JUSTIFICATION

Beneficence Non Maleficence Autonomy Justice

Not stipulated in the text = Patient’s Context

MedicalIndication

DEDUCTIVELOGIC

PRIMAFACIE

CETERIS PARIBUS

CREATIVE THINKING

(NEW) ILLAH = actual duty = contextuality

“OPPOSITION”

VALUECONFORM

>< : DETECTDEVIATION

TROEF = berubah menjadi ……

Beneficence Non Maleficence Autonomy Justice

MedicalIndication

pihak II UmumBAIK“kranjangSampah”

pihak IIkesakitan/menderita,gadar,pra-cacatDistressRentanuzur, terjepit tanpa pilihanMiskinbodoh.

capable person bebasElektifrentang >>hak pilih a// DRnya

pihak IIINon pasienwakil/walikluster popKomunitasPenyandangdanaBerpotensiDirugikan/Paling krg diuntungkan

The patient’s contexts for prima facie’s choice(Agus Purwadianto, 2004)

J usticeNon maleficence

AutonomyBeneficence

Time

General benefi t result, mos t o f people,

Elect iv e, educ at ed, bread-winner, ma ture person

Vu lnerab les, emergency, lif e sav ing, minor

> 1 p erson, others similari ty, community / social ’s r ights

TERGANTUNG ……. BERUBAH MENJADI

Micro levelClinical medicine

The Scope of ethics in Medicine

Macro levelPolitics of Health

Meso levelHealth services delivery

Macho levelHealth care teams

conscience

rights

ethics

selfreflection

justification

Deduction= logic

Induction= casuistry

bioethics

ConcreteDaily living

Goals of medicine

• Promotion of health and prevention of disease

• Relief of symptoms pain, and suffering

• Cure of disease• Prevention of untimely death

04/17/23 43

Goals of medicine (2)

• Improvement of functional status or maintenance of compromised status

• Education and counseling of patients regarding their condition and prognosis

• Avoidance of harm to the patient in the course of care

• Special Supplement: The Goals of Medicine: Setting New Priorities, Hastings Cent Rep 1996,26(suppl)(6): 1—27.

KKI & 4 kaidah dasar moral:

• Praktik kedokteran Indonesia mengacu kepada 4 kaidah dasar moral yaitu :

a) Menghormati martabat manusia (respect for person). Menghormati martabat manusia. Pertama, setiap individu (pasien) harus diperlakukan sebagai manusia yang memiliki otonomi (hak untuk menentukan nasib diri sendiri), dan kedua, setiap manusia yang otonominya berkurang atau hilang perlu mendapatkan perlindungan.

b) Berbuat baik (beneficence). Selain menghormati martabat manusia, dokter

juga harus mengusahakan agar pasien yang dirawatnya

terjaga keadaan kesehatannya (patient welfare). Pengertian ”berbuat baik” diartikan bersikap ramah atau menolong, lebih dari sekedar memenuhi kewajiban.

c) Tidak berbuat yang merugikan (non-maleficence). Praktik Kedokteran haruslah memilih pengobatan yang paling kecil risikonya dan paling besar manfaatnya. Pernyataan kuno: first, do no harm, tetap berlaku dan harus diikuti.

d) Keadilan (justice). Perbedaan kedudukan sosial, tingkat ekonomi, pandangan

politik, agama dan faham kepercayaan, kebangsaan dan kewarganegaraan, status perkawinan, serta perbedaan jender tidak boleh dan tidak dapat mengubah sikap dokter terhadap pasiennya. Tidak ada pertimbangan lain selain kesehatan pasien yang menjadi perhatian utama dokter. Prinsip dasar ini juga mengakui adanya kepentingan masyarakat sekitar pasien yang harus dipertimbangkan.