03/05/2011 1 THE WAY TO PROFESSIONALISM: Ethics and Medicolegal HERKUTANTO HERKUTANTO Department of Forensic Medicine & Department of Forensic Medicine & Medicolegal Medicolegal Studies Studies University of Indonesia University of Indonesia Herkutanto Herkutanto Professor of Forensic Medicine and Medicolegal Studies Professor of Forensic Medicine and Medicolegal Studies Fellow of Australian College of Legal Medicine PhD in Medicine, MD, Forensic Specialist – University of Indonesia – Faculty of Medicine Grad. Dip. Forens.Med. - Monash University, Australia – Medical Faculty Dip. Forens.Med - Netherland School of Public Health, The Netherland • Sarjana Hukum (LL.B) – University of Indonesia, Faculty of Law • Master of Laws (LL.M) La Trobe University, Australia, School of Law MEDICAL EDUCATION Others • Chair of Legal Comp. Indonesian Hospital Ass. • Expert Witness: Prita vs Omni Hosp Expert Witness: Prita vs Omni Hosp LEGAL EDUCATION Click to buy NOW! P D F - X C h a n g e w w w . d o c u - t r a c k . c o m Click to buy NOW! P D F - X C h a n g e w w w . d o c u - t r a c k . c o m
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03/05/2011
1
THE WAY TO PROFESSIONALISM:Ethics and Medicolegal
HERKUTANTOHERKUTANTO
Department of Forensic Medicine &Department of Forensic Medicine & MedicolegalMedicolegal StudiesStudiesUniversity of IndonesiaUniversity of Indonesia
HerkutantoHerkutantoProfessor of Forensic Medicine and Medicolegal StudiesProfessor of Forensic Medicine and Medicolegal Studies
Fellow of Australian College of Legal Medicine
PhD in Medicine, MD,Forensic Specialist –University of Indonesia –Faculty of MedicineGrad. Dip. Forens.Med. -Monash University, Australia– Medical FacultyDip. Forens.Med -Netherland School of PublicHealth, The Netherland
• Sarjana Hukum (LL.B) –University of Indonesia,Faculty of Law
• Master of Laws (LL.M)La Trobe University,Australia, School of Law
MEDICAL EDUCATION
Others
• Chair of Legal Comp. IndonesianHospital Ass.
•• Expert Witness: Prita vs Omni HospExpert Witness: Prita vs Omni Hosp
• Being part of a profession entails asocietal contract.
• The profession is granted a monopoly overthe use of a body of knowledge and theprivilege of self-regulation, and,
• in return, The profession guaranteessociety professional competence, integrityand the provision of altruistic service.
Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.MJA 2002 177 (4): 208MJA 2002 177 (4): 208--211211
PROFESSIONALISMPROFESSIONALISM• An occupation whose core element is work, based on
the mastery of a complex body of knowledge and skills.It is a vocation in which knowledge of some departmentof science or learning, or the practice of an art foundedon it, is used in the service of others.
• Its members profess a commitment to competence,integrity, morality, altruism, and the promotion of thepublic good within their domain.
• These commitments form the basis of a social contractbetween a profession and society, which in return grantsthe profession autonomy in practice and the privilege ofself-regulation.
• Professions and their members are accountable to thoseserved and to society.
Oxford English DictionaryOxford English Dictionary
• The privilege of self-regulation entails anabsolute obligation to guarantee thecompetence of members.
• recertification and revalidation are, withoutquestion, now regarded as professionalobligations
• The disciplining of unethical orincompetent practitioners must berigorous, open
Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.MJA 2002 177 (4): 208MJA 2002 177 (4): 208--211211
PROFESIONAL AUTONOMY• Individually, physicians are granted sufficient
autonomy to act in the “best interests of theirpatients”.– Until late in the 20th century, autonomy was expressed in a
paternalistic fashion, but ….– modern society, recognising patient autonomy, now views the
physician–patient relationship as a partnership.
• The profession is also granted collective autonomythrough self-regulation.– It has the privilege and obligation to set and maintain standards
for education and training, entry into practice, and the standardsof practice.
– It must guarantee the competence of its practitioners, and– has an absolute obligation to discipline unprofessional,
PROFESSIONALISM AUTONOMYProfessionalism autonomy rests on three claims:• that there is such an unusual degree of
knowledge and skill involved in medical workthat non-professionals are not equipped toevaluate or regulate it;
• that doctors are responsible-they may be trustedto work conscientiously, without supervision;
• that the profession itself may be trusted toundertake the proper regulatory action whenindividuals do not perform competently or ethically.
Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.Sylvia R Cruess, Sharon Johnston and Richard L Cruess. Professionalism for medicine: opportunities and obligations.MJA 2002 177 (4): 208MJA 2002 177 (4): 208--211211
SOCIAL CONTRACTSOCIAL CONTRACTPROFESSIONALSPROFESSIONALS -- COMMUNITYCOMMUNITY
William M Sullivan,William M Sullivan, Medicine under threat: Professionalism and professional identityMedicine under threat: Professionalism and professional identity, CMAJ 2000:162(5): 673, CMAJ 2000:162(5): 673
• Professionalism may be defined as theobligation of the physician to uphold theprimacy of patients’ interests, to achieveand maintain medical competency, andto abide by high ethical standards.
NEUROLOGY 2008;71:1283-1288
THREAT TOPROFESSIONALISM
• Recent commentary has suggested that medical professionalism
is being threatened by commercialism and the legal system.
• Consideration of judicial rulings centered on primacy ofpatients’ interests (informed consent, end-of-life care, andconflicts of interest), medical competence (standard of care inmedical malpractice cases, medical futility cases, andconfidentiality of peer review), and enforcement of ethicalstandards (peer review by professional organizations)demonstrates that the law generally defers to standards setby the medical profession,
• but competing views over what health care model is operativemay generate non-deferential outcomes.NEUROLOGY 2008;71:1283-1288
•• TRUSTTRUST– The patient believe that the practitioners have a
duty of care, without being asked•• JUSTICEJUSTICE
– To provide every patients’ rights•• RECIPROCITYRECIPROCITY
– The trust of the patients depend on the credibilityof practitioners (Credat emptor)
COUNCIL (BOARD)COUNCIL (BOARD)• Instrumen utk menjaga profesionalisme• Dibentuk oleh masyarakat (dg UU – Medical Act)• Bertujuan melindungi masyarakat• Terdiri dari wakil profesi, wakil masyarakat, dan
stake holder lain• Menentukan siapa yang boleh menjadi anggota
komunitas profesi (mekanisme registrasi)• Menjaga kualitas pelayanan• Memberi sanksi atas anggota profesi yang
melanggar norma profesi (mekanisme pendisiplinan)
Medical Practitioners Board of Victoria, Annual Report 2001, Melbourne, 2001
• Supports the concepts of professionalism– described the professions,– the rationale for their being,– stressed the service commitment of individual
professionals.
• It recognised the conflict between altruismand self-interest, butbut believed thatcommitment to service would result inaltruistic behaviour.
Parsons T. The professions and social structure.Parsons T. The professions and social structure. Social ForcesSocial Forces 1939; 17: 4571939; 17: 457--467.467.
the questioning society of the 1960s
• physicians exploited their monopoly tocreate a demand for services which they thensatisfied
• serious failures in self-regulation, and abuseof collegiality to protect incompetent orunethical physicians
• criticised physicians for pursuing their ownfinancial interests at the expense of bothindividual patients and society.
• it questioned the benefits of professionalismto society
Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd and Mead, 1970Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd and Mead, 1970
1980 - 2000• growing importance of governments and the
corporate sector in healthcare• medicine has lost control over the medical
marketplace– no longer dictating its structure, methods of payment,
or levels of remuneration• control shifted from the profession to the State
and/or the corporate sector• They have returned to support the "professional
model" - devoted to the public good — oneobserver calls it "civic professionalism".
The principal threats to medicine'sprofessional status
public mistrustpublic mistrust• medicine failed to self-regulate in a way that can
guarantee competence, and that it put its owninterest above that of patients and the public– Bristol: medicine has protected incompetent or
unethical colleagues in the name of collegiality• the dual role of medical associations
– acting as expert advisors on matters of health as wellas representing their members
– has created a difficult conflict of roles
Sullivan W. Work and integrity: the crisis and promise of professionalism in North America. New York: Harper Collins, 1995: 1Sullivan W. Work and integrity: the crisis and promise of professionalism in North America. New York: Harper Collins, 1995: 16.6.
The opportunity to rebuild trustThe opportunity to rebuild trust• control of healthcare has passed from
medicine to the State and the corporatesector, so has the blame for defects in thehealthcare system
• Patients remain attached to their physiciansand do not wish either the State orcorporate sector to make decisions abouttheir care.
• The public and physicians share a view ofthe changes needed in healthcare systems
Krause E. Death of the guilds: professions, states and the advance of capitalism, 1930 to the present. New Haven: Yale UniverKrause E. Death of the guilds: professions, states and the advance of capitalism, 1930 to the present. New Haven: Yale Universitsity Press, 1996.y Press, 1996.
Medical malpractice involves thephysician’s failure to conform to thestandard of care for treatment of thepatient’s condition, or lack of skill, ornegligence in providing care to thepatient, which is the direct cause ofan injury to the patient.
STATEMENT ON MEDICAL MALPRACTICESTATEMENT ON MEDICAL MALPRACTICE4444thth World Medical Assembly, Marbella, Spain, September 1992World Medical Assembly, Marbella, Spain, September 1992
STATEMENT ON MEDICAL MALPRACTICESTATEMENT ON MEDICAL MALPRACTICE4444thth World Medical Assembly, Marbella, Spain, September 1992World Medical Assembly, Marbella, Spain, September 1992
• A distinction must be made between medicalmalpractice and an untoward result occurring inthe medical treatment that is not the fault of thephysician
• An injury occurring in the course of medicaltreatment which could not be foreseen ….. is anuntoward result
• In an untoward result, physician should not bearany liability
What is foreseeableWhat is foreseeable –– is what the defendant will pay foris what the defendant will pay forI.Kennedy, A.Grubb, Principles of Medical Law, Oxford Univ.Press, London, 1998, p.415
• HARUS DI EVALUASI– KESAHAN IJASAH– ADAPTASI DAN SERTIFIKAT KOMPETENSI– SURAT ANGKAT SUMPAH/JANJI– KETERANGAN SEHAT FISIK & MENTAL– PERNYATAAN AKAN MEMATUHI ETIKA
PROFESI• MILIKI IJIN KERJA,• MAMPU BAHASA INDONESIA
• MEWAWANCARAI PASIEN• MEMERIKSA FISIK DAN MENTAL• MENENTUKAN PEMERIKSAAN PENUNJANG• MENEGAKKAN DIAGNOSIS• MENENTUKAN PENATALAKSANAAN• MELAKUKAN TINDAKAN MEDIS• MENULIS RESEP• MENERBITKAN SURAT KETERANGAN• MENYIMPAN OBAT• MERACIK OBAT, KHUSUS DI TERPENCIL
PENYELENGGARAAN PRAKTIK
1. SURAT IJIN PRAKTEK2. PELAKSANAAN PRAKTIK3. PEMBERIAN PELAYANAN:
– STANDAR PELAYANAN– PERSETUJUAN TINDAKAN– REKAM MEDIS– RAHASIA KEDOKTERAN– KENDALI MUTU DAN KENDALI BIAYA– HAK DAN KEWAJIBAN DOKTER– HAK DAN KEWAJIBAN PASIEN– PEMBINAAN
Pasal 50Dokter atau dokter gigi dalam melaksanakan
praktik kedokteran mempunyai hak
1. memperoleh perlindungan hukum sepanjangmelaksanakan tugas sesuai dengan standarprofesi dan standar prosedur operasional;
2. memberikan pelayanan medis menurut standarprofesi dan standar prosedur operasional;
3. memperoleh informasi yang lengkap dan jujurdari pasien atau keluarganya; dan
4. menerima imbalan jasa.
Pasal 51Dokter atau dokter gigi dalam melaksanakanpraktik kedokteran mempunyai kewajiban :
1. memberikan pelayanan medis sesuai dengan standarprofesi dan standar prosedur operasional sertakebutuhan medis pasien;
2. merujuk pasien ke dokter atau dokter gigi lain yangmempunyai keahlian atau kemampuan yang lebihbaik, apabila tidak mampu melakukan suatupemeriksaan atau pengobatan;
3. merahasiakan segala sesuatu yang diketahuinyatentang pasien, bahkan juga setelah pasien itumeninggal dunia;
4. melakukan pertolongan darurat atas dasarperikemanusiaan, kecuali bila ia yakin ada orang lainyang bertugas dan mampu melakukannya; dan
5. menambah ilmu pengetahuan dan mengikutiperkembangan ilmu kedokteran atau kedokteran gigi.
• TINDIK HARUS DISETUJUI “PASIEN”,SETELAH DIBERI PENJELASAN:– DIAGNOSIS DAN TATA CARA TINDIK– TUJUAN TINDIK– ALTERNATIF DAN RISIKO– RISIKO DAN KOMPLIKASI YG MUNGKIN– PROGNOSIS TINDIK