Kaidah Dasar Bioetika Kesehatan & Etikolegal -Prof. Dr. Dr. Agus Purwadianto, SpF(K), S.H, M.si, DFM
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Transcript of Kaidah Dasar Bioetika Kesehatan & Etikolegal -Prof. Dr. Dr. Agus Purwadianto, SpF(K), S.H, M.si, DFM
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KAIDAH DASAR BIOETIKA &
ETIKOLEGAL
Agus Purwadianto.Jakarta, 2013
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3 Masa Depan Dr (dari Praktiknya)
Makin jaya : jalur spesialisasi “basah”: cutting clinicians/ intervensif : monopolistik/ ’bunga berbunga” : income SpJP KKV : terkaya DARI PRAKTEKNYA SAJA di Jkt Rp.1M/sebulan NETT !!!!
Biasa-biasa saja : “cukup makan” ini kurva normal terbanyak!!!
Makin terpuruk : TIDAK KOMPETITIF (= dijauhi pasien ec unprofessionalism)apalagi + LITIGIOUS SOCIETY RISIKO turun reputasi & finansial pasca gugat/tuntut hukum
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Masa depan dokter gigi
Pemilik bbrp RS
Spesialis Orthodonti + pemilik bbrp klinik gigi
Konsultan industri produk mulut & gigi
Manajer RS
Praktisi + dosen
Pengusaha mis : pemilik stasiun TV
Bintang film dll
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Persoalan dunia medik
Suami minta Dr melakukan euthanasia thd istrinya yg “koma” Komisi Etik
RSCM hrs menjawab
Apa & bagaimana jawaban yg benar ?
Pasien pulang paksa benar /salah ?
Dapatkan sbg bahan pembelajaran sensitivitas etik mhsw FK ?
Dr peneliti membawa virus H5N1 ke LN & memuat data publikasinya ke Genebank ia terkenal ttp negara & masyarakat “tak ikut diuntungkan” OK atau tdk ?
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Persoalan Dental
Drg non spesialis membujuk
remaja “kurang PD” utk pasang behel
Mhsw FKG meminta tolong “tukang gigi” membuatkan prosto
Drg penderita HIV msh ngotot praktek
Drg Spes BM dikonsul trauma wajah o/ dokter spes kulit
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Persoalan Farmasi
Ketergantungan bahan baku obat
Obat mahal & palsu
Rendahnya minat apoteker komunitas yg dukung saintifikasi jamu
Konflik etikolegal industri DN - LN
Komisi ke Dr kepatuhan pd Mexico
City Principles
Penguasaan alkes & biologicals KL
Principles
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Persoalan Ners
Disparitas kompetensi & subsistensi
Orientasi kuratif – abai paradigma sehat (inkonsisten dg filosofi keperawatan)
Kurang jelas jabaran tindakan keperawatan dlm praktek
Belum advokator pasien
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Survey Ranking Professionals
on Level of
Moral Confidence & Trust
1980 Pharmacist
Clergy
Firefighter
Teacher
Police Doctor
Dentist
Accountant
Stock Broker
Lawyer
Funeral Director
Politician
1995 Firefighter
Pharmacist
Teacher
Dentist
Clergy
Stock Broker
Doctor
Accountant
Funeral Director
Police Lawyer
Politician
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Medis atau etis?
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KeputusanMedis
Keputusan etis
Pilar Keputusan Klinis sehari2Biomedik
Info-medik
Indikasimedik
pilihan pasienkualitas hidup
fitur kontekstual
Mindset non medisStruktur Psiko-Sosio-budaya
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Jamu = tidak ilmiahMbok jamu = kasta rendah BENARKAH ??
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Physician’s competence
Valid evidence Patient’s values
PATIENT’S PREFERENCEFROM STUDIES
JAMU DIPAKAI & BERMANFAAT(Riskesdas 2010)
EVIDENCE BASED MEDICINE – modifikasi Sudigdo S
HOLISTIC
“inter-subyektivitas”(bukan obyektivitas)
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SISI SEHAT ORANG SEHATSISI SEHAT ORANG SAKIT
WELLNESS
BIOKULTURALINFOMEDIK
Kedokt sosial
Sisi sakitOrang sakitKedokt Klinis
sinergi
kesmas
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Bioetika = abstrak ?
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Dr Sigap & Tergopoh-gopoh spt ini, benar atau tidak ?
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Kalau yang ini 1 dari ratusan korban tsunami, lumpur panas ?? (di luar RS >>)
KONTEKS : BENAR/SALAH ?
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Konteks : tertuju pd pihak II (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)
Hukum : kemaslahatan umum > dp gejolak sosial, kebebasan berpendapat/pers > otoriter
1.BENEFICIENCE : SIKAP/BERBUAT BAIK
(1)
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1.BENEFICIENCE : 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
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1.BENEFICIENCE : SIKAP/BERBUAT BAIK
(3)
General beneficence : berbuat baik kepada siapapun termasuk “yang tidak kita kenal” ( “bebas dari ..... =
impartially), merupakan etika normative
“keranjang sampah” nilai apapun
Specific beneficence : bermoral bila tindakan baik ditujukan kepada pihak khusus “yang kita kenal” (II) : pasien,
anak-anak, teman-teman.
Hal ini menimbulkan kewajiban “mutlak” profesi, khususnya secara psikologis.
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2.NON MALEFICENCE : TIDAK MERUGIKAN(1)
Konteks : tertuju pada pihak II (pasien) kesakitan/menderita, gawat darurat, menjelang cacat, distress, rentan, tidak/bukan otonom seperti uzur, terjepi tanpa pilihan, miskin, bodoh.
Sisi komplementer beneficence
Primum non nocere (pertama jangan menyakiti)
Hukum : asas Audi et alteram Partem (mendengarkan pihak yg akan diatur)
Asas persamaan bila disparitas (+), peduli (caring ethics)
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4.AUTONOMY : SELF DETERMINATION(1)
Konteks : ditujukan pada pihak II (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)
Hukum : Bebas utk ...., kehendak bebas,
hak & kewajiban (right based approach)
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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)
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Check list (Observation Sheets)
Beneficence Criterion Yes No
Promoting altruism
Guaranteeing human dignity
Viewing patient/family not as profit objects
Maximize agregat net benefit
Compassionate paternalism
Guaranteeing minimal life of patient
Restricting “goal based approach”
Maximize patient satisfactionTutor’s nameGroup No.
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Check list (Observation Sheets)
Beneficence Criterion (2) Yes No
Maximize overall highest happiness
Continuing professional development
Giving effective-low priced medicine
Applying Golden rule principle
Promoting patient’s best interest
etc
Tutor’s nameGroup No.
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Check list (Observation Sheets)
Non Maleficence Criterion Yes No
Helping emergency patient
Treating vulnerable patients
Not killing patient (no euthanasia)
Not humiliating/abusing patient
Not respect patient as object
Treating unproportionally
Not preventing patient from danger
Avoiding misrepresentation to P
Tutor’s nameGroup No.
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Check list (Observation Sheets)
Confidentiality Criterion Yes No
Not disclosing to friends/relatives
Careful waivers : duty/permission to warn
Careful relation about public figures
Prudent ommitting sensitive information from medical record
Prudent action to 3rd parties & public officials
Prudent action of partner notification
Tutor’s nameGroup No.
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Check list (Observation Sheets)
Justice Criterion Yes No
Applying everything universally
Taking last portion of dividing something
Giving P-same position’s similar opportunity
Respect P’s rights : affordability, equality, accessibilikty, availability, quality)
Respect P’s legal rights
etc Tutor’s nameGroup No.
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Check list (Observation Sheets)
Justice Criterion - GENERAL Yes N
o
Patient : compliance to the SOP – INA
DRG/clinical pathway
Patient : not demanding unproved / futile
treatment
Dr : using labs/hospitalization SOP on most
scientific rigorous (“golden” standard)
Dr : treat as best EBM n not excessively
burdensome
Health P : Proper use of scarce resource of d
whole society or preventive action of it
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Check list (Observation Sheets)
Justice Criterion Yes No
Respecting other’s rights
Caring the vulnerables (the least advantage people)
Not abusing/discriminating
Wise in macro-allocation
etc
etc
Tutor’s nameGroup No.
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Beneficen
ceNon Maleficence Autonomy Justice
2 KDB RIGID
Logika PENGGUGAT
Hrs diimbangi
Cara =
Logic Thinking critical analysis
Medical
Indication Profesionalisme SH
Profesionalisme DR
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Our own
(Dr. Tenar’s) cases
Implementation of the 1st year students
Select of 67 cases
WHO SEARO
Group Presentation Plennary
Individual/Group : Take home exam
EBP3KH ModuleBatch 2005
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Principles-based ethics Prima FacieT.Beauchamp & Childress (1994) & Veatch (1989)
Jonsen & Siegler (2002)
Beneficence
Non Maleficence
Autonomy
Justice
Contextual features
Quality of life
Clinical Decision
Making
Patient’s preference
Medical indicationValue-based medicine
EBM
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Deductive logic
Beneficen
ceNon Maleficence Autonomy Justice
Combination of
It’s characteristics = Patient’s Context
Method = ballancing of specification
= Logic + creative thinking =
critical analysis + wisdom
Medical
Indication
rules
Particular/Concrete case
principles
BALLANCING & SPECIFICATION
KODEKI
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KEBEKUAN LOGIKA
Pada model biomedik yg monolit kebenaran tunggal membungkam daya kritis mhsw cara pikir “IPA”
Belajar konteks (“IPS”) selain
kritis juga KREATIF
Ada 2 dokter berkumpul muncul
berapa pendapat ???
Bandingkan dengan lawyer !!!
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TROEF = berubah menjadi ……
Beneficen
ceNon Maleficence Autonomy Justice
Medical
Indication
pihak II UmumBAIK“kranjangSampah”
pihak IIkesakitan/menderita,gadar,pra-cacatDistressRentanuzur, terjepit tanpa pilihanMiskin
bodoh.
capable person bebasElektifrentang >>hak pilih a
// DRnya
pihak IIINon pasienwakil/walikluster popKomunitasPenyandangdanaBerpotensiDirugikan/Paling krg
diuntungkan
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CONTEXTUALITY CLINICAL SETTING
INTER-SUBJEC-TIVITY
SELF OTHERS ORGANIZATION SOCIETY
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ENRICHMENT OF
JUSTIFICATION
Beneficen
ce Non Maleficence Autonomy Justice
Not stipulated in the text =
Patient’s Context
Medical
Indication
DEDUCTIVELOGIC
PRIMAFACIE
CETERIS PARIBUS
CREATIVE THINKING
(NEW) ILLAH = actual duty = contextuality
“OPPOSITION”
VALUE
CONFORM
>< : DETECTDEVIATION
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Dari Kognitif menjadi Sikap ?
Awal pengembangan daya kritis mhsw LOGIKA (cara berpikir lurus)
Sikap Klinisi thd pasien setiap saat dapat dikritik DIALOGIS : ALASAN
PEMBENAR & ALASAN PEMAAF SEPANJANG IKLIM AKADEMIK ADA
Collective conscience collective action VIA VALUE CLARIFICATION
(Howard Brody)
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Determine Determine
what is at issue What is
unsatisfactory-what is wrong?
What is the REAL issue here for me?
Is there a moral or ethical threat to me or someone else?
Would this be a problem if a different person was involved?
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Options
What options do I have?
What are some extreme choices?
Am I considering several choices?
What resources or help do I have available?
• What resources?
• Whose help?
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Outcomes
What could happen based on the Option I Choose?
What could happen if I do nothing?
Who will be affected by what I do?
Is it the RIGHT thing to do
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Recycle
After an option is chosen, Return to see if the original question is still valid.
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Landasan komunikasi yg etis
Kelemahan umum Dr RI kemampuan
prognosis kurang krn hanya dilatih diagnosis & terapi (model IPA/biomedik)
“If men define situations as real, they are real in consequences” (R Merton)
“Bagaimana kondisi saya sehabis operasi dok ?”
Jawaban tanpa ceteris paribus
memperuncing “result oriented” harapan pasien
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Prima fac ie = a “c hang e in to” co ncept from one princ ip le to anothe r accord ing t o specific con textual
features of pa tie nt
JusticeNon maleficence
AutonomyBeneficence
Time
General benefi t
result, mos t of
people,
Elect iv e, educ at ed,
bread -winner, ma ture
person
Vulnerables,
emergency, lif e
sav ing, minor
> 1 p erson, others
similari ty, community /
social ’s rights
1a
1b2
3
Priority of specification in Tenar’s case : 1a/1b 2 3
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Profession
To profess = to proclaim something publicly
The act = trustworthiness = commitment to an ideal to which they should conform = the essence of profession
To be competent to help patients
To have the patients’ best interests in mind
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Etika Dokter RIdi KODEKI “IHSAN”
Kemurnian niat = sikap moral tanpapamrih/non maleficence = deontologis
Kesungguhan kerja = tindakan tgjwb tuntas , perhatikan keselamatan pasien (semua KDB) teleologi & utilitarian
Kerendahan hati = sopan virtue Integritas ilmiah & sosial
= martabat profesi luhur (hormat dirisendiri & adil) profesionalisme & etika sosial & petuhi sistem etikolegal
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Insight Core Problem – of
context
Keywords - text
Metode AP
INI MASALAH MEDIK SAJA ? –yg memerlukan keputusan medik !!!!!ATAU MASALAH ETIK ?yg memerlukan keputusan etik !!!!!ATAU CAMPURAN ?
TIMBANG SEKILAS –MICRO ETHICS ATAU MACHO ?AKANKAH JADI MASALAH HUKUM ???
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PASAL KODEKI
CAKUPAN PASAL
PENJELASAN CAKUPAN PASAL
PENJELASAN PASAL
Metode AP
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Core Problem
Keywords
Basic
Moral
Principle
Beneficence
Nonmaleficence
Autonomy
Justice
Metode AP
KALAU BINGUNG GUNAKAN “TEST PEN”
(HORIZONTAL LINE)
APAKAH MENGORBANKAN SALAH SATU BAYI = NON MALEFICENCE ?
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Prima Facie
Principle
Context vs Text
Choose 1-2 out
of 4 most
relevan
(problem
solving)
Metode AP
SIAPAKAH YG LBH OTONOM ? IBU ATAU BAPAK ??? SIAPAKAH YG HARUS DIKORBANKAN ?? NON MALEFICENCEMANA YG LEBIH KUAT ARGUMENTASINYA ???
DOKTER : HRS BENEFICENCE ATAU HRS ADIL ???
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Ethics
Theory Virtue - eudamonia
Duty - deontologist
Utilitarian –
teleologist eg
happiness /
consequentialist
Metode AP
DEONTOLOGIS : SEMUA BAYI HRS DIUPAYAKAN HIDUPTELEOLOGIS : BOLEH SALAH SATU DIKORBANKANVIRTUE : KEUTAMAAN SIKAP DOKTER BERDASARKANHATI NURANI ???
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Ethical
RelativismCulture
Custom
BUDAYA : BANYAK ANAK BANYAK REZEKI ???
ANAK LAKI-LAKI > BERHARGA ??? (GENDER)
ORIENTASI KEKUASAAN MENGEXPLOITIR
ORANG AWAM ?
MOTIVASI RS DAN DOKTER ????
Metode AP
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Ethical
Dilemma
Science &
technology
determinant
Societal &
capital
determinant
Metode AP
EBM : PROGNOSIS IMUNO-KOMPROMAIS VS KOSMETISBALON KADES SBG SPONSOR DANA
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Ceteris
ParibusChoose 1 most
influential
principle
BILA PILIHAN : TETAP PADA
DUKUNGAN KE IBU BAYI
OTONOMI IBU
BENEFICENCE, NON
MALEFICENCE, JUSTICE =
DIANGGAP TAK
BERPENGARUH
Metode AP
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Ethical
Problem
Solving
Consistency
Coherent
Corespondency
Pragmatic
Metode AP
SEMUA KEPUTUSAN MEDIK DIARAHKANKEPADA PENGHORMATAN KEPUTUSAN IBU KANDUNG SBG OTONOMI
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Ethico-
Legal
Option
Administrative
Penal
Civil
Metode APResponsibility
Accountability
Liability
PROFESIONALISM
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DSp senior/ konsultan yg dosen FK/pemguasa RS
DSp
PPDS “basah” /DPU/DU senior
Puskes 24 Jam PTT Preklinik Pasca PTT
PPDS minor Karyawan biasa
Koasisten
Etika Sosial &
Latent “UKP” Error
1 kesuksesan
BANYAK penderitaan
PARADOKS :
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Charter on Medical Professionalism
Fundamental Principles:
Principle of primary of patient welfare = beneficence + non maleficence
Principle of patient autonomy
Principle of social justiceAnnals of Internal Medicine, Vol 136 Issue 3, 5 Feb 2002
http://www.annals.org/cgi/content/full/136/3/243
relevansi
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Professional Responsibilities
Commitment to improving access to care
Commitment to a just distribution of finite resources
Commitment to scientific knowledge
Commitment to maintaining trust by managing conflict of interest
Commitment to professional responsibilitiesPlease visit : www.professionalism.org
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Professional Responsibilities
Commitment to professional competence
Commitment to honestly with patient
Commitment to patient confidentiality
Commitment to maintaining appropriate relations with patients
Commitment to improving quality of care
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Dinamika Pengertian Hukum
Medikolegal/legal
Gunakan peraturan yg sdh ada (dibuat oleh penguasa/pejabat sah masa lalu) sbg “payung hukum” = YURIDIS KEPASTIAN HUKUM ttp bisa
terus ‘KUNO” !!!
Etikolegal
Buat peraturan baru berbasis etika (penguasa/ejabat sah kini utk kepentingan masa depan), krn yg lama sdh tak memadai/kasus konkrit blm ada aturannya, akibat perkembangan iptek, masyarakat dunia/lokal, kapital, dll = SOSIOLOGI HUKUM utk capai KEADILAN & KEDAMAIAN HIDUP ANTAR PRIBADI
Bila telah disahkan : menjadi medikolegal masa depan
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PELANGGARAN DISIPLIN = nir tanggungjawab
1. Tdk kompeten/ tdkcakap
2. Tdk merujuk ke dr/ drg yg kompetensinyasesuai
3. Mendelegasikan pd nakes yg tdkkompeten
4. Dr/drg pengganti tdkkompeten & tanpapemberitahan pd pasien
5. Tdk laik praktik (kesfisik & mental)
6. Kelalaian dlmpenatalaksanaanpasien
7. Pemeriksaan & pengobatanberlebihan
8. Tdk berikan informasijujur, etis & adekuat
9. Tdk laksanakaninformed consent
10.Sengaja tdk buat/ menyimpan rekammedik.
11.Penghentian
PERKONSIL 7/06
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Medikolegal-EtikoLegal
Masa lalu
Masa kini
Masa depan
Produk Hukum
Hukum Medis
Evaluasi
Masih LAYAKditerapkan?
MoralitasEtika
Ide Perancangan Legislasi
Produk Hukum Masih valid Evaluasi
Hukum Medis
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AHLAK AHLAK
MUKADIMAH KODE ETIK APOTEKERImplementasi - Jabaran Kode Etik IAI:
Setiap apoteker dalam melakukan pengabdian dan pengamalan ilmunya harus didasari oleh sebuah niat luhur untuk kepentingan makhluk lain sesuai dengan tuntunan Tuhan Yang Maha Esa.
Sumpah dan Janji Apoteker adalah komitmen seorang apoteker yang harus dijadikan landasan moral dalam pengabdian profesinya.
Kode etik sebagai kumpulan nilai-nilai atau prinsip harus diikuti oleh apoteker sebagai pedoman dan petunjuk serta standar prilaku dalam bertindak dan mengambil keputusan
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KODE ETIK KEDOKTERAN GIGI = KEWAJIBANMORAL
Aturan Profesi : Nilai, Standar, Prinsip (Kaidah Dasar Bioetika) & Aturan (pasal-pasal)
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Fungsi Kode Etik Kewibawaan korps makin mantap
substansi etis yang diatur & prosedurnya, makin kredibel
Parameter normatif tolok ukur perlindungan etis klien/pasien
makin altruis/deontologis makin luhur
Self regulating self disciplining utk akuntabilitas profesi berani
memanggil, menyidangkan & menjatuhkan sanksi
KODEKGI SBG “HUKUM MATERIAL”, SDGKAN KOMPENDIUM TATALAKSANAMKEKG (sdg disusun) SBG “HUKUM FORMAL”
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Kau kepedulian utama-kuAku sopan & teliti kpd-mu
Martabat & privasi-ku ? Ya,ya ku-hargai
Kusimak & kehormati pendapat-mu
Kuberi info sesuai BHS-mu
Hak2-mu ? OK, Ayo, ikut urun rembug !!!
Jaga penget & ketrampilan-kusetiap saat
Tahu batas kompetensi pribadi-ku !!!
Hormati & Jaga Info RHS-mu
Jangan salah gunakan kekuasaan-ku
Inti Perilaku-Baik Profesi
Agus Purwadianto, 2008
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Agama-ku tak membuatprasangka terhadap-mu
Rèk ayo rèk !! Kerjasama TimDemi kepentingan
terbaik-ku
Jujur & Terpercaya !!!!!
Kalau tak laik-praktek
Cepat tanggap bertindak
Lindungi Pasiendari Risiko
Inti Perilaku-Baik Profesi-2
Agus Purwadianto, 2008
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Accountability
Discipline
Ethico-legal SystemAgus Purwadianto, 2005
Patients’ Safety
Law as
social engineering
Liability
Value ofHealth
Patient/ClientFamily
Health PersonnelHealth FacilitiesHealth system
Medical Goals
Responsibility
EthicsProfessional
Dignity
PROFESSIONALISM
SOCIAL CONTRACT
PUBLIC TRUST
BEST INTEREST,
PREFERENCES,
MEDICAL INDICATIONCONTEXTUALITY
BALLANCING
CONFLICT OF INTEREST
CommunitySociety
QUALITY OF LIFE
BALLANCING
VIA BIOETIKA
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