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KAIDAH

DASAR

BIOETIK &
Yuli Budiningsih

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 (Websters).
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 13 th Century Muslim Scholar Maulanas


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 20042007.

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.Deontology
2.consequentialism
3.principlism
4.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 counterproductive 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 decisionmaking 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 as
often 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 asalasalan).

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 diterima


Distributif (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.

Medical
Indication

Beneficence

Deductive logic
Non Maleficence

Autonomy

Justice

Method =
Logic Thinking critical analysis

Combination of
Its characteristics = Patients Context

Principles-based ethics
Prima Facie
T.Beauchamp & Childress (1994) & Veatch (1989)

Patients preference
Beneficence
Autonomy
Non Maleficence

Contextual features
Quality of life
Value-based medicine

Justice

Clinical Decision
Making

Medical indication

EBM

Medical
Indication
Beneficen
ce

ENRICHMENT OF
JUSTIFICATION
Non Maleficence

Autonomy

Justice

(NEW) ILLAH = actual duty = contextuality


PRIMA
FACIE
CETERIS PARIBUS
DEDUCTIVE >< : DETECT
LOGIC
DEVIATION
OPPOSITION

VALUE
CONFORM

CREATIVE THINKING

Not stipulated in the text =


Patients Context

Medical
Indication

Beneficence

pihak II
Umum
BAIK
kranjang
Sampah

TROEF = berubah
menjadi
Non Maleficence

pihak II
kesakitan/
menderita,
gadar,pra-cacat
Distress
Rentan
uzur,
terjepit
tanpa pilihan
Miskin
bodoh.

Autonomy

capable
person
bebas
Elektif
rentang >>
hak pilih a
// DRnya

Justice

pihak III
Non pasien
wakil/wali
kluster pop
Komunitas
Penyandang
dana
Berpotensi
Dirugikan/
Paling krg
diuntungkan

The patients contexts for prima facies choice


(Agus Purwadianto, 2004)

Time

Gen eral b en efi t


resu lt, mo s t o f
p eo p le,

Elect iv e, ed u c at ed ,
b read -win n er, ma tu re
p erso n

Beneficence

Autonomy

Non
maleficence

Justice

Vu ln erab les,
emerg en cy, lif e
sav in g , min o r
TERGANTUNG .

> 1 p erso n , o th ers


similari ty, co mmu n ity /
so cial s rig h ts

BERUBAH MENJADI

The Scope of ethics in Medicine


bioethics

rights
justification
conscien
ce

self
reflection
ethics

Macro level
Politics of Health

Deduction
= logic

Meso level
Health services delivery
Macho level
Health care teams
Micro level
Clinical medicine

Induction
= casuistry

Concrete
Daily living

Goals of medicine
43

Promotion of health and


prevention of disease
Relief of symptoms pain,
and suffering
Cure of disease
Prevention of untimely death

03/21/15

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): 127.

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 (nonmaleficence). 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.