ETHIC DECISIONS

IN LUNG CANCER
MANAGEMENT
DR. BAHTIAR HUSAIN, SP.P, MH.KES
PIT MHKI
24 SEPTEMBER 2017, UNIVERSITAS BUNG KARNO,
JAKARTA
 CURRICULUM VITAE
DATA PRIBADI
 Nama : Bahtiar Husain, dr, Sp.P, MH.Kes
 Tempat/tanggal lahir : Parepare, 7 April 1963
 Pekerjaan : Dokter PARU di RS PARU FIRDAUS
 Instansi : KEMENKUM- HAM
 Agama : Islam
 ALAMAT` : Jl. Siak No. 14, Kompleks Bea Cukai, Jakarta Utara

HP : 081319812424
E-MAIL : tiar63@yahoo.co.id / bahtiarhusain63@.gmail.com

PENDIDIKAN UMUM
 SMA Negeri I Parepere 1983, Sulawesi Selatan
 S1 : Fakultas Kedokteran Universitas Hasanuddin, Makassar 1991
 S2 : Fakultas Hukum Kesehatan , UNHAS 2009
 S3 : Mahasiswa program Doktor bidang Hukum Univ. Borobudur 2017

PENDIDIKAN SPESIALIS
 Fakultas Kedokteran bagian Pulmonologi, Universitas Indonesia 2004

ORGANISASI
 Ketua Lembaga Advokasi Kedokteran Indonesia ( LAKI)
 Anggota Majelis Kehormatan Etika Kedokteran Indonesia (MKEK) PB IDI 2015-2018
 Ketua Etik dan Hukum Perhimpunan Dokter Paru Indonesia, PDPI 2015 -2018
 Member of Council President World Association for Medical Law ( WAML )
GOALS
1. Why Lung cancer.
2. Avoid Ethical misconduct
■ Understanding the principles of ethics.
■ Understanding the ethical decision making
3. Make patient heal or confort always
 SUSPENDED FOR
PROFESSIONAL MISCONDUCT
• Prominent oncologist Dr Ang Peng Tiam has been
suspended for eight months on Tuesday (Jun 27) over
charges of professional misconduct.

• In April 2010, a 55-year-old woman with lung cancer

consulted Dr Ang, the medical director of Parkway
Cancer Centre, who told her there was “at least a 70
per cent chance that her disease would respond to
treatment and achieve control” with chemotherapy
and targeted therapy.
LUNG CANCER, POOR PROGNOSTIC
Lung cancer is a
Forty-five percent die The majority will have
worldwide health
within the year of stage III and IV, so the
problem causing more
diagnosis, despite the treatment is mostly
deaths than others
current best treatments. palliative.
cancer.

Often managed by
Often relapse, because Unresectability considering variables, such
as patient age, patient family
most biologically represents the poorest influence, insurance,
aggressive. prognostic. physician experience and
beliefs

Need support
ethical decision
in treating
 ESTIMATED MOST COMMON CANCERS DEATHS IN 2017

Cancer type Number of deaths 2017 % of all cancer deaths 2017

Lung 9,021 18.9

Colorectal (bowel) 4,114 8.6

Prostate (among males) 3,452 12.7

Breast 3,114 6.5

Breast (among females) 3,087 14.9

Pancreatic 2,915 6.1

POOR PROGNOSTIC
• Only one in five patients can have a
curative resection.
• The value in cancer care and
treatmen; benefit in life extension
and improved quality of life. FACE CONTROVERSY
• Many cancer drugs fail to meet this
standard.
• Decisions have to be made according
IN MEDICAL
to the goals of the care
• Clinicians must be aware an
DECISION MAKING
understanding of the basic ethical
principles
 WHAT IS ETHICS?

The ideal human Ethics has to do Ethics consists

Ethics is the
character and the reasons with what my of the standars
study of
that validate human feelings tell me of behavior our
morality
conduct as right or wrong is right or wrong society concepts

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 ETHICAL THEORIES

Teleology: looks to the

Deontology: It emphasizes Principlism : Beneficient,
consequences of an action
duty, rationality, and nonmaleficient, Justice and
in judging whether that
obedience to rules Autonomi
action is right or wrong
1) BENEFICENCE : THE
OBLIGATION TO PROVIDE
BENEFITS AND BALANCE
BENEFITS AGAINST RISKS.
THE ‘FOUR –
2) NON-MALEFICENCE: THE
OBLIGATION TO PREVENT
HARM (PREMIUM NON
PRINCIPLES’
APPROACH
NOCER).
3) AUTONOMY : THE
OBLIGATION TO RESPECT THE
DECISION-MAKING

4)
CAPACITIES OF
AUTONOMOUS PERSONS.
JUSTICE : OBLIGATIONS OF
TO HEALTH CARE
ETHICS
FAIRNESS IN THE
DISTRIBUTION OF BENEFITS
AND RISKS.

Beauchamp and Childress, in the 1980’s

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 The purpose of medicine
• To benefit the sick
HIPPOCRATIC • To refrain from harm

TRADITION “Practice two things in your dealings with disease: either help
or do not harm the patient”
(Hippocrates, 460 – 377 BC)
 ِ ‫الناس أ َ ْنفَعُ ُه ْم ِلل‬
‫ناس‬ ِ ‫َخي ُْر‬

MUHAMMAD
RASULULLOH
Sebaik-baik manusia adalah
yang paling bermanfaat
bagi manusia” (HR. Ahmad,
ath-Thabrani, ad-Daruqutni)
 • An old medical maxim, the goal of
MEDICAL MAXIM medicine concisely… Cure sometimes,
support frequently, confort always
The World Medical Association
Declaration of Geneva (1948):
Physician's Oath

‘The health of my patient will be my first

consideration’;
‘I will not use my medical knowledge to
violate human rights and civil liberties,
even under threat.’
BPJS ???
Ethical Decision Making Moral Principle

Lung cancer
Advance disease
Skill and knowledge
Moral
Personal Do Everything
Oath
Cost
Do Something
Goal Do Nothing
Time

OUTCOME, heal and confort

CERTAINTY DOES NOT EXIST

 Ethical Decision

Do Everything
Do Something
Do Nothing
The goals and expectations are different for
patients presenting resectable versus
unresectable disease.

Thus, what is best for each patient will be

different.
 ETHICAL QUESTIONS

Should patients know all

Ethical decision making is based on a aspects of a cancer
In making ethical disicion to help
prioritization of values (moral,
resolve the conflict , simply ask diagnosis, including survival
personal, religious, legal) that are
“How should we act with what we data, prognostic factors,
outside the scope of the medical
know? and probable future threats
knowledge base.
of their illnesses?
THE GOAL TREATMENT
General goals in medicine are to
heal and to comfort — to avoid
untimely death for patients, prolong
life, prevent disability and improve
function, diminish pain, reduce
unacceptable symptoms, and avoid
adding to patients’ unnecessary
suffering
The therapy chosen in the best
interest of a patient is chosen not
based upon what the clinical
team wishes to happen, but what is
the best judgement of collective
clinical experience, which the
team knows probably will happen for
the patient. (Justice)
 1 2 3 4
Begin by asking the Identify the goals of Begin by suggesting Suggest what
patient/family to care for the patient what interventions interventions may not
explain their would be helpful in be helpful in
understanding of the achieving the achieving the
current situation. patient’s goals of care patient’s goals of care

A STRATEGY FOR DISCUSSING GOALS OF CARE

 AVOID MEDICAL FUTILITY

Institutions have
Treatment is ethically
Conflicts: developed futility
Interventions that will futile if it will not serve
benefit/burden of polices to assist in
lead to no useful result the underlying interests
treatment determining when a
of the patient.
treatment is futile.
ETHICAL DILEMMA

A dilemma exists when a difficult problem seems to

have no satisfactory solution
• Or when all solutions to a problem appear to be
equally favorable.
• e.g. conflict between principle of non-malifecense and
autonomy
 WHAT IS ETHICAL DECISION MAKING?

Ethical
A low-quality
When faced with an ethical The risk is decision
decision can
dilemma the objective is to poor making is not
have a wide
make a judgment based on judgment i.e. a science. It is
range of
well-reasoned, defensible a low-quality however a skill
negative
ethical principles. decision -- a survival
consequences
skill
TWO TYPES OF ETHICAL CHOICES

Right vs wrong:
choosing right from Right vs right
wrong is the easiest

Situation contains
shades of gray i.e. all
Choosing “the lesser Objective: make a
alternative have
of two evils” defensible decision
desirable and
undesirable results
FINAL THOUGHTS

• If death has to occur at all, it should be with dignity, and at a reduced price.
• In treating lung cancer works well only:
• Mutual trust,
• Not of a physician's arrogance,
• Nor professional codes of conduct,
• Nor fear of liability,
• Nor irrational promises
• Nor patient — family unfounded expectations.
• Avoid destroys the fundamental principles of: Beneficient, nonmaleficient, autonomy and justice.
• The pulmonologist must identify the spectrum of treatments, patient preferences and goals in order to inform
the patient about the current disease.
TERIMA KASIH

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