Divisi Bioetika dan Humaniora

Fakultas Kedokteran
Universitas Sumatera Utara
2018
In the southeast Asian conception of
the relation of magic, religion, and
health, allowed the possibility of
social as well as strictly organic
origins of disease
 Pengobatan
Chiro
Ayuverda tradisional
practic
China

Homeopathy Unani
 As a practice embedded in theories, beliefs and
experiences which belong to different peoples,
traditional medicine has been used in some
communities for hundreds or even thousands of
years. It can be perceived as a fundamental feature of
their own identity and is often closely intertwined
with lifestyles, cultural frameworks and social
regulations, as well as domestic legislation.
 As medicine, the activity of traditional practitioners
has to comply with the requirements which are
appropriate to this practice, starting in the first place
with those of safety, efficacy and quality. This system
of knowledge, skills and practices is supposed to
contribute to improve health outcomes, which
include physical as well as mental and social well-
being.
 In traditional times, the societies of Asia
never adopted the exclusively biological
conception of disease that has become the
norm in modern Western societies.
 In traditional Indian Ayurvedic medicine, as
Desai Prakash argues, physicians classified
the etiology of disease in three categories:
external or invasive diseases caused by
foreign bodies or possession states; internal
diseases caused by disturbances of humors
brought about by lapses in discretion; and a
third category of disease brought about by
the inexorable workings of karma
 As Pinit Ratanakul notes in the article on
Southeast Asian countries, “This traditional
method of healing may be especially
suitable today for Southeast Asians, who,
living in societies with increased
urbanization and industrialization, need
physical, psychological and spiritual care to
enable them to cope with such change and
the strains and stresses of modern life.”
Today, then, as in the past, different
disciplines of medical treatment, each with
its own ethical standards and requirements,
exist side by side throughout much of Asia
 The preoccupation of traditional medicine
with magic, religion, and herbal concoctions
is due to its holistic approach to health and
healthcare. The practitioners work on their
patients at both the physical level and the
psychological/ spiritual level. While herbal
concoctions are mainly used to cure
patients’ physical illness, magico-religious
rites have a therapeutic effect on their
minds. The rites reassure patients of divine
blessing and protection, and strengthen
their selfconfidence.
One of the main challenges of
traditional medical practices is often
the difficulty in distinguishing
between real traditional healers and
so-called charlatans who can
physically and psychologically harm
those patients they claim to treat.
These pseudo-healers are actually a
heavy burden on the reputation of
traditional medicine as a whole.
 Loyalty to tradition does not give practitioners the
right to resort to the use of dangerous and harmful
practices. Potential harms also come from misusing
the herbal components. The common
misconception about the absence of side effects
and toxicity of natural products can lead to
uncontrolled and exaggerated intake resulting in
severe intoxication and acute health problems. This
misconception involves less, as well as highly
developed, countries, where people often resort to
“natural” products without appropriate awareness
and information about the associated risks,
especially in the case of overuse
• Ethical Decisions are Ultimately
Concerned with Life and Death
• Definition of Life and Death in Bioethics
Determine the Financial Burden of Health
Care
• - Science and Technology
- Culture
- Ethnic
- Local Belief
- Religion
Influence the Concept of Death
CONSCIOUSNES
S
• Cerebrum
The quality of
consciousness
• Brain Stem
off – on
consciousness
Qualitative Quantitative
(Glasgow)
(E, V, M Response)
Alert 4 – 5 – 6 (15)
Somnolent (13 – 14)
Soporous (9 – 12)
Comatous (3 – 8)
Unarousable unresponsiveness
May be caused by systemic causes
metabolic drugs, or cns damage
Reversible or irreversible
May ensue to BD/BSD/PVS

Coma ≠
BD/BSD
Three preconditons
• Patient on a ventilator
• Coma due to irremedial structural brain damage
• No - Depressant or neuromuscular blocking drugs
- Primary hypothermia
- Metabolic or endocrine abnormalities

Five tests
• No pupillary response to light
• No tracheal, gag or cough reflex
• No response to facial and peripheral pain
• No cold caloric responses
• No respiratory effort after achieving a PaCO2 of 50
mmHg for 10 min or more
Avoid premature diagnosis of BD / BSD
 Marlon Ploch, F, 18yr pregnant of 14 weeks
 Got car crash, severe brain damage, presented
in ER, already intubaled, respirated
 3 days later stated as BD
Q:
• Should the fetus be aborted
• Let the life support be maintained until the fetus
viable?
• Could a dead body deliver a healthy baby?
40 days after / 19 week pregnancy spont. aborted
 Viewpoint Beginning End
Philosophical Ensoulment Separation of
soul–body
Physiological Conception Irreversible
(Classic) function stop of
respiration /
cardiac
Physiological • Conception BD / BSD
(Modern) • Some time after
Conception
Three clinical criteria all be fulfilled
1. No evidence of awareness of self or
environment. No volitional response to
visual, auditory, tactile or noxious stimuli.
No evidence of language comprehension or
expression
2. Cycles of eye closure and opening
simulating sleep and waking
3. Sufficiently preserved hypothalamic and
brain stem function to maintain respiration
and circulation
 VEGETATIVE STATE
Other clinical features
1. Incontinence of bladder and bowel. Spontaneous
blinking and usually retained pupillary and corneal
responses. Conjugate or dyconjugate tonic response
to ice-water caloric testing’s
2. No nystagmus to caloric testing. No visual fixation,
tracking of moving objects whit eyes or response to
menace
3. May be occasional movements of head and eyes
towards sound or movement, and of trunk and limbs
in purposeless way. May have startle myoclonus. May
smile; may grimace to pain. May have roving eye
movements

(Royall College of Physicians Working Group, 1996)

One year outcomes of patients in VS after head
injury
Duration of VS n Dead Vegetativ Consciou Independe
(%) e s nt
(%) (%) (%)
1 month 140 51 11 36 10
3 months 49 49 31 20 0
6 months 30 52 16 0 B. Jennet, 2002
 VEGETATIVE STATE
AGE
Independence at 1 year from patients in VS 1
month after head injury

Age n % Independent
< 20 years 53 21
20 – 39 years 46 9
> 40 years 41 0
B. Jennet, 2002
ETHICAL PROBLEMS ON PVS
• How long should VS be stated as
PERSISTENT
• How long could a patient in VS live
• Could we limit/withdraw the treatment
once a VS is declared permanent
6 months ? 12 months ?
IDI =
… if the treatment is no more useful, contrary
to the goal of medicine…. it may be
discontinued.
(questionable, debatable, Darmadipura 2008)
• Death is a process. Not all cells of the body
are of the same vulnerable to hypoxia /
anoxia
• Definition of death
– Spontaneous arrest of resp. & cardiac
functions that is ananimous and
irreversible
– Brain dead
(consistent to Gvt. Decree 18/1981)
 Indonesian Medical Association
Statement & Recommendation
(IDI 231/PB/A.4/07/90)
• For the sake of organ transplantation the definition
of BD is used. All medical treatments are
maintained, to perfuse and maintain the functions
• Recommendation : in a certain condition in which
therapeutic / palliative treatment is not useful
anymore, that its maintaining is contrary to the
goal of medicine, it may be discontinued. The
cessation of it is recommended be consulted to at
leas one other doctor
CAUSING DEATH
Either : - Intentional
- Unintentional (by mistake, error, or
negligence)
- Upon Request
- Provoke other to Suicide
- Help other to Suicide
are prohibited
(Art. No. 338, 340, 344, 345)
He is Who gives life and causes death and
to Him you (all) shall return
(Yunus, 10:56)

Only Allah has the right to take one’s life

Asking to die (ISLAM)
Committing suicide (ISLAM, LAW/KUHP)
Praying for dying (ISLAM)
Helping someone to die (KUHP)
Helping someone to commit suicide (KUHP)
The beginning and the end of life is most closely
related to the principle of respect for person
1. Brain Death (BD), or more accurately Brain
Stem Death is largely accepted as one of the
definitions of death. But still ethically and
philosophically problematic
2. Persistent Vegetative State (PVS) is debatable
on the discontinuation of therapeutic efforts
3. Any murder (causing death) either
intentional, unintentional, helping other to die
or suicide is criminal