Ethics in Optometric Practice- the Obligations that Define a Profession

Dear Editor:
THE DEFINING FEATURE OF A PROFESSION
The use of the word profession has expanded so far beyond its original meaning that a
clear definition has become obscured and marred by colloquial usage1. It is not
uncommon to find the term professional misused to describe sportsmen, tradesmen and
even politicians. Yet, when we speak about a professional there is a tacit understanding
that only individuals engaged in certain occupations belong to that category: doctors,
lawyers, teachers. A fundamental distinction between a profession and any other
occupation, is that individuals engaged in a profession have an ethical obligation to
whomever they offer their services. In other words, a profession is required to have a
Code of Ethics.
THE ORIGIN OF ETHICAL CODES
Optometry ranks amongst the leading healthcare professions and various national Codes
of Ethics for Optometry exist1. These can all be traced back to one of the original sources
of medical ethics in the Western world: the famous oath of Hippocrates1. Hippocrates
lived around 460-380 BC and was believed to be part of a physicians cult in ancient
Greece who were faithful to Asclepius, the god of medicine and healing. Indeed, the
memory of the worship of Asclepius lives on in modern medicine: the snake around the
physicians staff is attributed to this god as snakes were part of the ancient healing ritual.
Whilst reptilian remedies do not form part of medicine and healthcare today and
Hippocrates original oath (as we understand it through modern translations2) includes
statements that would not concord with modern practice: e.g. a pledge to remain chaste
and religious and never to procure abortion2, the essence of the Hippocratic oath endures
in current principles of medical and healthcare ethics.
The oath has been transposed through history and more recently was incorporated into
the Declaration of Geneva (1948) that followed the aftermath of the Second World War1.
The following year, in response to Nazi War Crimes, the World Medical Association
adopted The International Code of Medical Ethics1. This has formed the basis of the
codes of ethics of a number of healthcare professions.
ETHICAL PRINCIPLES
The ethical codes contain guiding principles. These serve to help practitioners in their
decisions and in practicing in accordance with a set of standards that are expected of a
healthcare practitioner. Beauchamp and Childress3 cite beneficence, non-maleficience,
respect for autonomy and justice as the four major ethical principles in healthcare. These
principles can be described as follows:
(i) Beneficence is striving to do good and to do the best for every patient. This recognises
that a practitioner has a duty of care to every patient and that paramount is the objective

to do good so that every patient leaves the practice in a better state then when they
entered, or at the very least, not in a worse condition.
(ii) Non-maleficience, directly traceable to the Hippocratic oath (above all to do no
harm)1, is about the avoidance of harm. This requires balancing risks and benefits of
treatment and making decisions that will optimise the benefits and minimise the risks of
harm.
(iii) Respect for autonomy requires a practitioner to respect the choices and decisions that
a patient makes about his/her own health. This involves keeping the patients informed of
their condition, treatment choices and options so that decisions made are based on
pertinent facts.
(iv) Justice entails being fair to all patients in a way that transgresses legal justice. It
includes deciding how much time is spent on a patient, how many and what types of
resources are devoted to treatment of that patient and how this compares to the time and
resources distributed to other patients.
In addition to beneficence, non-maleficence, respect for autonomy and justice, the
principles of confidentiality, protection of the vulnerable and collegiality have been
included to form the ethical principles that should guide optometric practice1.
Confidentiality means non-disclosure of patient details and health records in order to
respect the privacy and preserve the dignity of each patient. Like nonmaleficence, it can
be traced directly to the Hippocratic oath: Whatever I see or hear, professionally or
privately, which ought not to be divulged, I will keep secret and tell no one1.
Protecting the vulnerable involves standing up for the rights of those who may be unable
to speak or act for themselves. Although all patients are to some extent vulnerable for
they come for help to the practitioner, some are more vulnerable than others. These
include children, the frail elderly and patients who are unable to make decisions for
themselves. Whilst some of these patients may not be considered autonomous by law
(such as children) and others may be mentally unable to exercise autonomy, their dignity
must at all times be respected and the duty of care the practitioner owes them may require
a degree of protection that extends beyond the usual duty of care.
Collegiality calls for support of colleagues and fellow practitioners and professionals.
This is the only ethical principle that does not apply to patients but to the way
practitioners treat one another. Collegiality means mutual respect and understanding for
fellow optometrists, for other professionals and for their respective roles in the health
care team.
THE PROBLEM WITH ABSOLUTE APPLICATION
Each of these principles would appear to be sound and simple to follow, almost too
obvious to need stating. Yet, for each one of them situations that may render that principle
limiting or difficult to apply will arise. This illustrates the paradox that whilst these

principles are essential tools for ethical practice, if applied too rigidly, they can be
problematic. No principle can be applied absolutely. Take the example of beneficience. It
is easy to say that a practitioner should at all times do his/her best for a patient but it is
not so simple to define how good is good enough? Should a practitioner become so
completely selfless that (s)he commits his entire life and all available time to helping
patients at the expense of a private life and duties to family? The difficulty with
beneficence is that it is limitless and every practitioner needs to decide how far (s)he
wants to take this principle.
Non-maleficence may not be limitless but it may be limiting. No practitioner will ever set
out to harm a patient, yet certain practice methods will incur a risk of harm: contact
tonometry or the prescription of a contact lens can result in unwanted side effects. To
apply non-maleficence rigidly would require a practitioner to abandon all practice
methods with the potential of harm, no matter how minimal the harm or how small the
risk. This would limit the practitioner to such an extent that optometric practice may not
be feasible.
Respecting the autonomy of a patient who refuses to wear a prescription without which
(s)he is below the legal standard for driving, can pose difficulties. Can the optometrist
always respect the choice of a patient whose behaviour may be unreasonable and
potentially dangerous? More poignant illustrations of limits on autonomy are seen in
cases of patients who are suffering from debilitating and painful conditions and wish to
die. In many countries, where euthanasia is illegal, such patients wishes cannot be
respected.
Justice means being fair to all patients but that involves the complexity of deciding the
basis of this fairness and how time and resources should be distributed. It would be
easiest to say that all patients should be given half an hour of an optometrists time but
this may prove to be too inflexible: some patients may need less time and some
considerably more. Similarly, it may sound just to declare that the same treatment should
be given to patients with the same condition. How is this to be reconciled in the case of a
ninety year old lady with cataracts that leave her with visual acuity of 6/18 and the forty
year old long distance driver with the same type of cataract and same visual acuity?
Should both necessarily be referred for cataract surgery?
Confidentiality may be compromised when a patient discloses to a practitioner something
that may have serious ramifications for the patient and potentially for others. It can be
very difficult for an optometrist to decide whether or not to keep confidential the details
of a patient who admits to having AIDS but asks the optometrist to keep this secret from
his (the patients) wife.
Protecting the vulnerable may require deciding how far this protection can extend.
Should the parent of a child patient who appears with multiple bruising be reported even
though the matter has nothing to do with eye care? Reporting such a matter to social
services may result in innocent parents having to defend themselves against charges of
child abuse. Not reporting, may leave a vulnerable child open to further risk of harm.

Collegiality is easy to practice with those who have similar interests and outlooks. It can
be more difficult when working with a fellow optometrist who has different perspectives,
opinions, attitudes and behaviour. If the colleague is practicing ethically, personal
differences should be put aside. Collegiality also has no place for prejudice or
professional jealousy. If a colleague is behaving in a manner that may be inappropriate
for a professional, collegiality cannot be used as an excuse to protect what is wrong. Help
should be offered but in some cases a colleague may need to be reported.
ETHICAL DILEMMAS
In addition to situations that complicate the application of each principle, there will be
circumstances that cause principles to conflict: applying one will almost certainly require
disregarding another. In such cases, the practitioner is confronted with an ethical
dilemma.
This is obvious in the case of an overweight diabetic who presents to the optometrist with
early signs of retinopathy. The patient is a smoker and is reluctant to stop this habit
claiming that he needs to smoke to try to reduce his weight. Beneficience requires the
practitioner to do his/her best for the patient. The very best is clearly to do whatever is
possible to alter the lifestyle of the patient. Yet, the patient insists that he will continue to
smoke and the practitioner is also obliged to respect the patients choices. The conflict
between beneficence and respect for autonomy is clear. It is also clear that in such a case
a practitioner cannot enforce smoking cessation on the patient. The best that can be
offered is advice. The autonomy of the patient and respect for his choices presides over a
more active application of beneficence.
A less obvious dilemma arises in the case of a patient requesting treatment about which
the practitioner has reservations. How does a practitioner, who is concerned about the
risks of orthokeratology in young patients, respond to the parents of a young myope who
have heard about the alleged beneficial effects of orthokeratology in retarding the
progression of myopia and insist on this method of correction being prescribed for their
child? The dilemma between non-maleficence, respect for autonomy and protection of
the vulnerable is evident. What may be less evident is the dilemma that a practitioner
faces when research about a method is conflicting and, therefore, presenting patients with
reliable information is, not possible.
CONCLUSIONS
Unlike laws and regulations, which are prescriptive and rigid, the principles of ethics are
flexible and how they are applied depends on the individual practitioner. This places on
each optometrist: a) the responsibility of developing personal ethical standards and b) the
expectation of possessing the requisite self-discipline to practice in accordance with these
standards. It is these responsibilities and expectations that are the hallmarks of a
profession.

Barbara Pierscionek
Professor of Vision Science. School of Biomedical Sciences,
University of Ulster, Cromore Road, Coleraine, BT52B 1SA U.K.
REFERENCES
1. Pierscionek BK. Law & Ethics for the Eye Care Professional. Butterworth
Heinemann Elsevier, Edinburgh, London, 2008.
2. Chadwick J, Mann WN. Hippocratic writings. Penguin Books, London, 1950.
3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th edn New York:
Oxford University Press; 2001.

Euthanasia And The Principal

Of Nonmaleficence
David San Filippo, M.A., LMHC
October 5, 1992
Introduction
The practice of euthanasia has grown in the past 40 years. In 1950, one-third of
Americans believed that doctors should be allowed to practice euthanasia. By
1991, the figure had grown to nearly two-thirds of the Americans surveyed
(Hamburg, 1992, p. 10). According to a 1975 Gallup poll, 41% of the
respondents believed that someone in great pain with "no hope of improvement"
had the moral right to commit suicide. By 1990, 66% of the people polled
believed that it was acceptable to end their own life when recovery was not
expected (Ames, 1991, p. 41).
The option that more and more patients, and their families, demand is to leapfrog
dying if death is all that awaits. While many people choose death, no one
chooses dying. Although there are no national statistics, anecdotal evidence
suggests that more than half of hospital deaths follow a decision to limit or
withhold life-sustaining treatment. This is not suicide, or euthanasia, for both of
those mean ending life. It is, rather, a desire to end dying, to pass gently into the
night without tubes running down the nose and a ventilator insistently inflating
lungs that have grown weary from the insult (Begley, 1992, p. 44).
Attitudes towards euthanasia are changing. As the Begley quote demonstrates,
many people consider ending dying as being different than ending life. This
appears to be a matter of semantics. Death, by either perspective, results in
ending both life and the process of dying.
The moral principle of nonmaleficence espouses the belief of not inflicting harm
on an individual (Beauchamp, 1989, p. 120). The version of the Hippocratic oath,

which is considered the source of the principle of nonmaleficence, approved by

the American Medical Association (1975), states,
That into whatsoever house you shall enter, it shall be for the good of the sick to
the utmost of your power, your holding yourselves far aloof from wrong, from
corruption, from the tempting of others to vice.
That you will exercise your art solely for the cure of your patients, and will give
no drug, perform no operation, for criminal purpose, even if solicited, far less
suggest it (unpaginated).
At first reading, the Hippocratic oath and the principle of nonmaleficence could be
considered to be in conflict with the practice of euthanasia. In this paper, I will
present the position that euthanasia is not in conflict with the principle of
nonmaleficence or the Hippocratic oath but is a service to individuals who are
suffering and waiting to die.
Euthanasia
By definition, euthanasia is derived from two Greek terms "eu", which means
"good" and "thanatos," which means "death," and can be interpreted as signifying
" a good death," a "beneficial death," or an "acceptable death." Euthanasia is not
considered killing. Killing, by definition, implies the taking of life against the will of
the person who is to die (Humphry, 1986, p. 86).
There are two types of euthanasia, passive and active. Passive euthanasia is
considered to be the act of allowing a person to die without attempting any
"heroic measures" to sustain the life of the individual. A famous example of a
passive euthanasia case is that of Karen Ann Quinlan. She lapsed into an
irreversible coma following the ingestion of drugs and alcohol. Her parents
requested that she be taken off of a respirator but allowed her to be fed through a
nasogastric tube. She lived for almost ten years after she was removed from the
respirator. The act of passive euthanasia allows the individual to die naturally
(Humphry, 1986, 1990; Beauchamp, 1989).
Active euthanasia involves the taking of positive steps to end the life of a
terminally ill individual. The Hemlock Society is a group which supports active
euthanasia for the individual that rationally decides to end his or her life
(Humphry, 1990, pp. 116-117). The actions of Dr. Kevorkian, by developing and
providing the "suicide machine" for individuals who were terminally ill and in pain,
can be considered an act of active euthanasia (Kovorkian, 1991).
According to Beauchamp (1989), conditions that might lead to the discontinuance
of treatment and the consideration of active or passive euthanasia is when
treatment might be pointless, or the burdens of treatment may outweigh the
benefits, and or the quality of life is poor.

Treatment is not obligatory when it offers no prospect of benefit to the patient

because it is pointless.
If the patient is not dead or dying, medical treatment is not obligatory if its
burdens outweigh its benefits to the patient. When patients are not irreversibly
dying and their deaths are not imminent, medical treatment may be optional even
if it could prolong life for an indefinite period.
Judgement that treatments are optional often presuppose or otherwise rely on
standards of the quality of life. Any attempt to make life - understood as a set of
vital logical processes - unconditionally good in itself is a "vitalism" that should be
rejected in favor of a view that life is only conditionally good. The maintenance of
biological life thus should not automatically be considered a (net) benefit to the
person.
It is [also] important not to confuse quality of life for the patient with the quality
or the value of life for others. Quality of life is not tantamount to social worth or
group preferences (pp. 155-158).
The quality of life question should be a personal assessment of the individual's
perception of his or her value of life, not the value assessed by others.
Principle of Nonmaleficence
The principle of nonmaleficence is considered by some rule-deontological and
rule-utilitarian theorists to be the foundation of social morality. Some
philosophers view nonmaleficence and beneficence as similar and distinct
obligations of human life. Beneficence suggests the acts of mercy, kindness, and
charity. It includes any form of action that benefits another (Beauchamp, 1989, p.
194).
Philosopher, William Frankena believes that the principle of beneficence includes
four elements, one which is the principle of nonmaleficence.
1. One ought not to inflict evil or harm.
2. One ought to prevent evil or harm.
3. One ought to remove evil or harm.
4. One ought to do or promote good.
Nonmaleficence is distinguished from and part of the principle of beneficence by
its commitment to not inflict harm to an individual. Beneficence involves positive
acts of preventing harm, removing harm, and promoting good (Beauchamp, pp.
121-123).
The principle of nonmaleficence supports several moral rules. Rules prohibiting
harmful actions are at the core of morality - for example, "Don't kill," "Don't cause

pain," "Don't deprive of freedom of opportunity," and "Don't deprive of pleasure,"

(Beauchamp, p. 125).
The principle of double effect, which is a part of the principle of nonmaleficence,
provides for the understanding that good can come out of a bad act.
The principle of double effect has been invoked to support claims that an act
having a harmful effect such as death does not always fall under moral
prohibitions such as the rule against killing (Beauchamp, p. 127).
Death can be considered a major harm to the human being. It therefore could be
considered a conflict with the principle of nonmaleficence.
Discussion
The morality and the legality of euthanasia should be two different discussions
and considerations. The legality of euthanasia should be an evolution from the
moral principles and beliefs of society regarding euthanasia. For the purpose of
this discussion, I will focus on a moral consideration of the individual's right of
choice regarding his or her death by euthanasia as a non-violation of the moral
principle of nonmaleficence.
The morality of euthanasia could be justified by the moral principle of
nonmaleficence even though there may appear to be dilemma with the principle
of "do[ing] no harm."
Moral dilemmas take at least the following two general forms. (1) Some
evidence indicates that act X is morally right, and some evidence indicates that
act X is morally wrong, but the evidence on both sides is inconclusive. (2) The
agent believes that, on moral grounds, he or she both ought not to perform act X
(Beauchamp, 1989).
The act of euthanasia does not cause the dying individual harm because the
harm to the individual is in the pain and or suffering of his or her continued life.
Morally, the terminating of an individual's life, either passively or actively, could
be considered a positive response to the terminally ill person by relieving his or
her pain and suffering. An element of suffering could be considered the lack of a
quality of life, as determined by the suffering individual. In the situation where
the individual is incapacitated from making a decision regarding his or her quality
of life, this decision would fall to a proxy person who would be expected to act in
the manner consistent with the dying person's desires.
In order for an act with a good and bad effect to be justified, the principle of
nonmaleficence's double effect principle specifies that four conditions need to be
satisfied.

1. The action itself (independent of its consequences) must not be intrinsically

wrong (it must be morally good or at least morally neutral).
2. The agent must intend only the good effect and not the bad effect.
3. The bad effect must not be a means to the end of bringing about the good
effect; that is, the good effect must be achieved directly by the action and not by
way of the bad effect.
4. The good result must outweigh the evil permitted; that is there must be a
proportionality or favorable balance between the good and bad effects of the
action (Beauchamp, p. 128).
The action of passive or active euthanasia is not wrong if the individual, whose
life is to be ended, consciously has requested that his or her life be ended. The
act of euthanasia is not intended to inflict harm on the individual but to end his or
her pain and or suffering. In order to not defy the third double effect condition,
"the bad effect must not be a means to the end of bring about the good effect,"
the method of euthanasia should not inflict additional pain or suffering on the
individual. Therefore, it could be argued that the withholding of medical nutrition
and hydration could be harmful to the conscious patient and should only be
considered for unconscious, comatose individuals.
The American Medical Association has also made two influential
pronouncements on this general subject. In 1982, the AMA's Council on Ethical
and Judicial Affairs stated that in cases of well-confirmed irreversible coma, "all
means of life support may be discontinued." In 1986, the council clarifies the
earlier statement by specific reference on MN&H, holding that "life-prolonging
medical treatment includes medication and artificially or technologically supplied
respiration, nutrition, or hydration," (Beauchamp, p. 165).
Non-painful methods of euthanasia, such as drug overdose, could be considered
an acceptable method for discontinuing the life of non-comatose individuals.
However, the decision on how to end one's life should be the decision of the
dying individual, when he or she is capable of making that decision (Humphry,
1986, 1990).
The fourth condition of the double effect principle, of nonmaleficence, states that
"the good result must outweigh the evil permitted." The "evil" act could be
argued since it could be considered that the "evil" act of ending an individual's life
is a positive act, similar to the use of chemotherapy to eradicate cancer.
Euthanasia relieves the pain and or suffering of the individual's life, similar to
where chemotherapy potentially ends the suffering of cancer. Therefore the "evil"
act is good.

The principle of nonmaleficence states that no harm should be brought upon an

individual. However, if a person is suffering from intractable pain, is terminally ill,
and or his or her quality of life is poor - from his or her perspective, than the use
of euthanasia could be considered acceptable and the principle of
nonmaleficence remains intact. Physicians should be free to practice
euthanasia, if requested by the individual or proxy, and not be in breach of their
Hippocratic oath with the exception of the criminality of the act, which is a legal
issue. By practicing euthanasia, the physician is doing "good of the sick", by
relieving/"curing" him or her of his or her pain and suffering in this life. By
relieving the individual of the pain of his or her condition, euthanasia is not
inflicting evil or harm but is an act of nonmaleficence and beneficence towards
the human being.
REFERENCES:
American Medical Association. (1975). Hippocratic Oath. [Brochure],
unpaginated.
Ames, K. (1991, August 26). Last rights. Newsweek, pp. 40-41.
Beauchamp, T. L. & Childress, J. F. (1989). Principles of biomedical ethics - 3rd
edition. New York: Oxford University Press.
Begley, S. (1991, August 26). Choosing death. Newsweek, pp. 43-46.
Gibbs, N. (1990, March 19). Love and let die. Time, pp. 62-71.
Hamburg, J. (1992, June 28). Till we meet again. Florida Magazine.
pp. 9-14.
Humphry, D. (1986). Let me die before I wake - Hemlock's book of selfdeliverance for the dying. New York: Grove Press.
Humphry, D. & Wickett, A. (1990). The right to die - An historical and legal
perspective of euthanasia. Eugene, OR: The Hemlock Society.

Humphry, D. (1991). Final exit. Eugene, OR: The Hemlock Society.

Kevorkian, J. (1991) Prescription: Medicine - The goodness of planned death.
Buffalo, New York: Prometheus Books
Podolsky, D. (1991, December 2). A right-to-die reminder. U.S. News & World
Report. p. 74.
Scofield, G. (1990, January/February). The calculus of consent. Hastings
Center Report. pp. 44-47.

Pengantar Etika Kedokteran

June 18th, 2009 dyagnoz Leave a comment Go to comments
Sebelum kita mengenal lebih jauh mengenai etika kedokteran mari kita simak cermati
kasus berikut :

dr. T seorang ahli bedah yang berpengalaman, baru saja akan menyelesaikan tugas
jaga malamnya di sebuah rumah sakit sedang. Seorang wanita muda dibawa ke
RS oleh ibunya, yang langsung pergi setelah berbicara dengan suster jaga bahwa
dia harus menjaga anak-anaknya yang lain. Si pasien mengalami perdarahan
vaginal dan sangat kesakitan. dr. P melakukan pemeriksaan dan menduga bahwa
kemungkinan pasien mengalami keguguran atau mencoba melakukan aborsi. dr. T
segera melakukan dilatasi dan curettage dan mengatakan kepada suster untuk
menanyakan kepada pasien apakah dia bersedia opname di rumah sakit sampai
keadaaanya benar-benar baik. dr. Y datang menggantikan dr. T, yang pulang tanpa
berbicara langsung kepada pasien.

Dari kasus tersebut mengandung refleksi etis. Kasus tersebut menimbulkan pertanyaan
mengenai pembuatan keputusan dan tindakan dokter bukan dari segi ilmiah ataupun
teknis, namun pertanyaan yang muncul adalah mengenai nilai, hak-hak, dan tanggung
jawab. Dokter akan menghadapi pertanyaan-pertanyaan ini sesering dia menghadapi
pertanyaan ilmiah maupun teknis.
Jadi apakah sebenarnya etika itu dan bagaimanakah etika dapat menolong dokter
berhadapan dengan pertanyaan-pertanyaan seperti itu?
Secara sederhana etika merupakan ilmu/kajian mengenai moralitas refleksi terhadap
moral secara sistematik dan hati-hati dan analisis terhadap keputusan moral dan perilaku
baik pada masa lampau, sekarang atau masa mendatang. Moralitas merupakan dimensi
nilai dari keputusan dan tindakan yang dilakukan manusia. Bahasa moralitas termasuk

kata-kata seperti hak, tanggung jawab, dan kebaikan dan sifat seperti baik dan
buruk (atau jahat), benar dan salah, sesuai dan tidak sesuai. Menurut dimensi ini,
etika terutama adalah bagaimana mengetahuinya (knowing), sedangkan moralitas adalah
bagaimana melakukannya (doing). Hubungan keduanya adalah bahwa etika mencoba
memberikan kriteria rasional bagi orang untuk menentukan keputusan atau bertindak
dengan suatu cara diantara pilihan cara yang lain. Dari definisi dan penjelasan tersebut
maka dapat kita ketahui bahwa etika kedokteran merupakan salah satu cabang dari etika
yang berhubungan dengan masalah-masalah moral yang timbul dalam praktek
kedokteran. Etika kedokteran berfokus terutama dengan masalah yang muncul dalam
praktik pengobatan sedangkan bioetika merupakan subjek yang sangat luas yang
berhubungan dengan masalah-maslah moral yang muncul karena perkembangan dalam
ilmu pengetahuan biologis yang lebih umum. Bioetika juga berbeda dengan etika
kedokteran karena tidak memerlukan penerimaan dari nilai tradisional tertentu dimana
hal tersebut merupakan hal yang mendasar dalam etika kedokteran. Sebagai seseorang
yang profesinya bergelut dibidang medis, tentu dengan memahami etika kedokteran kita
akan siap menghadapi berbagai kasus yang mengandung refleksi etis tersebut dengan
jawaban, sikap, dan tindakan yang tepat.
Ada empat kaidah dasar bioetik yang digunakan dalam etika kedokteran yaitu
beneficience, non-maleficence, autonomy, dan justice.

Berikut ini adalah penjelasan singkat mengenai masing-masih kaidah dasar bioetik
tersebut :
1. beneficience

prinsip berbuat baik

melakukan tindakanselalu diutamakan untuk kebaikan
dalam konteks medis berarti berusaha melakukan tindakan medis terbaik kepada
pasien

2. non-maleficence

prinsip untuk tidak melakuan tindakan berbahaya(buruk) yang merugikan

terhadap pasien
kewajiban dokter untuk tidak mencelakakan pasien

3. autonomy

mengakui hak-hak individu untuk menentukan nasib sendiri

prinsip menghargai hak pasien

4. justice

Prinsip keadilan atau bertindak adil terhadap semua pasien

Dalam pelaksanaannya sehari-hari beberapa kaidah dasar tersebut bisa saling

bertentangan satu dengan yang lainnya. Tentu hal itu sangat wajar karena masing-masing
kaidah tersebut mempunyai kekhasan nilai masing-masing. Namun kita harus dapat
memilih yang mana lebih prioritas. Contoh kecil saja yaitu ketika seorang dokter lebih
mendahulukan pasien baru, yang datang dalam keadaan gawat darurat daripada pasienpasien yang telah antri lama di tempat praktiknya. Hal itu menunjukkan adanya
pertentangan antara kaidah justice dan non-maleficence. Namun tindakan dokter tersebut
dapat dibenarkan karena dalam kasus ini yang menjadi prioritas adalah kaidah nonmalefincence. Dari uraian yang sangat singkat ini maka diharapkan kita akan lebih
berusaha untuk memahami etika kedokteran, karena pada seorang dokter tidak hanya
dibutuhkan ketereampilan teknis dan teori semata tetapi juga kemampuannya dalam
menghadapi kasus-kasus yang berhubungan dengan etik.
Semoga bermanfaat.
Referensi
1. Anonymous. 2009. Medical Ethics. Diakses dari Wikipedia tanggal 18 Juni 2009
2. Husairi, A. 2008. Materi Kuliah Kaidah Dasar Bioetik dan Pemecahan
Masalah/Dilema Etik Menggunakan Prima Facie. Banjarmasin : Bagian EHK FK
Unlam
3. William, JR. 2006. Medical Ethics Manual(Panduan Etika Medis Disertai dengan
Studi Kasus Etika Pelayanan Medis Sehari-hari). Yogyakarta : Pusat Studi
Kedokteran Islam Fakultas Kedokteran Universitas Muhammadiyah Yogyakarta.

Pasien membawa resep dokter lain

Alinea 1
Dokter Hendro, tempat praktiknya walaupun masih dalam satu kecamatan, jaraknya
terpaut hanya 4 km dari tempat praktik dokter Pujo. Dalam hal senioritas dokter Hendro
adalah yunior dokter Pujo. Namun demikian keduanya selalu membina hubungan baik,
terbukti tidak ada konflik diantara mereka berdua, dan keduanya sama-sama menjabat
pengurus IDI di kabupaten. Dokter Pujo adalah ketua sedangkan dokter Hendro menjabat
sebagai sekretaris.
Alinea 2
Hingga datanglah bu Erna dengan anaknya.

Dokter Hendro, sebenarnya pagi ini saya sudah memeriksakan Evi anak saya ini ke
tempat praktik dokter Pujosaya datang mendapatkan nomor urut yang ke tiga. Saya
mendengar dari sesama yang antre, katanya dokter Pujo itu kalo ngasih obat dosis tinggi.
Meski demikian saya tetap mengikuti antrean dan tetap bersedia kalau Evi diperiksa
dokter Pujo. Kata bu Erna.
Sudah dapat resep? tanya dokter Hendro.
Sudah dokter jawab bu Erna.
Terus? tanya dokter Hendro.
Karena ada berita semacam itu, saya tidak yakin dokter, makanya saya datang ke sini
ini dokter, resep dari dokter Pujo kata bu Erna sambil menyerahkan resep dari dokter
Pujo.
Sebentar bu, maksud ibu, anak Evi mau diperiksakan ke saya? tanya dokter Hendro.
Iya, mohon dokter untuk bersedia memeriksa Evi sekaligus memberikan resepnya.
Sama mau nanya apa benarresep dokter Pujo itu termasuk dosis tinggi dokter? Kata bu
Erna.
..
Alinea 3
Akhirnya dokter Hendro, memeriksa anak Evi dan menyimpulkan diagnosis untuk anak
Evi adalah Infeksi saluran pernafasan akut dengan disertai gastritis.
Kok resep dokter Pujo belum dibaca dokte? tanya bu Erna.
O..iya kata dokter Hendro
..
Alinea 4
Betapa terkejutnya dengan kombinasi obat yang diberikan oleh dokter Pujo.
Anak Evi, umur 3 tahun, berat badan 15 kg
R/ Amoxicilin 150 mg
Thiamphenicol 150 mg
Narfoz tab

Metoclopropamid tab
Mfla pulv dtd no XX
S 3 dd pulv 1
R/ Intunal syr no I
S 3 dd C 1
R/ Antacid syr no I
S 3 dd C 1
..
Alinea 5
Dalam benak dokter Hendro kombinasi antibiotic amoxicillin dengan thiamfenicol terlalu
berlebihan, termasuk juga kombinasi metoclopropamid dengan narfoz terus masih
ditambah dengan antacid untuk mengatasi rasa mual dan kembung juga berlebihan.
Termasuk dalam hal biaya. Tetapi bagaimana cara mengomunikasikan keadaan ini kepada
pasien? Kalau seandainya ia mengatakan yang sebenarnya, apa yang dikatakannya
sampai juga ke telinga dokter Pujo. Apa yang dia katakan akan menjadi hujah atau dalil
untuk membenarkan berita bahwa dokter Pujo kalau memberikan obat dosis tinggi.
Berarti akan mengganggu hubungan harmonis yang sudah terjalin antara dia dengan
dokter Pujo. Tetapi bagaimana cara mengatakannya ya?
.
Alinea 6
Begini ya bu Erna setiap dokter pasti mempunyai pertimbangan sendiri-sendiri dalam
memberikan apa yang terbaik buat pasien-pasiennya. Saya sudah menuliskan resep yang
menurut saya terbaik untuk anak ibu kata dokter Hendro.
Oo begitu ya doktersetiap dokter pasti mempunyai pertimbangan sendiri-sendiri. Apa
tidak ada standar dalam mengobati pasien? tanya bu Erna
Standar itu adalah rambu-rambu yang tidak boleh dilanggar bu kata dokter Hendro.
Ya sudah doktertampaknya masih banyak antrean yang menunggu di luar. Berapa
dokter..saya harus bayar? tanya bu Erna.
..

Daftar Kaidah Dasar Bioetika yang dihadapi pada kasus pasien membawa resep yang
terlalu berlebihan, seperti kasus dokter Hendro.
1. Beneficence : dokter memberikan yang terbaik bagi pasien. Dokter berusaha
menerapkan Golden Rule Principle. Dokter berusaha meminimalisir akibat buruk
bagi pasien. Dan menjamin nilai pokok harkat dan martabat manusia.
2. Non maleficence : dalam pandangan dokter Hendro atau kita yang mendapati resep
teman sejawat yang memberikan obat terlalu berlebihan atau bahkan kombinasi yang
membahayakan, maka bila mengganti resep yang lebih aman dan tidak berlebihan
non maleficence; berusaha memberikan obat secara proporsional, berusaha
memberikan manfaat yang lebih besar berhadapan dengan resiko dokter Hendro atau
kita berhadapan dengan terancamnya hubungan baik sesame teman sejawat.
3. Autonomi : kita memberikan penjelasan mengapa kita memberikan resep yang berbeda
(secara diplomatis) sebisa mungkin tanpa mengurangi wibawa teman sejawat kita di
mata pasien.
4. Justice : dalam kasus ini menghargai hak sehat pasien. Pasien berusaha memeroleh
kesehatannya. Kalau kita tidak mengoreksi resep yang salah dan kita menganggap
akan menambah sakitnya pasien, maka kita akan berada dalam posisi mengabaikan
hak mendapatkan sehat bagi pasien. Tidak memerlakukan sama dengan pasien lain
yang sama-sama memeriksakan diri ke dokter Hendro (kita yang dimintai tolong
pasien yang membawa resep dokter lain).
Kemungkinan PRIMA FACIE yang terjadi
Kebutuhan menerapkan kaidah beneficence, non maleficence dan justice LEBIH
DIUTAMAKAN ketimbang autonomi pasien yang berusaha ingin mendapatkan alasan
rasional mengapa kita mengganti resep teman sejawat yang kita pandang berlebihan,
menambah kesakitan bahkan malah membahayakan jiwa pasien.

Dari sudut pandang MEDICAL INDICATIONS (beneficence & non maleficence):

Bahwa resep yang kita ketahui ada obat yang berlebihan, interaksi obat yang saling
melemahkan bahkan membahayakan, maka secara medis ada indikasi yang bisa
membenarkan bahwa memberikan resep baru yang kita buat dapat menghindarkan pasien
dari keadaan yang membahayakan.
Dari sudut pandang PATIENT PREFERENCES (autonomi):
Secara mental dan secara hukum pasien ini (ibu pasien) capable. Serta kondisi yang
dihadapi adalah bukan kegawatan. Jadi secara mendasar harus memperhatikan autonomi
ibu pasien. Sedangkan pasien sendiri karena anak-anak, relative bisa diabaikan
autonominya.
Karena membawa resep dari dokter lain yang kebetulan kita kenal dekat dengan dokter
itu, maka kemungkinan besar ibu pasien menyangsikan keputusan medis yang dibuat
teman sejawat. Artinya pasien tidak dapat bekerja sama dengan dokter sebelumnya. Di
sini kita juga menghargai hak pasien untuk memilih dokter mana yang merawat dirinya.
Walaupun akhirnya kita juga mengetahui ada peresepan yang tidak rasional dan
membahayakan.
Permasalahan yang timbul dari hubungan kita dengan pasien ini ketika mengatakan yang
sebenarnya akan mempengaruhi hubungan kita dengan teman sejawat yang sebelumnya
pernah mendapatkan konsultasi dari pasien.
Mengatakan yang sebenarnya sebenarnya adalah HAK pasien untuk mendapatkan
informasi yang benar. HAK untuk memperoleh kesehatannya.
Dalam hubungan dokter pasien tidak ada dilemma. Tetapi dilemma muncul ketika
memerhatikan hubungan sesama teman sejawat.
Dari sudut pandang QUALITY OF LIFE (prinsip beneficence dan non maleficence
dengan memperhatikan autonomi)

Memberikan pengertian mengapa kita memberikan resep yang berbeda dengan teman
sejawat, (autonomi) dengan alasan kemanfaatan yang rasional (beneficence) dan
memperhatikan dampak jangka panjang pengobatan yang tidak berakibat membahayakan
(non maleficence) dan sebisa mungkin memilih kata-kata yang tidak berdampak
menjatuhkan kewibawaan teman sejawat.
Kita memilih obat yang berbeda dengan alasan efektifitas dan tidak menimbulkan efek
samping yang berarti dan berdampak pada menurunnya kualitas hidup penderita.
Dari sudut pandang CONTEXTUAL FEATURES (Kondisi yang mendasari)
Bagian yang sangat diperhatikan disini adalah :
o Pemilihan obat yang rasional berdampak pada efektivitas dan efisiensi pengobatan
berdampak pada aspek financial.
o Kehati-hatian dalam mengungkapkan perbedaan (walaupun sebenarnya kesalahan
teman sejawat dalam memberikan pengobatan yang tidak rasional) dengan bahasa
yang netral seperti :
setiap dokter pasti mempunyai pertimbangan sendiri-sendiri dalam memberikan
apa yang terbaik buat pasien-pasiennya. Saya sudah menuliskan resep yang menurut
saya terbaik. Dan ini berbeda dengan pertimbangan dengan teman sejawat saya
o Ketidak hati-hatian dalam berkata atau mengomunikasikan pada ibu pasien bisa
berdampak
Secara hukum ucapan kita dijadikan hujah untuk menyerang teman sejawat.
Atau dijadikan hujah untuk membenarkan isu yang selama ini terjadi misalnya
dokter A selalu memberikan obat dosis tinggi. Kalau sampai nama kita disebut
dengan jelas membuat hubungan dengan sesama teman sejawat akan
berdampak sangat buruk. (menebarkan isu membuat persaingan tidak sehat)