ETIKA KEDOKTERAN DALAM BIDANG BEDAH DIGESTIF

Riwanto

KERANGKA PIKIR
Etika profesi kedokteran Etika umum (KODEKI)

Hak asasi manusia

Hubungan antar manusia

Hubungan dokter-pasien (transaksi terapuetik)

Hubungan dokter bedah (digestif)pasien (transaksi terapuetik)

Hukum umum Peraturanperaturan lainnya

Undang-undang kesehatan

Undang-undang praktek kedokteran

Peraturan-peraturan terkait kesehatan Apa yang spesifik?

Basic Concept
Ethics: the disciplined study of morality Morality comprises both good and bad character and right and wrong behavior General question: What ought morality to be (in Surgery)? 1. What ought the character of surgeons to be? Ethics analyzes characteristic of virtues and vices. 2. What ought the conduct of surgeon to be? Ethics analyzes ethical issue about right and wrong actions.
Mcculloughe al. Principle and Practice of Surgical Ethics. In. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

ETIKA PROFESI
Etik= Ethos (Yunani) : yang baik Merupakan norma-norma, nilai-nilai atau pola tingkah laku kelompok profesi tertentu (dokter) dalam memberikan pelayanan jasa kepada masyarakat. Pekerjaan profesi mempunyai ciri-ciri sbb: 1. mengikuti pendidikan sesuai dengan standard nasional 2. pekerjaannya berlandaskan etika profesi 3. mengutamakan panggilan kemanusiaan dari pada keuntungan 4. pekerjaannya legal melalui perijinan 5. angota-anggotanya belajar sepanjang hayat 6. anggota-anggotanya bergabung dalam suatu organisasi profesi
Hanafiah J, Amir A. Etika Kedokteran & Hukum Kesehatan EGC 1999.

HUKUM KEDOKTERAN
Hukum: peraturan perundang-undangan yang dibuat oleh suatu kekuasaan, dalam mengatur pergaulan hidup dalam masyarakat Hukum Kesehatan: semua ketentuan hukum yang berhubungan langsung dengan pemeliharaan/ pelayanan kesehatan dan penerapannya
(menurut PERHUKI)
Hanafiah J, Amir A. Etika Kedokteran & Hukum Kesehatan EGC 1999.

PERSAMAAN ETIK DAN HUKUM

1. Sama-sama merupakan alat untuk mengatur tertibnya hidup bermasyarakat 2. Sebagai objeknya adalah tingkah laku manusia 3. Mengandung hak dan kewajiban anggotaanggota masyarakat agar tidak saling merugikan 4. Menggugah kesadaran untuk bersikap manusiawi 5. Sumbernya adalah hasil pemikiran para pakar dan pengalaman para anggota senior.

PERBEDAAN ETIK DAN HUKUM

1. Etik berlaku dilingkungan profesi, hukum berlaku untuk umum 2. Etik disusun berdasar kesepakatan anggota profesi, hukum disusun badan pemerintah 3. Etik tidak seluruhnya tertulis, hukum tercantum secara rinci dalam kitan Undang-Undang atau lembaran negara 4. Sangsi pelanggaran etik berupa tuntunan, sangsi pelanggaran hukum berupa tuntutan 5. Pelanggaran etik diselesaikan oleh MKEK IDI, pelanggraan hukum diselesaikan oleh MDKI (Majelis Disiplin Kedokteran Indonesia) dan pengadilan 6. Penyelesaian pelanggaran etik tidak selalu disertai bukti fisik, sementara penyelesaian pelanggaran hukum dibutuhkan bukti fisik.

ETIKA & HUKUM

Melangar etika kedokteran belum tentu melanggar hukum Melanggar hukum kedokteran pasti melanggar etika Membicarakan etika kedokteran ada khasanah yang bersinggungan dengan hukum.
Dahlan s. Dosen Hukum & Etika Kedokteran FK UNDIP (Komunikasi Pribadi) 2005

WHAT IS MEDICINE BUSINESS? WHAT IS THE GOAL OF MEDICINE?

Human happiness? Prolongation of life? Maintenance or restoration of health and relief of suffering?

Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

Human happiness
Put forward by the WHO health as a state of complete physical, mental and social wellbeing.
Factual condition:
Suffer from chronic illness for many years may live lives of great satisfaction. A professional golfer learns that having one of her breast removed would improve her golf swing

Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

Prolongation of life or Prevention of death

What will we do with the patients: - comatose for long time. - suffer from end-stage respiratory failure. Should we prolong life to patients in such condition?
Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

Maintenance or restoration of health and relief suffering?

Health English : wholeness Greek : hygieia = living well euexia = well-habitness = good bodily habits

Well-working of the human organism as a whole

Limitation: 1. Health is not merely the absence of disease 2. Health is the object of a body knowledge and understanding about which doctors are experts 3. Health is relative to the individual and to their stage in life
Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

Apa bisnis dokter spesialis bedah digestif?

Maintenance or restoration of health and relief suffering mostly by abdominal/ GI tract surgery Bisnis berhubungan dgn Patients compliance Pasien berharap mendapatkan kesembuhan yang sempurna? Apa mungkin harapan pasien tersebut tercapai 100%? Etika: Perlu penjelasan bahwa tindakan tersebut bisa terdapat komplikasi atau kematian atau sekuele agar akhirnya bisa diterima oleh pasien

HAL-HAL SPESIFIK DALAM BEDAH DIGESTIF

1. Teknologi pembedahan baru yang berkembang sangat pesat (laparoskopi, endoskopi, stapling, teknologi laser dll) konsekuensi finansial 2. Operasi pengangkatan organ (Splenektomi, kholesistektomi, reseksi hepar) bisa berdampak gangguan/ perubahan fungsi 3. Operasi reseksi organ dan rekonstruksi (Gastrectomi, pankreatiko-duodenektomi, reseksi usus halus, kolektomi) sequele yang akan muncul 4. Diversi ekterna (ileostomi, colostomi) problem perawatan dan sosial 5. Damage control surgery operasi yang berulang 6. Perluasan operasi dari yang direncanakan konsekuensi morbiditas, keuangan 7. Kanker dalam stadium terminal 8. Syok septic 9. Dll

Evidence Based dalam bedah digestif: mendasari informasi yang diberikan kepada pasien.

Four well known principle of ethics (Georgetown mantra)

1. Beneficence, the act of doing good for each patients. 2. Non-maleficence, the avoidance of doing harm. 3. Respect for the individual autonomy of each patients as a decision maker, 4. Justice, the principle of equal treatment for each person, regardless of their personal or cultural attributes.
Little JM. Ethics of resource allocation. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

BAGAIMANA MENERAPKAN PRINSIP-PRINSIP ETIKA TERSEBUT DALAM BIDANG BEDAH DIGESTIF? Harus menguasai managemen pasien dan teknik operasi yang akan dilakukan dengan baik. Harus memahami, indikasi, prosedur, komplikasi, sequele setiap operasi digestif Harus memahami dan menghayati hak-hak pasien Mampu & mau memberikan informasi secara baik, didasarkan evidence terbaru Memberi kesempatan pasien untuk menentukan pilihan & membiarkan pasien mencari opini ke dokter lain.

UU RI No 29 2004, tentang Praktik Kedokteran, Pasal 52

a. Pasien, dalam menerima pelayanan pada praktik kedokteran, mempunyai hak: Mendapatkan penjelasan secara lengkap tentang tindakan medis sebagamana dimaksud dalam pasal 45 ayat 3. Meminta pendapat dokter atau dokter gigi lain. Mendapatkan pelayanan sesuai dengan kebutuhan medis Menolak tindakan medis Mendapatkan isi rekam medis

b. c.

d. e.

UU RI No 29 2004, tentang Praktik Kedokteran, Pasal 45 (3)

(3) Penjelasan sebagaimana dimaksud pada ayat (2) sekurang-kurangnya mencakup: a. diagnosis dan tatacara tindakan medis;
b. c. d. e. tujuan tindakan medis yang dilakukan; alternatif tindakan lain dan risikonya; risiko dan komplikasi yang mungkin terjadi; & prognosis terhadap tindakan yang dilakukan.

Peraturan Menteri Kesehatan RI No:585/Men.Kes/Per/IX/1989 Tentang Persetujuan Tindakan Medis

Pasal 6. 1. Dalam hal tindakan bedah (operasi) atau tindakan invasif lainnya, informasi harus diberikan dokter yang akan melakukan operasi tersebut. 2. Dalam keadaan tertentu dimana tidak ada dokter sebagaimana dimaksud ayat 1, informasi harus diberikan dokter lain dengan pengetahuan atau petunjuk yang bertanggung jawab. Pasal 7. 1. Informasi juga harus diberikan jika ada kemungkinan perluasan operasi 2. Perluasan operasi yang tidak dapat diduga sebelumnya, dapat dilakukan untuk menyelamatkan jiwa pasien 3. Setelah perluasan operasi sebagaimana dimaksud ayat 2 dilakukan, dokter harus memberikan informasi kepada pasien dan keluarganya.

American Hospital Association: A Patients Bill of Right

1. The right to considerate and respectful care 2. The right to obtain from his physician complete current information concerning the diagnosis, treatment and prognosis 3. The right to receive from his physician information necessary to give inform consent prior to the start of any procedure and or treatment. 4. The right to refuse treatment to the extent permitted by law and to be informed of the medical consequences of his action 5. The right to every consideration of his privacy concerning his own medical care program.

6. The right to expect that all communications and records pertaining to his care should be treated as confidential 7. The right to expect that within its capacity a hospital must make reasonable response to the request of a patient for services 8. The right to obtain information as to any relationship of his hospital or other health care and educational institutions in so far as his care is concerned 9. The right to be advised if the hospital proposes to engage in or perform human experimentation affecting his care or treatment 10. The right to expect reasonable continuity of care 11.The right to examine and receive an explanation of his bill regardless of source of payment 12.The right to know what hospital rules and regulation apply to his conduct as a patient
Hanafiah J, Amir A. Etika Kedokteran & Hukum Kesehatan EGC 1999.

7 Basic Right of the (Surgical) Patients

3 negative right: 1. Not to be killed intentionally or negligently by the surgeon, 2. Not to be harmed by intent or negligence of the surgeon 3. Not to be deceived by surgeon 4 positive right: 4. Adequately informed about risk and benefit of surgery 5. To be treated by a knowledgeable, competent practitioner 6. To have his or her health and wellbeing more highly valued than the surgeons own economic interest 7. To decide whether to accept treatment under the conditions described
Mcculloughe al. Principle and Practice of Surgical Ethics. In. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

Surgeon as Fiduciary of the Patients

Being fiduciary is legally understood to be a person holding the character of trustee, in respect of the trust and confidence involved in it and scrupulous good faith and condor which it requires. The key concept: fiduciary should put aside self interest, focus primarily on the interest of the person for whom he or she serves as fiduciary, act to protect and promote that individuals interest
Mcculloughe al. Principle and Practice of Surgical Ethics. In. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

4 Steps of Surgical Ethics Workup

1. Identifying the fact of the case (identified alternatives that have positive and at least neutral risk/benefit ratio) 2. Ethical analysis 3. Ethical argument 4. Issues of Authority and Power
Mcculloughe al. Principle and Practice of Surgical Ethics. In. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

Ethical analysis
a. b. c. d. Appeal to Virtues: identified the virtues of surgeon relevant to the case Appeal to Consequences: beneficence-based clinical judgment is concerned with the clinical consequences of reasonable alternatives for managing the patients problem Appeal to Right: patients has 7 rights, consideration of the clinical implication of these right will help the patients to make decision. Appeal to Justice and Equality: patients be treated as equally as possible, and get adequate information about the quality of medical and surgical care from difference provider and allowing patients and providers to make their own decision The four appeal together. The implication of 4 appeals together for clinical judgment, decision making and behavior should be identified. Areas of agreement and areas of conflict should be precisely stated.

e.

Ethical argument
Present clearly stated premises that together support a conclusion about what surgeon clinical judgment, decision making and behavior ought to be in the case under consideration. Question to check the argument: Are the reason clearly stated? Do the reasons connect to each other? Are there other conclusions that could follow? What clear and coherent opposing reasons could be offered?

a) b) c) d)

Issue of authority and power

Surgeon is in charge of intra-operative and immediate post-operative care and the patients is in an especially passive role in this time period surgeon in position an authority, while patients in position in authority. The surgeon is surely an intellectual authority about matters of clinical judgment and decision making. Patients expect the surgeon to be knowledgeable in these matters and tend to treat surgeons as authority.
Mcculloughe al. Principle and Practice of Surgical Ethics. In. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

Seven steps informed consent process

1. Tell the patient, his or her attendance briefly about the process of informed consent. 2. Elicit the patients understanding of his or her problem and the alternatives for managing it. 3. Elaborate on the patients condition and option of treatment 4. Assist the patient in developing cognitive understanding of his/ her situation. The surgeon should also explain his/her own limitation with respect to predicting and controlling the outcome and the idiosyncratic responses of individual patients to the same or similar procedures. 5. Assist the patient in evaluating the alternatives available. 6. Offer the recommendation 7. Patient articulates a decision for or against surgery.
Mccullough BL et al. Informed consent: Autonomous Decision Making of the Surgical Patient. InIn. Mcculloughe al (EDS) Surgical Ethics. Oxford 1998

 To enable the patients to make his or her own health care decisions wisely, doctors (and other health professionals) must take care to explain clearly and simply the nature of a proposed procedure, any risks inherent in it to which the patients is likely to attach significance, and the patients prognosis if the procedure is not undertaken.
Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

When may treatment be withheld or withdrawn?

When treatment would be futile. Futile:
- when medical treatment no longer serves the goal(s) of medicine for a particular patients, - when it no longer cures illness, - when it no longer maintains that person in a reasonably satisfactory condition, - when the benefits it promises for that person are outweighed by the burdens it will impose, - when it no longer palliates the symptoms of illness - when it no longer save the life.
Decision require experience
Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

 The withdrawing or withholding of futile treatment is not only good medical practice but it is perfectly legal. Halsburys Laws of Australia 280-3030.. It is lawful to withdrawal or withhold treatment of the request of the competent adult patients, or treatment that is futile. In some cases this principle may extent to not offering alls treatments that may be available if that is not recommended by the treating doctors for critically ill patients
Tobin BM. Withholding and withdrawing treatment. In Dooley BJ et.al (eds) Surgery, Ethics and the Law. Blackwell Science Asia Pty Ltd Victoria 2000

Pembelajaran Etika Kedokteran dalam pendidikan spesialis bedah

Peningkatan pengetahuan kesehatan dari masyarakat meningkatkan ketidak puasan meningkatkan tuntutan Pembelajaran Etika Kedokteran perlu diintensifkan Meskipun pembelajaran Etika terdapat dalam kurikulum humaniora namun belum terlaksana dengan baik Perlu dikembangkan modul pembelajaran Etika praktek pelayanan bedah

DOCTOR-PATIENTS RELATIONSHIP
At time when the consumerist movement is demanding a shift from medical paternalism, based on trust in the doctor, to a doctor patient partnership in decisionmaking, the task is more difficult. Parallel with the decline in the trust exhibited by patients is a decline in societys confidence in the profession as a whole.
(Arnold . Why Medical Board. Surgery Ethic and the Law 2000)

As medical and surgical treatments become more complex, and as an increasingly educated public moves away from the doctor known best paradigm, there is an increasing need for trainee physicians and surgeons to become concerned with the ethical and legal framework of the health care system.
(Sir Gustav Nossal. Foreword in Dooley BJ et al. Surgery Ethics and the Law.

Blackwell Science Asia Pty Ltd, 2000)

 Every surgeon must know and understand that he or she has obligation and responsibilities to their patients, to the community in which they live and work, and to their profession.
(Waller L. Foreword in Dooley BJ et al.(eds) Surgery Ethics and the Law. Blackwell Science Asia Pty Ltd, 2000)

Surgeon have a proud record as professionals and in accepting full responsibility and accountability in the overall management of their patients. Medicine is not an exact science. It is also an art. No doctor can be perfect, but practitioners do their best in every way.
(Dooley et al. Preface in Dooley et al (eds) Surgery Ethics and the Law. Blackwell Science Asia Pty Ltd, 2000)

Good Medical Practice

(General Medical Council) Patients must be able to trust doctors with their lives and well-being. To justify that trust, doctor as a profession have a duty to maintain a good standard of practice and care and to show respect for human life. Essential elements for Good Medical Practice are: 1. Professional competence, 2. Good relationships with patients & colleagues, 3. Observance of professional ethical obligations.

Good Medical Practice

(General Medical Council)

You must work with colleagues to monitor and maintain the quality of the care you provide and maintain a high awareness of patients safety. In particular you must take part in regular and systematic medical and clinical audit, recording data honestly.Where necessary you must respond to the result of audit to improve your practice, for example by undertaking further training.

CRITERIA FOR SURGEON IN GENERAL

(Gough MH. How should surgical trainee be selected. Dalam Morris & Malt (ed) Oxford Text Book of Surgery 1994)

1. Interpersonal skills 2. Communication skills 3. Responsibility and leadership skills 4. Evaluative and analytical skills 5. Broad and balanced perspective 6. Decision making skills 7. Personal organization skills 8. Stress tolerance BAGAIMANA 9. Self motivation KRITERIA DOKTER 10. Political awareness BEDAH 11. self-insight and integrity INDONESIA? 12. Basic skill and abilities: a. basic academic ability b. technical competence (including manual dexterity, good eyehand coordination, spatial skills and capacity for focused and sustain attention.

Competence and doctor competence

Competence is the condition of being capable: the capacity to perform task or role. The role of doctor encompasses: The medical expert; Professional; Communicator; Health advocate; Scholar; Collaborator; Manager.

CLINICAL COMPETENCE
(NSWMB 1997)

1. 2. 3. 4. 5.

Clinical judgment Medical knowledge Clinical skill Humanistic quality Communication skill

PRINSIP PELAKSANAAN PENDIDIKAN PROFESI

Keep in tract the objectives of the study Mastering by intensive training Involve the trainee in the education process Prepare the trainee: - right and responsibility (obligation) - ethical, behave to the medical student, nurse colleague, seniors and patients (including their family) - communication skill - clinical skill before handling the real patients - respect to the patients right - keep the patients data secret Monthly written comprehensive schedule of activities and should be evaluated. Reporting and responsibility.

Kesimpulan
1. Transaksi terapuetik antara dokter bedah (digestif) dengan pasien dilandasi juga secara umum oleh KODEKI, seperti halnya dokter lain pada umumnya namun secara khusus ada hal-hal yang spesifik 2. Pengangkatan organ, rekonstruksi pasca pembedahan, diversi akan berdampak terhadap perubahan fisiologi, damage control memerlukan operasi ulang yang mana semua itu bisa memberikan beban psikologis dan finansial, kalau tidak dikomunikasikan secara baik dengan pasien akan memunculkan kekurang puasan pasien yang bisa berujung penuntutan. 3. Pemahaman tentang hak-hak pasien dan menempatkan kepentingan pasien diatas kepentingan dokter merupakan kunci utama etika hubungan dokter- pasien. 4. Didalam memberikan informasi kepada pasien dalam rangka mendapatkan persetujuan (informed consent) dikenal dengan 7 langkah. 5. Pendidikan Etika dalam pelayanan pasien harus dioptimalkan dalam pendidikan dokter spesialis