Bioethical : an

introduction to
medical ethics

Dr.titia rahmania, MHKes

Learning objective
Students should be able to explain the

difference between medical ethics and

bioethics
Students should be able to differentiate
bioethics, law, culture, and religion
Students should be able to explain the
principles of bioethics and how to
balance these principles in practice

Bioethic VS medical ethic

Bioethic bios and ethike (Bahasa Yunani)

Bios hidup

Bioetik suatu ilmu tentang penerapan etika..

Suatu studi ttg masalah etik yg timbul atau
diantispasi akan timbul pd suatu kegiatan
keilmuan

Cakupan bioethic itu luas, tidak hanya medical

ethic, tetapi juga mencakup riset bioscience,
etika lingkungan hidup, etika reproduksi, serta
masalah sosial lainnya yang berkaitan dengan
kesehatan

Ethike ilmu/studi ttg isu etik yg timbul dalam

praktek suatu ilmu

how healthcare
professional, legislator,
life-scientists,
authorities ought to
behave in a particular
situation? this is a
bioethic

Medical Ethics
Medical ethics is the discipline of evaluating
the merits (kebaikan), risks, and social
concerns of activities in the field of medicine.

System of values common to the medical profession.

Systematic application of values concerning the practice of

medicine.

Standards of behaviour by which the physician may

evaluate his/her relationships with patients, colleagues and
society.

Medical Ethics
Medical ethics is the discipline of evaluating
the merits (kebaikan), risks, and social
concerns of activities in the field of medicine.
Many methods have been suggested to help
evaluate the ethics of a situation. These
methods tend to introduce principles that
should be thought about in the process of
making a decision.
http://www.wordiq.com/definition/Medical_ethics

Bioethics-ethics

The goal of ethics is not to compete with law, but to promote

wise decisions among people and professional excellence.

Bioethics does not look for what is legally right but for what is
humanly best.
The goal of bioethics is to promote excellence

Bioethics and Law

Conjunction between of ethical and legal decision making

(creation and implementation);

From originally ethical issues has grown tremendous impact
to that ethical issues in the law;
Private matters rather than public.

Law & Bioethics

Similarities
Both provide guidance on what

physicians may and may not do

The law may reflect an ethical
consensus in society
Court opinions offer reasons for
decisions, provide analysis of pertinent
issues
Clinicians, ethics committees should be
aware of what law says about issues in
clinical ethics

Difference
Law sets only minimum standards of

conduct
Law explicitly grants physicians
discretion in clinical decision making
Law may provide no clear action guides
in some clinical ethical situations
Law and ethics may directly conflict
Actions permitted by law may be
ethically controversial

While actions prohibited by law may be

regarded as ethically defensible by many
people

Authority of law based on police power

of state

Scope of medical ethics

includes:

1. development of ethical codes and

2.
3.
4.
5.

guidelines
promotion of ethical practice
prevention of ethical breaches
(pelanggaran)
recognition of ethical dilemmas
resolution of ethical conflicts

Medical Ethical Values

Autonomy
Beneficence
Non-Maleficence
Justice
Social
Distributive

GENERAL PRINCIPLE
Autonomy : Clinicians are obligated to respect
patients as individuals and to honor their
preferences in medical care. The patient has the
right to refuse or choose their treatment (Voluntas
aegroti suprema lex)
Beneficence: Physicians have a responsibility to
act in the patients best interest (the physician
is a fiduciary/pengabdi ).
Patient autonomy may conflict with beneficence.
A practitioner should act in the best interest of the
patient (Salus aegroti suprema lex.)

GENERAL PRINCIPLE
Non-maleficence : Do no harm. If the
benefits of an intervention outweigh the
risk, however, a patient may make an
informed decision to consent and proceed.
(Primum non nocere)
Paternalism (pengayom): Physicians at
times make decisions for their patients, or
act to prevent a patient from carrying out
a decision, on the premise (dasar) that it is
for the patients benefit.

Cont
Justice : Concern the distribution of scarce (jarang)
health resources, and the decision of who gets what
treatment (fairness and equality).
Dignity (martabat): the patient (and the person
treating the patient) have the right to dignity.
Truthfulness (sesuai kenyataan) and honesty
(kejujuran): the concept of informed consent has
increased in importance since the historical events of
the Doctors Trial of Nuremberg trials and Tuskegee
Syphilis Study.

Utility of Medical Ethics

Medical ethics principles provide a framework for discussing
ethical issues and for medical decision making
The principles provide consistent guidance where there are
substantive considerations on both sides of an issue

Medical Ethics

Ethical discussion and decision making is

not about morality.
The important features of ethical
discussion and decision making is having
a consistent method to evaluate the areas
of concern.
The ethical decision should not be labeled
as morally good or morally bad. There
are behaviors and decisions that would
be considered unethical or even illegal.
The discussion of these differences is
important.

16

Ethical Dilemma:

Value conflicts, no clear

consensus as to the right
thing to do. A conflict
between moral obligations
that are difficult to reconcile
and require moral reasoning.

17

Ethical Dilemma:

Situations necessitating a
choice between two equal
(usually undesirable)
alternatives.

PHYSICIANS PLEDGE
JANJI DOKTER

I solemnly (penuh hikmat)

pledge to:
1. dedicate my life to the service of
humanity;
2. give due respect and gratitude to my
teachers;
3. practise my profession with
conscience (hati nurani) and dignity
(bermartabat)
4. make the health of my patient my
first consideration;

7. respect my colleagues as my
professional brothers and sisters;
8. not allow the considerations of race,
religion, nationality or social
standing to
intervene between my duty and my
patient;
9. maintain due respect for human life;
10. use my medical knowledge in
accordance with the laws of humanity;
11. comply with the provisions of the
Ethical Code;
12. and constantly strive to add to my
knowledge and skill;

Components of Medical Ethics

The Physician -- Patient
Relationship
The Physician -- Physician
Relationship
The relationship of the Physician to
the System of Healthcare

THE PRINCIPLES IN
MEDICAL ETHICS
The Principle of Non-Maleficence
The Principle of Beneficence
The Principle of Autonomy
The Principle of Veracity/kejujuran
The Principle of Confidentiality(or Fidelity/kesetiaan)
The Principle of Social Responsibility and Justice

The Principle of Non-Maleficence

first do no harm
Sanctity/kesucian of life
calculated risk or risk benefit
Question of how much of an effect it plays in
secular ethics since most treatments have risks

The Principle of Beneficence

do only that which benefits the
patient
patients welfare as the first
consideration
care consideration competence
The obligation (kewajiban) to provide
and accept beneficial treatment

The Principle of Autonomy

right to information and self determination
free and informed consent
free will and accord (persetujuan) intentional participation in treatment
respect and dignity (martabat) maintained
The right of an individual to choose between various alternatives presented
to them

The Principle of
Veracity/kejujuran

Truth telling
Obligation to full and
honest disclosure
(memberikan keterangan)

The Principle of Confidentiality

Based on loyalty (kesetiaan) and trust
Maintain the confidentiality of all personal, medical and
treatment information
Information to be revealed (dinyatakan) with consent
and for the benefit of the patient
Except when ethically and legally required
Disclosure (pemberian keterangan) should not be
beyond what is required

The Principle of Justice and Social

Responsibility
Actions are consistent, accountable and transparent
not to discriminate on age, sex, religion, race, position
or rank
greater good of society
respect of the Law
equity and distribution of burden & benefits
Determining what is good for the society as a whole

Conflicts of Ethical Principles

paternalism
Nonmaleficence
tidak merugikan

research
Autonomy
hak azazi

Veracity
kejujuran

family
interest

dual
obligations
(kewajiban
rangkap)

Justice keadilan
payer's
interest

Confidentiality
kerahasiaan

Beneficence
kemanfaatan

Contoh kasus

Kasus 1
Adinda adalah seorang dokter spesialis penyakit dalam dan berkarya di suatu rumah sakit
umum daerah yang menjadi rujukan dari berbagai daerah. Pada suatu hari dia menerima
rujukan seorang pasien pria dari sebuah kabupaten diluar propinsi tempat dia bekerja.
Diagnosis dari dokter setempat adalah tidak ditemukannya gejala spesifik dari pasien
tersebut. Adinda curiga akan hasil medis rujukan tersebut dan melakukan pemeriksaan
darah dan test HIV terhadap pasien. Pasien pada saat pemerikasaan menyetujui langkah
tersebut namun setelah pemerikasaan dilakukan datanglah keluarganya dan mereka
tidak bisa menerima tindakan medis yang dilakukan oleh Adinda. Keluarga serta merta
menuduh dan mengancam Adinda telah melakukan tindakan yang melecehkan harkat
dan martabat pasien yang memiliki latar belakang keluarga terhormat.
Diskusikan kasus tersebut!

Kasus 2
X adalah seorang sarjana lulusan s2 fakultas hukum sebuah universitas ternama di Jakarta.
Sejak 2 tahun lalu setelah kematian Ibu dan ayahnya, hidupnya semakin lama semakin tidak
karuan. Salah satunya adalah X memutuskan berhenti bekerja di sebuah perusahaan
akuntasi ternama di dunia khususnya di Jakarta. Sejak saat itu, kehidupannya tidak seperti
biasanya dan X memilih hidup terisolir seperti layaknya orang yang depresi. Tidak ada
kawan tidak ada teman dekat sehingga X memutuskan untuk mengakhiri hidupnya secara
hukum dengan mengajukan judicial review ke Mahkamah Konstitusi atas ketentuan dalam
KUHP yang melarang menghilangkan nyawa seseorang dengan cara melawan hukum
dengan membolehkan menghilangkan nyawa sesui dengan hukum. Walaupun kasus X
tersebut akhirnya tidak berlanjut, perdebatan etika atas penghilangan nyawa secara hukum
dalam konteks HAM telah masuk menjadi ranah perdebatan umum akhir-akhir ini.
Diskusikan kasus tersebut!

Kasus 3
Setelah berlakunya sistem BPJS, dokter-dokter memiliki keterbatasan dalam memberikan
preskripsi atas suatu tindakan medis mengunakan produk obat dari farmasi tertentu. Hal
tersebut berbeda dengan sebelumnya bahwa dokter memiliki keleluasaan untuuk
memberikan preskripsi sesuai dengan diagnosis dan analisanya sehingga ia memperoleh
penghargaan dari farmasi untuk mengikuti pendidikan dan latihan terkini ilmu kedokteran
dari akumulasi resep obat terhadap farmasi tersebut yang sangat penting untuku
meningkatkan kapasitas dan kompetensinya. Tak jarang, pendidikan tersebut dilakukan di
luar negeri selama beberapa kali dan dalam jangka waktu yang agak lama sehingga
memerlukan biaya yang besar. Mutualisme terjadi dalam kasus tersebut dan setelah
berlakunya BPJS, intesitas tersebut jauh berkurang dan berdampak pada menurunnya
partisipasi doketr dalam ajang-ajang peningkatan kemampuan mereka.
Diskusikan kasus tersebut!

Terima kasih