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ETHICAL DECISION

MAKING
BUDI SAMPURNA

CIRI-CIRI PROFESI DALAM


MEMBUAT KEPUTUSAN

KEBEBASAN PROFESI
INDEPENDEN
IMPARTIAL
OBYEKTIF
REASONABLE MEDICAL CERTAINTY
ETIS

KEPUTUSAN ETIS
MEMPERTIMBANGKAN NILAI-NILAI
YANG HIDUP DI DALAM MASYARAKAT,
PROFESI DAN PASIEN
MEMPERTIMBANGKAN:

TEORI ETIKA
PRINSIP MORAL
KETENTUAN MORAL
KEPUTUSAN KHUSUS PADA KASUS

HIRARKI
ETHICAL THEORIES
PRINCIPLES
RULES
PARTICULAR JUDGMENT & ACTIONS

BAGAIMANA MENENTUKAN
SESUATU PERBUATAN ITU
BENAR ATAU SALAH,
BAIK ATAU BURUK ?

TEORI ETIKA
ACUAN YANG PALING TINGGI DALAM
MENILAI BENAR-SALAHNYA (SECARA
ETIK) SUATU TINDAKAN

TEORI ETIKA
BERGANTUNG KEPADA
AGENT : VIRTUE
ACTS : DEONTOLOGI
ENDS : TELEOLOGICAL
CONSEQUENCES : CONSEQUENTIALIST
(UTILITARIAN)

TEORI BERDASARKAN
AGENT
FIDUCIARY
BERDASARKAN VIRTUE (NILAI
KEUTAMAAN)
JUJUR, BAIK HATI, RAMAH, WELAS-ASIH,
PERHATIAN, DLL

HUBUNGAN DOKTER PASIEN HARUS


BERDASARKAN KONSEP INI, JANGAN
HANYA BERDASARKAN HUKUM

TEORI BERDASARKAN
ACT
DEONTOLOGI
DEON = DUTY
BENAR SALAHNYA INHEREN KEPADA
TINDAKANNYA

Pemuka: Immanuel Kant


Judgment benar-salah diambil dari agama,
hukum alam, hukum benar-salah (penalaran
manusia)
WD Ross : Intuisi dan common sense : cukup

TEORI BERDASARKAN
HASIL
TELEOLOGI:
BENAR SALAHNYA BERGANTUNG
KEPADA HASIL AKHIR

CONSEQUENTIALIST:
BENAR SALAHNYA BERGANTUNG
KEPADA KONSEKUENSINYA / AKIBATNYA

David Hume, Jeremy Bentham, John


Stuart Mill
YANG MENONJOL: UTILITARIAN (AZAS MANFAAT)

UTILITARIAN
BUKAN SEKEDAR

TUJUAN MEMBENARKAN CARA


GREATEST GOOD FOR THE GREATEST
NUMBER

TETAPI JUGA : POSSITIVE BALANCE


OF VALUE OVER DISVALUE
MEMAKSIMUMKAN BENEFIT,
MEMINIMUMKAN RISK & COST

TEORI LAIN

NATURAL LAW (Aristoteles, St Thomas Aquinas)


RAWLSS THEORY (John Rawls)
CASUISTRY (Jonsen and Toulmin)
VIRTUE ETHICS (Pellegrino & Thomasma)
ETHICS OF CARE (Carol Gilligan)
EMOTIVISM, LEGALISM, CULTURAL
RELATIVISM, FIDEISM, REASONED
ANALYSIS (ORourke)

PILIH TEORI MANA?


TERGANTUNG KEPADA:

KONSISTENSI DAN KOHERENSI


KESEDERHANAAN
LENGKAP DAN KOMPREHENSIF
KAPASITAS MEMPERHITUNGKAN
PENGALAMAN MORAL KITA

TAK ADA YG MEMUASKAN

PRINSIP-PRINSIP
MORAL / KAIDAH
DASAR MORAL
HIRARKI KEDUA (DI BAWAH TEORI)
DALAM MENENTUKAN BENARSALAHNYA SUATU TINDAKAN

PRINSIP MORAL
KAIDAH DASAR:
AUTONOMY :
Self determination, Truth telling, Confidentiality,
Privacy

BENEFICENCE
Providing benefit, Balancing the benefit and
harms

NON MALEFICENCE
Primum non nocere, Above all do no harm

JUSTICE : fairness
Equal treatment of equals, Unequal treatment of
unequal

Prinsip AUTONOMY
MENGHORMATI HAK PASIEN
UNTUK MENENTUKAN APA YANG
BOLEH DILAKUKAN TERHADAP
DIRINYA

PRINSIP AUTONOMY
SELF GOVERNANCE, LIBERTY
RIGHTS, INDIVIDUAL CHOICES
KANT : TIAP ORANG MEMILIKI
KAPASITAS UNTUK MEMUTUSKAN
NASIBNYA SENDIRI
MILL : KONTROL SOSIAL ATAS
INDIVIDU HANYA SAH APABILA
TERPAKSA UNTUK MELINDUNGI HAK
ORANG LAIN

ELEMEN INFORMED
CONSENT

THRESHOLD ELEMENTS (PRECONDITIONS)


1.
2.

COMPETENCE (TO UNDERSTAND & DECIDE)


VOLUNTARINESS (IN DECIDING)

INFORMATION ELEMENTS
3. DISCLOSURE (OF MATERIAL INFORMATION)
4. RECOMMENDATION (OF A PLAN)
5. UNDERSTANDING (OF 3 AND 4)

CONSENT ELEMENTS
6. DECISION (IN FAVOR OF A PLAN)
7. AUTHORIZATION (OF THE CHOSEN PLAN)
BEAUCHAMP & CHILDRESS, 1994

PRINSIP NON
MALEFICENCE
TIDAK BOLEH MELAKUKAN SIKAP /
TINDAKAN YANG MEMPERBURUK
KEADAAN PASIEN

PRINSIP NON
MALEFICENCE

PRIMUM NON NOCERE


ABOVE ALL DO NO HARM
SATU CONTINUUM DG BENEFICENCE

NOT TO INFLICT EVIL OR HARM


PREVENT EVIL OR HARM
REMOVE EVIL OR HARM
DO OR PROMOTE GOOD

PRINSIP NON MALEFICENCE2


PRINSIP DOUBLE EFFECT
TINDAKAN YG MERUGIKAN TIDAK SELALU
DIANGGAP TINDAKAN YG BURUK
BILA TINDAKAN TSB SECARA INTRINSIK TIDAK
SALAH (SETIDAKNYA NETRAL)
BILA NIATNYA MEMPEROLEH AKIBAT BAIK
(AKIBAT BURUK BOLEH FORESEEN &
TOLERATED)
BILA AKIBAT BURUK BUKAN CARA UNTUK
MENCAPAI AKIBAT BAIK
BILA PERIMBANGAN YG LAYAK ANTARA
AKIBAT BAIK DENGAN AKIBAT BURUK

PRINSIP
BENEFICENCE
SETIAP SIKAP / TINDAKAN
HARUS BERORIENTASIKAN
KEPADA KEBAIKAN PASIEN

PRINSIP BENEFICENCE
TERDIRI DUA PRINSIP:
PRINSIP POSITIVE BENEFICENCE
PREVENT EVIL OR HARM
REMOVE EVIL OR HARM
DO OR PROMOTE GOOD

PRINSIP BALANCING OF UTILITY /


PROPORTIONALITY
BALANCING OF BENEFIT AND HARM

PRINSIP BENEFICENCE-2
PRINSIP OF UTILITY = BALANCING OF
COST-RISK-BENEFIT
COST BENEFIT ANALYSIS:
DIPERHITUNGKAN DALAM HITUNGAN UANG

COST EFFECTIVENESS ANALYSIS:


DIPERHITUNGKAN BUKAN DALAM UANG

RISK ASSESSMENT
PROBABILITAS DAN BESARNYA RISIKO

PRINSIP JUSTICE
KEADILAN
KETERBUKAAN
KEJUJURAN

PRINSIP JUSTICE
TERDAPAT DUA ISTILAH:
JUSTICE ; FAIRNESS
SESEORANG MENERIMA YANG
SELAYAKNYA DIA TERIMA

DISTRIBUTIVE JUSTICE
DISTRIBUSI SUMBER DAYA DALAM
MASYARAKAT

PRINSIP JUSTICE-2
TEORI TENTANG JUSTICE
EGALITARIAN:
EQUAL ACCESS TO THE GOODS

LIBERTARIAN:
RIGHTS TO SOCIAL AND ECONOMIC
LIBERTY (fair procedure and system)

UTILITARIAN:
KOMBINASI KEDUA DI ATAS
MEMAKSIMALKAN PUBLIC UTILITY

KETENTUAN
MORAL TURUNAN
VERACITY
PRIVACY
CONFIDENTIALITY
FIDELITY

MORAL RULES
VERACITY: telling the truth
Bagaimana bila informasi tsb memperburuk?
Bagaimana bila pasien menolak ?

PRIVACY & CONFIDENTIALITY

Derivat dari hak otonomi


Tujuan: menjaga kepercayaan
Apa pengertian rahasia kedokteran ?

FIDELITY
Promise keeping

BAGAIMANA
MENGGUNAKAN PRINSIP
DAN RULES?
SEBAGAI RULES OF THUMB

Prinsip yang hanya untuk disebut, sama sekali


tidak mengikat

SEBAGAI ABSOLUT
Prinsip yang tak dapat diabaikan, sangat
mengikat

SEBAGAI PRIMA FACIE


Prinsip dipakai sebagai pedoman, tetapi tidak
mengikat. Prinsip dapat dikalahkan oleh prinsip
lain yang terbukti lebih benar
GUNAKANLAH SEBAGAI PRIMA FACIE !!

MASALAH IMPLEMENTASI
TAK ADA PEDOMAN TENTANG BOBOT
MASING-MASING KAIDAH DASAR
MORAL DAN KAIDAH TURUNANNYA
TIAP KAIDAH DIANGGAP SAMA
BOBOTNYA, DAPAT SALING
MENGALAHKAN

CLINICAL ETHICS
PENDEKATAN
PRAKTIS
PENGAMBILAN
KEPUTUSAN

THE FOUR TOPICS


INDICATION FOR MEDICAL
TREATMENT
PREFERENCES OF PATIENTS
QUALITY OF LIFE
CONTEXTUAL FEATURES

MEDICAL INDICATIONS
WHAT IS THE PATIENTS MEDICAL PROBLEM?
HISTORY? DIAGNOSIS? PROGNOSIS?
IS THE PROBLEM ACUTE? CHRONIC? CRITICAL?
EMERGENT? REVERSIBLE?
WHAT ARE THE GOALS OF TREATMENT?
WHAT ARE THE PROBABILITIES OF SUCCESS?
WHAT ARE THE PLANS IN CASE OF
THERAPEUTIC FAILURE?
IN SUM, HOW CAN THIS PATIENT BE BENEFITED
BY MEDICAL AND NURSING CARE, AND HOW CAN
HARM CAN BE AVOIDED?
PERTIMBANGKAN PULA ADAKAH KONTRA-INDIKASI

PATIENT PREFERENCE
IS THE PATIENT MENTALLY CAPABLE AND
LEGALLY COMPETENT? IS THERE EVIDENCE OF
INCAPACITY?
IF COMPETENT, WHAT IS THE PATIENT STATING
ABOUT PREFERENCES FOR TREATMENT?
HAS THE PATIENT BEEN INFORMED OF BENEFITS
AND RISKS, UNDERSTOOD THIS INFORMATIONS,
AND GIVEN CONSENT?
IF INCAPACITATED, WHO IS THE APPROPRIATE
SURROGATE? IS THE SURROGATE USING
APPROPRIATE STANDARDS FOR DECISION
MAKING?

PATIENT PREFERENCE (2)


HAS THE PATIENT EXPRESSED PRIOR
PREFERENCES, E.G. ADVANCED
DIRECTIVES
IS THE PATIENT UNWILLING OR UNABLE TO
COOPERATE WITH MEDICAL TREATMENT?
IF SO, WHY?
IN SUM, IS THE PATIENTS RIGHT TO
CHOOSE BEING RESPECTED TO THE
EXTENT POSSIBLE IN ETHICS AND LAW?

QUALITY OF LIFE
WHAT ARE THE PROSPECTS, WITH OR
WITHOUT TREATMENT, FOR A RETURN TO
NORMAL LIFE?
WHT PHYSICAL, MENTAL, AND SOCIAL
DEFICITS IS THE PATIENT LIKELY TO
EXPERIENCE IF TREATMENT SUCCEEDS?
ARE THERE BIASES THAT MIGHT
PREJUDICE THE PROVIDERS EVALUATION
OF THE PATIENTS QUALITY OF LIFE?

QUALITY OF LIFE (2)


IS THE PATIENTS PRESENT OR
FUTURE CONDITION SUCH THAT HIS
OR HER CONTINUED LIFE MIGHT BE
JUDGED UNDESIRABLE?
IS THERE ANY PLAN AND RATIONALE
TO FORGO TREATMENT?
ARE THERE PLANS FOR COMFORT
AND PALLIATIVE CARE?

CONTEXTUAL FEATURES
ARE THERE FAMILY ISSUES THAT MIGHT
INFLUENCE TREATMENT DECISIONS?
ARE THERE PROVIDER (PHYSICIANS AND
NURSES) ISSUES THAT MIGHT INFLUENCE
TREATMENT DECISIONS?
ARE THERE FINANCIAL AND ECONOMIC
FACTORS?
ARE THERE RELIGIOUS OR CULTURAL
FACTORS?

CONTEXTUAL FEATURES(2)
ARE THERE LIMITS ON CONFIDENTIALITY?
ARE THERE PROBLEMS OF ALLOCATION
OF RESOURCES?
HOW DOES THE LAW AFFECT TREATMENT
DECISIONS?
IS CLINICAL RESEARCH OR TEACHING
INVOLVED?
IS THERE ANY CONFLICT OF INTEREST ON
THE PART OF THE PROVIDERS OR THE
INSTITUTION?

PERANAN HUKUM
DAPAT MEMBANTU MENYELESAIKAN
MASALAH ETIK
DAPAT MEMBATASI PILIHAN ETIK
DAPAT MENCIPTAKAN KONFLIK ETIK

CONTOH KASUS