RESOLVING

ETHICAL DILEMMAS
Ali Taufan
Insight

¨  The capacity to gain an accurate and deep intuitive

understanding of problem.

¨  Synonyms: Intuition,Perception,Awareness, Understanding.

¨  Psycology : an understanding of the motivasional forces

behind one’s action, thoughts, or behavior.

Steinberg (1996)
Isu Etik

Suatu permasalahan yang muncul dari suatu

situasi yang dihadapi dan menuntut seseorang
atau organisasi untuk menentukan apakah
permasalahan dalam situasi tersebut etis atau
tidak etis.
Dilema Etis

Suatu situasi terdapat dua atau lebih

prinsip-prinsip etis saling bertentangan
satu sama lain sehingga menimbulkan
kesulitan dalam mengambil keputusan.
Prinsip etis yang diambil dapat tetap
menimbulkan pertentangan dengan
prinsip etis yang lainnya .
PRINCIPLE-BASED ETHICS
( 4 KAIDAH DASAR MORAL)
1.  Beneficence

2.  Autonomy

3.  Nonmaleficence

4.  Justice

Tom L. Beauchamp dan James F. Childress, Principles of Biomnedical

Ethics (6th ed.), Oxford University Press, Oxford, 2008
 Beneficence

¨  Kata Beneficence berasal dari :

Benefits of others / bonum comune:
kebaikan, keuntungan, bermurah hati.

¨  Prinsip ini mewajibkan kepada kita

memberikan kebaikan bagi pasien.
“refers to actions that promote the well being of
others (patient)”

Tom L. Beauchamp dan James F. Childress, Principles of

Biomnedical Ethics (6th ed.), Oxford University Press, Oxford,
2008
 Autonomy
§  Kata autonomy berasal dari kata bahasa Yunani
“autos” yang berarti diri sendiri dan “nomos” yang
berarti memerintah.

§  Otonomi diri berarti bahwa pasien bebas

menentukan sendiri pilihan-pilihannya yang
sesuai dengan tata nilai yang dianut.

Tom L. Beauchamp dan James F. Childress, Principles of

Biomnedical Ethics (6th ed.), Oxford University Press, Oxford,
2008
3 syarat tindakan disebut sebagai tindakan otonomi:

1
Intentionally : Tindakan diputuskan dengan maksud tertentu

2 Understanding : Dengan pemahaman yang benar

3 Without Influence : Tanpa pengaruh yang mengendalikan pilihan

Terdapat 2 kondisi utama dalam menentukan otonomi seorang
individu:

1
Liberty (bebas dari pengaruh yang mengendalikan)

2
Agency (kapasitas pribadi untuk melakukan tindakan yang bertujuan)

3
Kompetensi dan Kapasitas Pasien

Kompetensi

Kondisi seseorang pasien berhak memberikan persetujuan : pasien

yang dalam keadaan sadar, sehat mental, telah berusia 21 tahun.
(Permenkes no. 290 Tahun 2008)

Kapasitas

q  Derajat seseorang pasien dapat mengerti informasi yang

berhubungan dengan pengambilan keputusan persetujuan tindakan
medis dan menyadari konsekwensi yang akan terjadi bila keputusan
tersebut diambil atau tidak diambil. (Latus 2002)
q Dapat berubah sepanjang waktu misalnya karena pengaruh kondisi
beratnya penyakit, obat - obatan (Latus 2002)
 Nonmaleficence
§  Kata Nonmalefecince berasal dari kata:
nonmale (tidak jahat) fic (berbuat). Hal ini sesuai
dengan prinsip dari sumpah Hippokrates “primum
non nocere” (first do no harm).

§  Prinsip nonmaleficence berarti adanya kewajiban

untuk tidak mencelakai (melukai) atau berbuat
jahat pada pasien.

Tom L. Beauchamp dan James F. Childress, Principles of

Biomnedical Ethics (6th ed.), Oxford University Press, Oxford,
2008
 Justice
q  Prinsip justice sebagai : equality, fairness
yaitu : penyama-rataan, kesetaraan.
q  Dalam konteks pelayanan kesehatan,
‘distributive justice’ menuntut bahwa setiap
orang mendapatkan akses pelayanan
kesehatan dasar yang sama dan setara
(equal), sesuai dengan HAM.
q  The distributive justice:
1.  To each person an equal share
2.  To each person according to need
3.  To each person according to efford
4.  To each person according to contribution
5.  To each person according to merit
6.  To each person according to free market
exchange Tom L. Beauchamp dan James F. Childress, Principles of
Biomnedical Ethics (6 ed.), Oxford University Press, Oxford,
th

2008
 Beneficence Criterion Yes No
Altruisme

Menjamin nilai pokok harkat&martabat manusia

• 
Memandang pasien tak hanya sejauh menguntungkan dokter
Mengusahakan manfaat > dibanding keburukan

Paternalisme bertanggung jawab/kasih sayang

Maksimalisasi pemuasan kebahagiaan/preferensi

Minimalisasi akibat buruk

Menghargai hak-hak pasien secara keseluruhan

Tidak menarik honorarium diluar kepantasan
Mengembangkan profesi secara terus-menerus
Memberikan obat berkhasiat namun murah
Menerapkan Golden Rule Principle

Post Graduate ”Bioethics, Medical Law, and Human Right” . FK.UI, Jakarta Mei 2006
 Nonmaleficence Criterion Yes No
Menolong pasien emergensi
Kondisi untuk menggambarkan kriteria ini adalah:
- Pasien dlm keadaan amat berbahaya(darurat)/beresiko
• 
hilangnya sesuatu yg penting
- Dokter sanggup mencegah bahaya atau kehilangan tersebut

- Tindakan dokter tadi terbukti efektif

- Manfaat bagi pasien >

Mengobati pasien yg luka

Tidak melakukan euthanasia
Tidak merendahkan pasien
Mengobati secara proposional
Menghindari misinterpretasi pasien
Tidak membahayakan kehidupan pasien karena kelalaian
Memberikan semangat hidup
Tidak melakukan White Collar Crime
Post Graduate ”Bioethics, Medical Law, and Human Right” . FK.UI, Jakarta Mei 2006
 Autonomi Criterion Yes No
Menghargai hak menentukan nasib sendiri
Tidak mengintervensi pasien dlm membuat keputusan(elektif)
• 
Berterus terang
Menghargai privasi
Menjaga rahasia pasien
Menghargai rasionalitas pasien
Melaksanakan Informed consent
Membiarkan pasien dewasa dan kompeten mengambil
keputusan sendiri
Mencegah pihak lain mengintervensi pasien dlm mengambil
keputusan termasuk keluarga pasien sendiri
Sabar menunggu keputusan yg akan diambil pasien pd kasus
non emergensi
Tidak berbohong pd pasien walaupun demi kebaikan pasien
Memperoleh hak second opinion
Post Graduate ”Bioethics, Medical Law, and Human Right” . FK.UI, Jakarta Mei 2006
 Justice Criterion Yes No
Memberlakukan segala sesuatu secara universal
Mengambil porsi terakhir dari proses membagi
• 
Memberikan kesempatan yg sama thdp pribadi dlm posisi
yang sama
Menghargai hak sehat pasien
Menghargai hak hukum pasien
Menjaga kelompok yg rentan(yg paling dirugikan)
Tidak melakukan penyalahgunaan
Memberikan kontribusi yg relatif sama dg kebutuhan pasien
Meminta partisipasi pasien sesuai kemampuannya
Kewajiban mendistribusikan keuntungan dan kerugian
Mengembalikan hak kepada pemiliknya pd saat yg tepat dan
kompeten
Tidak membedakan pelayan pd pasien atas dasar SARA,
status sosial , dll
Post Graduate ”Bioethics, Medical Law, and Human Right ”. FK.UI, Jakarta Mei 2006
 Sistem etika
Terdapat 2 sistem (aliran yg berpengaruh
sampai sekarang)
1.  Utilitarisme(David Hume&Jeremy Bentham)
Konsekuensialisme: Baik tdknya perbuatan
tergantung pd konsekuensinya yang
menitikberatkan pd tujuan.
Misal: tujuan moral ad.memaksimalkan
kegunaan/kebahagiaan bagi sebanyak
mungkin org.
 Lanjutan Sistem Etika

2.  Deotologi(Immanuel Kant&W.D Ross)

Berarti: Apa yg hrs dilakukan; kewajiban.
•  Immanuel Kant
Sesuatu dikatakan baik adalah kehendak yg
baik, apa yg menyebabkan? Bila bertindak
karena kewajiban tanpa motif lain.
3. Primafacie duty
•  W.D Ross
Kewajiban tsb selalu merupakan
kewajiban primafacie, suatu kewajiban
sementara sampai timbul kewajiban yg
lebih penting lagi yg mengalahkan
kewajiban pertama tadi.
 Relevansi  Prima  Facie  
ž tak  jarang,  pada  satu  kasus  klinis  terdapat  
saling  mempengaruhi  antar  KDM  mana  
yang  paling  relevan  atas  kasus  konkrit  
tertentu,  sehingga  tetap  sulit  diyakinkan  
mana  KDM  yang  paling  dominan.    
 
ž Kasus  yang  memuat  ”pertentangan  antar  
KDM”  ini  hingga  ke  ;ngkat  analisis  
mendalam,  yang  (;nggal)  memunculkan  
”2  dari  4  KDM”  yang  sesuai  dg  konteksnya    
ž Penetapan    1  KDM  ter-­‐”absah”  sesuai  konteksnya  
berdasarkan  data  atau  situasi  konkrit  terabsah  inilah  
yang  disebut  pemilihan  berdasarkan  asas  prima  facie.    
 
ž Dua  KDM  yang  dilema;s  tadi  tetap  berlaku,  sampai  
yang  paling  mutakhir  ada  ”novum”  (buk;/konteks  
absah  terbaru)  yang  menggeser  KDM  tersisih,  dengan  
memunculkan  KDM  yang  lebih  unggul.    
 
ž Jadi  disini,  prima  facie  mirip  seper;  ”troef  card”  pada  
permainan  kartu  bridge,    dimana  kartu  bernominal  
kecil,  sepanjang  telah  ditetapkan  sebagai  ”troef”,  
senan;asa  dimenangkan  dibandingkan  dengan  kartu  
As  warna  lain  yang  bukan  ”troef”  pada  permainan  
saat  itu.    
 ANALOGI BERMAIN KARTU BRIDGE
•  permainan bridge dimulai dengan cara membagi
kartu kepada 4 orang pemain ( DOKTER, PASIEN ,
KELUARGA PASIEN,...)
•  setelah itu, dimulai dari pemain yang membagikan
kartu (dealer) melakukan penawaran (bidding) .
Yang menjadi pertimbangan kondisi pasien pada
saat masuk rumah sakit. penawar tertinggi akan
memenangkan kontrak (bridge) untuk mulai
melakukan permainan. Keadaan Umum, sakit
ringan, sedang atau berat ?
•  pemenang kontrak ditentukan oleh nilai trik yang
sanggup dipenuhi (minimal 7 trik maks 13 trik).
KDM PRIMAFACIE (MEDICAL INDICATION )
PADA SAAT AWAL.
•  MASIH ADA KEMUNGKINAN musuhnya harus
menggagalkan kontrak tersebut.(CONTEXTUAL
FEATURES)

•  Dalam proses penawaran (bidding), kita bisa

memperoleh informasi mengenai kartu pegangan
saya,teman dan musuh. tapi yang perlu menjadi catatan
adalah informasi yang disampaikan( KEADAAN PASIEN
SAAT DI RAWAT, MELIHAT KEMBALI RIWAYAT
PENYAKIT TERDAHULU )
•  Dalam proses bidding bukan hanya informasi kepada
partner saja tetapi musuh pun harus mengetahuinya.
artinya tidak ada kode2 rahasia! KARTU TROEF KDM
YG AKAN DI PILIH Apa yang diketahui partner musuh
pun harus tahu apa saja yang diinformasikan dalam
proses bidding? ( INFORMASI MEDIK / INFORMED
CONSENT )
    
ž Prinsip  prima  facie  akan     mempersyaratkan  
secara  sederhana,  adanya  konteks  baru  absah  
yang  ada  pada  diri  pasien  atau  keluarganya  
ke;ka  tengah  dalam  proses  perawatan  medik  
(proses  bersamaan  dengan  adanya  clinical  
judgment,  yang  berasal  dari  kewenangan  clinical  
privilege  yang  dipunyai  dokter).    
 Ciri-­‐ciri  KDM  yang  berbasis    Prima    Facie.  

ž Dalam  konteks  beneficence,  prinsip  prima  

facienya  adalah  ke;ka  kondisi  pasien  
merupakan  kondisi  yang  wajar  dan  berlaku  pada  
banyak  pasien  lainnya,  sehingga  dokter  akan  
melakukan  yang  terbaik  untuk  kepen;ngan  
pasien.  
ž   Juga  dalam  hal  ini  dokter  telah  melakukan  
kalkulasi  dimana  kebaikan  yang  akan  dialami  
pasiennya  akan  lebih    banyak  dibandingkan  
dengan  kerugiannya.    
•  Dalam    konteks  non  maleficence,  prinsip  
prima-­‐facienya  adalah  ke;ka  pasien  dalam  
keadaan  gawat  darurat  dimana  diperlukan  
suatu  intervensi  medik  dalam  rangka  
penyelamatan  nyawanya.    
•  Dalam  konteks  autonomy,  ciri  prima  
facienya  bila  menghadapi  pasien  yang  
berpendidikan,  pencari  naKah,  dewasa  dan  
berkepribadian  matang.    
ž Sementara  Jus;ce    prima  facienya  pada  konteks  
membahas  hak  orang  lain  selain  diri  pasien  itu  
sendiri.  Hak  orang  lain  ini  khususnya  mereka  yang  
sama  atau  setara  dalam  mengalami  gangguan  
kesehatan  di  luar  diri  pasien,  serta  membahas  hak-­‐
hak  sosial  masyarakat  atau  komunitas  sekitar  
pasien.    
 
ž Dapat  pula  dalam  konteks  ke;ka  menghadapi  
pasien  yang  rentan,  mudah  dimarjinalisasikan  dan  
berasal  dari  kelompok  anak-­‐anak  atau  orang  uzur  
ataupun  juga  kelompok  perempuan  (dalam  konteks  
isu  jender).  
 BIOETHICS IN CLINICAL
SETTING
METODE JOHNSON AND SIEGLER  

  Ali Taufan

 
§  Indikasi
 medik
 

 
 merupakan
 kemampuan
 seorang
 dokter
 untuk
 
melakukan
 penilaian
 klinis
 sebagai
 hasil
 
pendidikan,
 pengalaman
 dan
 sikap
 
profesionalisme
 nya
 dalam
 hal
 menegakan
 
diagnosis,
 prognosis,
 dan
 terapi
 
§  Preferensi
 atau
 pilihan
 pasien
 

 
 
 Dalam
 memberikan
 terapi,
 dokter
 berpegang
 
pada
 pilihan
 pasien
 untuk
 menyetujui
 atau
 
menolak
 tindakan
 yang
 akan
 dilakukan
 
terhadapnya.
 

 Kompetensi
 dan
 kapasitas
 pemberi
 persetujuan
 
§  Quality
 of
 life
 atau
 mutu
 kehidupan
 pasien.
 

 
 
 (meliputi
 diagnosis,
 prognosis,
 dan
 terapi)
 yang
 
memiliki
 potensi
 untuk
 mengurangi
 mutu
 kehidupan
 
pasien.
 salah
 satu
 tujuan
 intervensi
 medik
 adalah
 
memperbaiki.
 Oleh
 karena
 itu
 dalam
 setiap
 situasi
 
medik,
 mutu
 kehidupan
 pasien
 harus
 dipertimbangkan.
 
apakah
 setelah
 pengobatan
 akan
 menurun,
 menetap
 
atau
 membaik.
 Bagaimana
 dampak
 thdp
 kehidupan
 
sosialnya.
 
§  Faktor-­‐faktor
 kontekstual
 yaitu
 faktor-­‐faktor
 
eksternal
 yang
 berhubungan
 dengan
 pengobatan
 dan
 
perawatan
 pasien,
 misalnya
 faktor
 keluarga,
 ekonomi,
 
sosial-­‐budaya
 dan
 hukum.
 Johnson and Sieglers Method
1.  Medical Indication
• 
Beneficence and Nonmaleficence
What’s the patient’s medical problem ? History ?
dignosis ? prognosis ?
•  Is the problem acute ? Chronic ? Critical ? emergent ?
reversible ?
•  What are the goals of treatment ?
•  What are the probalities of success?
•  What are the plans in case of theurapeutic failure ?
•  In Sum, how can this patient be benefited by medical
and nursing care and how can harm be ovoided ?
3. Quality Of Life
Beneficence, Nonmaleficence, and Autonomy
•  What are the prospects, with or without treatment, for
a return to normal life ?
•  What physical, mental, and social deficits is the patient
likely to experience if treatment succeeds ?
•  Are there biases that might prejudice the provider’s
evaluation of the patient’s quality of life?
•  Is the patient’s present or future condition such that
his or her continued life might be judged as
undesirable ?
•  Is there any paln and rationale to forgo treatment ?
•  Are there plans for comfort and palliative care ?
2. Patient Preferences
• 
Autonomy
Is the patien mentally capable and legaly competent ? Is there
evidence of capacity ?
•  If competent, what is the patient stating about preferences for
treatment ?
•  Has the patient been informed of benefits and risk,
understood this information, and given consent?
•  If incapasitated , who is the appropiate surrogate ? is the
surrogate using appropiate standards for decision making ?
•  Has the patient expressed prior preferences ( e.g advance
directives ) ?
•  Is the patient unwilling or unable to cooperate with medical
treatment ? if so why ?
•  In sum, is the patient’s right to choose being respected to
the extent possible in ethics and law ?
4. Contextual Features
Justice
•  Are there family issuesthat might influence treatment
decisions ?
•  Are there provider (physician,nurse) issues that might
influence treatment decisions ?
•  Are there financial and economic factors ?
•  Are there religious or cultural factors ?
•  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 ?
Medical Indication

 
1.  What’s the patient’s medical problem ? History ?
dignosis ? prognosis ?
2.  Is the problem acute ? Chronic ? Critical ? emergent ?
reversible ?
3.  What are the goals of treatment ?
4.  What are the probalities of success?
5.  What are the plans in case of theurapeutic failure ?
6.  In Sum, how can this patient be benefited by medical and
nursing care and how can harm be ovoided ?

 
Patient Preferences  
1.  Is the patien mentally capable and legaly competent ? Is
there evidence of capacity ?
2.  If competent, what is the patient stating about preferences
for treatment ?
3.  Has the patient been informed of benefits and risk,
understood this information, and given consent?
4.  If incapasitated , who is the appropiate surrogate ? is the
surrogate using appropiate standards for decision
making ?
5.  Has the patient expressed prior preferences ( e.g advance
directives ) ?
6.  Is the patient unwilling or unable to cooperate with
medical treatment ? if so why ?
7.  In sum, is the patient’s right to choose being respected
to the extent possible in ethics and law ?
Quality Of Life
 
1.  What are the prospects, with or without treatment, for a
return to normal life ?
2.  What physical, mental, and social deficits is the patient
likely to experience if treatment succeeds ?
3.  Are there biases that might prejudice the provider’s
evaluation of the patient’s quality of life?
4.  Is the patient’s present or future condition such that his or
her continued life might be judged as undesirable ?
5.  Is there any plan and rationale to forgo treatment ?
6.  Are there plans for comfort and palliative care ?
Contextual Features
 
1.  Are there family issues that might influence treatment
decisions ?
2.  Are there provider (physician) issues that might influence
treatment decisions ?
3.  Are there financial and economic factors ?
4.  Are there religious or cultural factors ?
5.  Are there limits on confidentiality ?
6.  Are there problems of allocation of resources ?
7.  How does the law affect treatment decisions ?
8.  Is clinical research or teaching involved ?
9.  Is there any conflict of interest on the part of the providers
or the institution ?  
Ethical Principles

¨  Autonomy/Freedom
¨  Veracity

¨  Privacy/Confidentiality

¨  Beneficence/Nonmaleficence

¨  Fidelity

¨  Justice

39
Autonomy

¨  The right to participate in and

decide on a course of action
without undue influence.
¨  Self-Determination: which is the
freedom to act independently.
Individual actions are directed
toward goals that are exclusively
one’s own.

40
Veracity

¨  The duty to tell the truth.

Truth-telling, honesty.

41
Privacy/Confidentiality

¨  Respecting privileged knowledge.

¨  Respecting the “self” of others.

42
Beneficence/Nonmaleficence

¨  The principle and obligation of doing

good and avoiding harm.
¨  This principle counsels a provider to

relate to clients in a way that will always

be in the best interest of the client,
rather than the provider.

43
Fidelity

¨  Strict observance of promises or

duties.
¨  This principle, as well as other

principles, should be honored by

both provider and client.

44
 Justice

¨  The principle that deals with fairness,

equity and equality and provides for an
individual to claim that to which they are
entitled.
¤  Comparative Justice: Making a decision based
on criteria and outcomes. ie: How to determine
who qualifies for one available kidney. 55 year
old male with three children versus a 13 old girl.
¤  Noncomparative Justice: ie: a method of
distributing needed kidneys using a lottery
system.

45
Socrates…
}  learned from the Oracle of Delphi to
“know thyself.” Knowing thyself (and
values) increases knowledge and
wisdom. Wisdom leads to increased
critical reasoning and problem solving
skills.

Knowledge and
} 
wisdom à
leads to acting
Ethical.
 The framework

1.  Recognition of an Ethical Issue

2.  Get the Facts
3.  Evaluate alternative actions
4.  Make a Decision and Test It
5.  Act and Reflect on the Outcome
A framework for making good ethical decisions
is necessary because…

¨  ethical decision making is a skill

¨  a skill needs to be practiced

¨  when practiced regularly, the method becomes

so familiar that we work through it

automatically without consulting the specific
steps
Making good ethical Decisions requires…

¨  Recognition of an Ethical Issue

A clue that an action or situation needs an
ethical rather than simply a business
judgment is that the action/situation could
- be damaging to someone
- violate what is generally consider
right/good
- be more than what is legal/most
efficient
¨  Get the Facts
- What are the relevant facts of the
case? What facts are not known? Can I
learn more about the situation? Do I
know enough to make a decision?
- What individuals and groups have an
important stake in the outcome? Are
some concerns more important? Why?
- What are the options for acting? Have
all the relevant persons and groups
been consulted? Have I identified
creative options?
¨  Evaluate alternative actions by asking the
following questions:
- Which option will produce the most good
and do the least harm? (Utilitarian
Approach)
- Which option best respects the rights of
all who have a stake? (Rights Approach)
- Which option treats people equally or
proportionately? (Justice Approach)
- Which option best serves the community
as a whole, not just some members?
(Common Good Approach)
- Which option leads me to act as the sort
of person I want to be? (Virtue Approach)
¨  Make a Decision and Test It
- Considering all approaches, which
option best addresses the situation?
- If I told someone I respect of the
option I have chosen, what would they
say?
¨  Act and Reflect on the Outcome

- How can my decision be implemented

with the greatest care/attention to
concerns of all stakeholders?
- How did my decision turn out and what
have I learned from this specific event
Approaches to making ethical decisions
¨  Utilitarian Approach
Common Good Approach
¨  Deontological approach

¨  Rights Approach

¨  Casuist approach

¨  Fairness/Justice Approach

¨  Virtue Approach

¨  Putting the Approaches Together

 Utilitarian theory

§  the choice that yields the greatest benefit to

the most people is the choice that is ethically
correct

§  founded on the ability to predict the

consequences of an action

§  provides a logical and rationale argument for

each decision and allows a person to use it on
a case-by-case context
Example
A baby born prematurely at 24 weeks
gestation is put in intensive care. However
she is not thriving and scans suggest she
has profound brain damage. She cannot
breathe unassisted and the care team
believe she is suffering and it is not in her
interest to keep her alive. The parents do
not agree. What should the clinician do?
Utilitarian

•  Greater benefit to more people if life

terminated as the medical staff and
facilities will be freed even at the
expense of the parents happiness
 Flaws
¨  Based on predicting the future. No human
being can be certain that his predictions
will be true and this uncertainty can lead to
unexpected results

¨  Necessity to compare the various types of

consequences against each other on a
similar scale. Eg., money vs happiness

¨  Not always concerned with justice/

beneficence/autonomy for an individual, if
oppressing the individual leads to the
solution that benefits a majority of people.
•  Possibility of conflicting benefits/risks
What is ethically right for a surgeon who is
running late for his list?
- to drive breaking traffic rules to arrive
at his surgical list on time because the
fasting patients benefit from this
decision
- follow the traffic law because this
benefits an entire society

•  A group for whom there is a risk of harm

may not be the group likely to receive any
benefit - clinical research trials.
Common good approach
•  Ideal derived from utilitarianism

•  Community members are bound by the

pursuit of common values and goals
(Affordable healthcare, Unpolluted
environment)
 Flaws
¨  Individualism (Individual freedom goals &
interests
¨  “Free-rider problem”

Available to everyone even those who don’t

do their part. Therefore if more free riders
common good will be destroyed
¨  Pluralistic society

Different people have different ideas.

Impossible to agree on one social
system.
 Deontological theory

¨  States that people should adhere to their

obligations and duties when analyzing an
ethical dilemma

¨  A person who follows this theory will

produce very consistent decisions since they
will be based on the individual's set duties
 Flaws…
• No rationale for deciding an individual's
duties.
Eg., an MOH may decide that it is his duty to
always be on time to meetings. What is the
rationale for this? Not to keep others waiting
or to the fact that he has to always sit in the
same chair

• Does not provide guidance when there are

conflicting obligations
Eg., a person who must be on time to meetings
is running late, how is he supposed to drive? Is
he supposed to speed, breaking his duty to
society to uphold the law, or is he supposed to
arrive at his meeting late, breaking his duty to
be on time?
 Is lying right or wrong?
¨  Utilitarian/Consequentialist may argue that
lying is wrong because of the negative
consequences produced by lying. However a
consequentialist may allow that certain
foreseeable consequences might make lying
acceptable
¨  A deontologist might argue that lying

is always wrong, regardless of any potential

"good" that might come from lying
 Casuist theory

¨  Compares a current ethical dilemma with

similar ethical dilemmas and their outcomes

¨  Allows to determine the severity of the

situation and to create the best possible
solution according to others' experiences
 Flaws

¨  There may not be a set of similar examples

for a given ethical dilemma. eg., is new and
unexpected

¨  Assumes that the results of the current

ethical dilemma will be similar to results of
the previous experience
Rights theory
¨  Human rights of the individuals set forth by
society are protected and given the highest
priority
¨  Rights are considered to be ethically correct
and valid since a large or ruling population
endorses them
¨  Examples of Rights to be adhered to :

- right to the truth/privacy/not to be

injured/what is agreed
 Example

¨  A couple with primary subfertility were tested

for STD before assisted reproduction. The
man was diagnosed with STD. He requested
their doctor not to disclose his diagnosis to a
third party including his wife. He even
threatened with suicidal intention and denial
of treatment. How should the doctor deal
with this situation?
Flaws
¨  Conflicting rights
Right to privacy vs right to truth
Duty vs right
Fairness & Justice Approach
Everybody needs to be treated equally. If
individuals, can’t be treated equally then
they need to be treated properly based on
some criteria/standard. This means that the
communities or people affected by your
decisions can’t be favoured or benefit from
an unfair advantage.
Virtue theory
¨  Act after judging a person by his character
rather than by an action that may deviate from
his normal behavior

¨  It takes the person's morals, reputation and

motivation into account when rating an
unusual and irregular behavior that is
considered unethical.
 Example
A person plagiarized a passage that was
detected by a peer
The judgment will be based on whether the
plagiarizer normally follows the rules and has
good standing amongst his colleagues, if so the
peer may judge his friend more leniently.
(Perhaps the researcher had a late night and
simply forgot to credit his or her source
appropriately). Conversely, a person who has a
reputation for scientific misconduct is more likely
to be judged harshly
 Flaws
¨  Does not take into consideration a person's
change in moral character. Eg.,, a scientist
who may have made mistakes in the past may
honestly have the same late night story as the
scientist in good standing. Neither of these
scientists intentionally plagiarized, but the act
was still committed. On the other hand, a
researcher may have a sudden change from
moral to immoral character may go unnoticed
until a significant amount of evidence mounts
up against him or her
 Decision-making process

¨  Although all of the ethical theories attempt

to follow the ethical principles in order to
be applicable and valid by themselves, each
theory falls short with complex flaws and
failings.

¨  However, these ethical theories can be

used in combination in order to obtain the
most ethically correct answer possible for
each scenario.
 a utilitarian may use the casuistic theory and
¨ 
compare similar situations to his real life
situation in order to determine the choice
that will benefit the most people.
- the deontologist and the utilitarian who are
running late for their list may use the
rights ethical theory when deciding whether
or not to speed to make it to hospital in time.
Instead of speeding, they would slow down
because the law in the rights theory is given
the highest priority, even if it means that the
most people may not benefit from the
decision to drive the speed limit.
 Ethics is knowing the difference between
what you have a right to do and what is right
to do
Who is the Decision Maker?
Presumption of Capacity

§  A patient is presumed to have capacity until

two physicians certify that the individual lacks
the capacity to make health care decisions or
a court has appointed a guardian of the
person to make health care decisions

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Certification of Incapacity

§  If the individual lacks capacity, the attending

physician and a second physician must certify
in writing that a patient lacks the capacity to
make health care decisions
ú  One of the physicians must have examined the
patient within two hours before making the
certification
§  Only one physician’s certification is needed if
the patient is unconscious or unable to
communicate by any means

82
Who Makes Decisions if the Patient
Lacks Capacity
1.  A designated health care
agent
2.  If no agent is designated
or the agent is not
available or is unwilling
to act, a surrogate
decision maker is used

83
Determining the Appropriate
Surrogate Decision Maker
If there is no health care agent, Maryland law
specifies the type and order of the surrogate
decision maker(s) as follows:
1.  Guardian of the person
2.  Spouse or domestic partner
3.  Adult child
4.  Parent
5.  Adult brother or sister
6.  Friend or other relative

84
Domestic Partners

§  Not related to the individual

§  Not married
§  Gender irrelevant
§  “In a relationship of mutual inter-
dependence in which each contributes to
the maintenance and support of the other”

85
Authority of Surrogates

§  All surrogates in a category have the same

authority
§  All surrogates of equal authority must agree
on a decision regarding life-sustaining
interventions
§  A physician may not withhold or withdraw
life-sustaining procedures if there is
disagreement among persons in the same
class

86
Resolving Disputes Among
Equally Ranked Surrogates
§  Hospitals and nursing homes are required to
have a patient care advisory committee
§  Refer the issue to the patient care advisory
committee
§  Attending physician has immunity for
following the recommendations of the patient
care advisory committee

87
Patient Care Advisory Committee

§  Patients, family members, guardians, or

caregivers may request advice from the
committee
§  Committee must notify patients, family
members, guardians, and health care agents
of the right to discuss an issue
§  Committee’s advice is confidential and
members not liable for good faith advice

88
Documenting the Process

§  The process that has been used in

determining the correct surrogate decision
maker should be documented in the medical
record
§  When the patient is transferred to another
care setting, contact information for the
surrogate decision maker should be sent to
the receiving facility or program

89
What are Qualifying Conditions?
Withdrawing Life-Sustaining
Treatments
§  If no health care agent was appointed,
then life-sustaining treatments may only
be withdrawn when:
1.  Certification of incapacity by attending
physician and second physician
2.  Certification of condition by attending
physician and second physician which could
include:
   Terminal condition
   End-stage condition
   Persistent vegetative state

91
Withdrawing Life-Sustaining
Treatments
§  Or, two physicians certify a treatment as
medically ineffective for this patient

92
Terminal Condition

§  A terminal condition is incurable

§  There is no recovery despite life-sustaining
procedures
§  Death is imminent, as defined by a physician

93
End-stage Condition

§  An advanced, progressive and irreversible

condition caused by injury, disease, or illness
§  Severe and permanent deterioration
indicated by incompetency and complete
physical dependency
§  Treatment of the irreversible condition would
be medically ineffective

94
Persistent Vegetative State

§  The individual has no awareness of self or

surroundings
§  Only reflex activity and low level
conditioned responses
§  Wait “medically appropriate period of time”
for diagnosis
§  One of two physicians who certify a
persistent vegetative state must be a
neurologist, neurosurgeon, or other
physician who is an expert in cognitive
functioning

95
What are Advance Directives?
Advance Directive

§  An advance directive is a written or

electronic document or oral directive that:
1.  Appoints a health care agent to make health
care decisions - and/or –
2.  States the patient’s wishes about medical
treatments when the patient no longer has
capacity to make decisions (living will)

97
Living Will

§  A living will contains a patient’s wishes about

future health care treatments.
§  It is written “if, then”:
ú  “If I lose capacity and I’m in (specified
conditions),
ú  Then use or do not use a specific medical
intervention

98
Authority of a Health Care Agent

§  The advance directive determines when the

health care agent has authority
ú  “When I can no longer decide for myself”: The
individual may decide whether one or two
physicians must determine incapacity
ú  “Right away”: When the document is signed, the
agent has authority

99
Basis of Agent’s Decisions

§  The health care agent is to make decisions

based on the “wishes of the patient”
§  If the patient’s wishes are “unknown or
unclear,” then decisions are to be based on
the “patient’s best interest”

100
An  Exception  to  Following  a  
Living  Will  
§  In some instances, a living will may allow
the health care agent to act in the
patient’s best interest, regardless of what
wishes are stated in the living will
§  Most living wills are not written this way

101
Revoking an Advance Directive

§  A competent individual may revoke an

advance directive at any time by:
1.  Completing a new written or electronic
advance directive
2.  Giving an oral statement to a health care
practitioner
3.  Destroying all copies of the advance directive

102
 “Mom didn’t understand
what she signed”
See  the  link  below:  

 
http://www.dhmh.state.md.us/ohcq/download/
alerts/alert-­‐v1-­‐n1-­‐sum2002.pdf  
 

103
What is Medical Ineffectiveness?
Medical Ineffectiveness

§  A medically ineffective treatment is a medical

procedure that will not prevent or reduce the
deterioration of the patient’s health or
prevent impending death
§  Physicians need not offer medically
ineffective treatments

105
Advising Patients of Medical
Ineffectiveness
§  If two physicians determine an intervention is
medically ineffective, the patient or ADM must
be informed of the decision
§  The physician must make a reasonable effort
to transfer the patient to another physician if
the patient or ADM requests it
§  Pending transfer, the physician must provide
the requested treatment if failure to do so
would likely result in the patient's death

106
Medical Ineffectiveness in the
Emergency Room
§  In an Emergency
Room, if only one
physician is available, a
second physician
certification of medical
ineffectiveness is not
required

107