ISSU ETIS DALAM

KEPERAWATAN
M.Fathoni, S.Kep, Ns.

Isu-isu etik khusus : hidup dan mati,

mempertahankan/mengakhiri pemberian makanan
dan minuman, mengakhiri bantuan kelangsungan
kehidupan, AIDS, AI (Avian Influenza) alokasi
sumber-sumber kesehatan

Tujuan pembelajaran
1.
2.
3.

Mendefinisikan etik dan etika keperawatan

Mengidentifikasi dilema etis yg sering terjadi
Menguraikan strategi membantu dalam membuat
keputusan etis

Introduksi

Perkembangan IPTEK mempengaruhi perkembangan hidup

manusia
Isu Perinatal : skrening genetika, fertilisasi invitro,
pengambilan dan pembekuan embrio, operasi perinatal
Awal kehidupan : bayi prematur dg bantuan alat canggih, anak
dan dewasa transplantasi organ
Mixed blessing akibat peningkatan biaya
HIV / AIDS, Degeneratif dsb.

Definisi istilah

1.

Etika versus moralitas

- Etika studi filosofi moralitas
berdasarkan teori formal,
aturan, prinsip dan kode
prilaku untuk menentukan
bagian yg benar suatu
tindakan
- Etika studi lebih formal,
sistematik dari keyakinan
moral

- Moralitas

menggambarkan
komitmen pribadi thd nilai
yg sering dipengaruhi
norma dan pengharapan
masyarakat
- Moralitas ketaatan thd
nilai personal informal

Pendekatan thd etik

1.

Etika non normatif

- Meta etik : konsep dan terminologi linguistik dalam etika :
Baik , Kebajikan, Benar
Contoh informed concent
- Etika deskriptif : Mengidentifikasi prilaku dan keyakinan
etis tanpa melakukan penilaian
(bersifat netral : Contoh antropologi, sosiologi)

Lanjutan
2. Etika normatif
- Filosofi moral yg seharusnya/ sebaiknya
- Proses penetuan tindakan moral dalam menjawab apa yang
seharusnya saya lakukan dalam situasi seperti ini
- Disebut juga etika normatif umum
- Jika dilakukan pada disiplin yg lebih spesifik disebut etika
terapan

Situasi moral
Kata lain :
Situasi moral, delema moral, ketidak pastian moral,
distres moral
Delema terjadi konflik yg nyata antara dua atau lebih
prinsip moral yg saling berkompetisi the lesser of
two evils
Contoh Px sakit parah mentaati kesucian hidup, orag
lain menganggap memperpanjang penderitaan

Ketidak pastian moral & moral distress

Delema perawat ketidak pastian moral

- Lansia dg pembedahan tidak mengalami kemajuan
- Px tidak siap dipulangkan
Distress moral
- Kebijakan RS, Px menanyakan Apakah sayan
menderita kanker ? Dr, kluarga tidak
menginformasikan I

Ethical Theories

Teleology - the value of a situation is determined by its consequences.

Deontology - the intrinsic significance of an act itself as the criterion
for the determination of good.
Situational Theory - holds that there are no set rules or norms. Each
situation must be considered individually.
Caring-Based Theory - focuses on emotions, feelings, and attitudes.

Teori Etik Klasik

1.
2.
3.
4.

Teleologi
Deontologi
Etik kebajikan
Etik pluralisme

1. Teleologi

Telos (yunani) = akhir, yang penting memperhatikan

hasil akhir/konsekwensi dari tindakan
( Konsekuensialisme)
a. Utilitarisme (kemanfaatan) terbaik bagi yg
terbanyak
- John Stuart Mill prinsip kebahagian
terbesar

The Kantian Model

Central insight: people

cannot be treated like mere
things.
Key notions:
Autonomy & Dignity
Respect
Rights

2. Deontologi

Deon (yunani) tugas/hak/ kewajiban (formalis)

Pembenaran tindakan moral lebih penting dari pada
konsekwensi
Imanual Kant(1785/1983) Moralitas dibangun niat baik
Contoh seorang perawat yg lalai memberikan obat dan
melaporkan hanya karena takut tindakan hukuman jika
kesalahan tsb diketahui ketimbang kawatir efek yg
membahayakan maka perawat tidak bertindak dalam
perspektif moral
Perspektif kan disebut monistik/ imperatif moral
(ketaatan satu prinsip (rasionalitas)
Golden Role (memperlakukan orang lain seperti
memperlakukan diri sendiri.(respek kemanusiaan)

3. Etika kebajikan

Sifat karakter individu (Aristotle dan Plato bahwa prilaku

morla berjembang sesuai perkembangan prilaku kabijakan.
Saya harus menjadi apa dari pada Apa yang harus saya
lakukan
Contoh kebajikan Keyakinan, harapan, cinta dan amal dalam
keagamaan
Mewarnai etika normatif (kemurahan hati, kejujuran, keadilan)

4. Etik Pluralisme

Tergantung konteks lebih baik dari yang lain dengan

mempertimbangkan beragam kerangka kerja

Pluralisme
WD. Ross (Inggris, 1930) Prima facie (kondisional atau semua
hal lain yg serupa) dan eksistensi aktual(keberadaan)
Contoh secara moral berkata bohong itu salah, namun kadang
membenarkan tindakan ini lebih mendesak karena menghindari
bahaya orang lain.

Prinsip etika secara mum

- Otonomi
-Kemurahan hati
- Kerahasiaan
-Efek ganda
- Kesetiaan
-Keadilan
- Non maleficence(tidak membahayakan)
- Paternalisme
-Respek Individu
- Kemulian hidup -Kejujuran

Ethics in Health Care

Bioethics is the application of ethical principles to

health care.
Ethics affects every area of health care.
Ethics helps provide structure by raising questions
that ultimately lead to answers.

Prinsip etika umum

Otonomi :
- Peraturan diri, hak individu, privacy, pilihan, kemampuan
membuat pilihan yang bebas dari ekternal
2. Kemurahan hati
- Melakukan hal yang baik, penuh kebajikan, kebaikan dan
kemurahan
3. Kerahasiaan
- Privasi, tidak menyebarkan utk org lain
1.

Lanjutan
4. Efek ganda
- Tindakan dapat menghasilkan efek positif dan nengatif dg
kriteria :
a. Tindakan itu ssecara moral baik
b. Secara tulis berniat efek yang baik(efek buruk diramalkan
tapi tidak diminati)
c. Efek baik tidak diraih dg cara efek buruk
d. Terdapat keseimbangan proporsional yg baik dan buruk
5. Kesetiaan :
- Menepati janji (komitmen)

Lanjutan

6. Keadilan :
- Memperlakukan sesuai hak dan kewajiban
individu dan
sosial antara lain (Kesetaraan,
kebutuhan, upaya,
kontribusi masyakarakat, kebaikan, legal)
7. Non malificence :
- tidak membebankan utk mencegah dan
menyingkirkan bahaya
8. Paternalisme
- Bekerjasama utk kemurahan hati,
kesejahteraan /
kebutuhan orang lain,
mencegah keburukan

Lanjutan

8. Paternalisme
- Bekerjasama utk kemurahan hati,
kesejahteraan /
kebutuhan orang lain,
mencegah keburukan
9. Respek utk individu :
- Mengotimalkan dan memampukan orang lain membuat pilihan
10. Kemuliaan hidup :
- Eksistensi biologis harus lebih penting diatas kriteria ekternal
11. Kejujuran
- Kewajiban mengatakan yg benar, tidak bohong, tidak menipu
orang lain

Domain etika keperawatan

1.
2.
3.
4.

Memberikan perawatan berkesinambungan

Tidak memandang penyakit /status sosial
Bertangung jawab
Bertindak sesuai kode etik profesi

Jenis masalah etis keperawatan

1.
2.
3.
4.
5.

Kerahasiaan
Restrein
Hubungan saling percaya
Kematian dan sekarat
Menolak perawatan

Ethical Dilemma

Defined as making a
choice between two
or more equally
undesirable
alternatives

Lanjutan

Kerahasiaan
- Informasi Dx. Medis, keperawatan, diskusi Px ditempat
tertutup
2. Restrein (penggunaan pengikat)
- efek keselamatan, agitasi/bingung, menanyakan anggota
kluarga /relawan
3. Hubungan saling percaya
- Kejujuran, tidak berbohong kepada pasien, informasi yg
jelas prosedur dan diagnosa keperawatan,
mengkomunikasikan pada kluarga dan dokter permintaan
pasien akan informasi.
1.

Ethical Decision Making

Ethical Reasoning
Thinking through what one ought to do in an orderly,
systematic manner
Justification of actions based on principles

Trial-and-Error
Decision Making

Reflect for a minute on

how
you make decisions

Ethical Decision Making

Framework for Ethical Decision Making

Which theories are involved?

Which principles are involved?
Who will be affected?
What will be the consequences of the alternatives?
What does the client desire?

Ethical Decision Making

Steps of Ethical Analysis

Gathering of relevant data to identify the problem

Consideration of all the people involved
Selection of a course of action
Evaluation of the resolution process

Ethical Issue

Euthanasia
Refusal of Treatment
Scarce Resources

Euthanasia

Good or gentle death

Mercy killing (deliberate ending of life as a humane
action)

Euthanasia

Active euthanasia is taking deliberate action that will

hasten the clients death.
Assisted suicide is a form of active euthanasia.

Passive euthanasia is the omission of an action that

would prolong dying.
Discontinuing the clients tube feedings is a form of passive
euthanasia.

Refusal of Treatment

The clients right to refuse treatment is based on the

principle of autonomy.
A clients right to refuse treatment and the right to die
challenge the values of some health care providers.

Scarce Resources

The availability of specialists and organs, is

contributing to a scarcity of resources.
The use of expensive services is influenced by social
and political forces.
Health care reform is needed to ensure services to all.

Ethics and Nursing

Professional nurses actions are both legal and ethical.

Sound nursing practice involves making ethical
decisions.
Ethics affects nurses in every health care setting.

Ethics and Nursing

Ethics Committees
One approach for facilitating dialogue regarding ethical
dilemmas

Nurse as Client Advocate

Nurses are accountable for protecting the rights and
interests of the client.

Ethical Decision-Making Model

ANALYSIS
ASSESSMENT
AND DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
ProblemAssessing
identification:
Consideration
Determination
Carryingthe
outoutcome
Statement
selected
ofofpriorities
claims
of
moral
of
moral
and
of
the
claims;
actions
parties
ethical
actions;dilemma
Generation ofWere
alternatives
the actions
for resolving
ethical?the dilemma;
Consideration
Whatofwere
the consequences
the consequences?
of alternatives

Web Resources,
2

Before I Die
With Bill Moyers

http://www.pbs.org/wnet/bid/

Web Resources, 3

The End of Life: Explaining Death in America

http://www.npr.org/programs/death/

What is a good death?

Eudaimonistic utilitarians: a
good death is a happy death.
John Stuart Mill

Jeremy Bentham.
Hedonistic utilitarians: a good
death is a painless death.

Appendix 1
From whole to parts
Soul
Person

Priest,
Minister
Rabbi

Mind

Psychologist

Body

Psychiatrist
ENT
Ophthalmologist
Doctor
Urologist
Oncologist

Appendix 2
Stakeholders in the Decision-making Process

Patients
Family

Physician

Patient

Insurer/
HMO

End-of-life decisions involve more than the patient and the

physician.

Lanjutan
4. Kematian dan sekaratul
maut Tidak ada yg dapat
dilakukan lagi
Teknologi akan memperpanjang hidup perlu biaya
tinggi
Fokus peran asuh
Resustiasi
a. Dukungan hidup
b. Makanan dan cairan
c. Kontrol nyeri

Lanjutan
5. Menolak perawatan
- Konflik nilai
- Takut cedera
- Keterasingan
- Takut biaya

Pembuatan keputusan etis

1.

Pengkajian :
Situasi etis/moral dari masalah
a.Dimensi etis, hukum, profesional
- Apakah situasi mengandung masalah
moral (konflik prisip etis dan kewajiban
profesional)
- Apakah ada konflik prosedural (siapa yg
harus membuat keputusan, apakah ada konflik
pemberi asuhan, kluarga, px)
- Identitas orang terpenting yg terlibat dan
mempengaruhi keputusan

Ethical Decision Making

ASSESSM EN T
D e t e r m in a t io n o f c la im s a n d p a r t ie s

A N A L Y S IS & D IA G N O S IS
I d e n t ific a t io n o f p r o b le m : S t a t e m e n t o f e t h ic a l d ile m m a

P L A N N IN G
C o n s id e r a t io n o f p r io r it ie s o f c la im s
C o n s id e r a t io n o f c o n s e q u e n c e s o f a lt e r n a t iv e s

IM P L E M E N T A T IO N
C a r r y in g o u t s e le c t e d m o r a l a c t io n s

E V A L U A T IO N
E v a lu a t io n o f o u t c o m e o f m o r a l a c t io n s
" W e r e t h e a c t io n s e t h ic a l? " " W h a t w e r e t h e c o n s e q u e n c e s ? "

An Exciting Time
for Ethics

New technologies

Policy vacuums

Ethical & legal quandaries

Lanjutan

2. Perencanaan :
Kumpulkan informasi :
a. Fakta medis, pilihan pengobatan, Dx. Keperawatan, data
legal, nilai, keyakinan,
komponen keagamaan
b. Buat perbedaan antara faktual dan nilai /
keyakinan
c. Validasi kepastian pasien atau kurang kapasitasa membuat
keputusan
d. Indentitas informasi lain yg relevan
e. Identifikasi isu etis/ moral dan klaim persaingan

Lanjutan

3. Implementasi
a. Urutkan alternatif
Bedakan alternatif dg prinsip etis yg dapat diterapkan dan
kode etik profesi, dapat memilih salah satu atau keduanya
bandingkan :
Pendekatan utilitarisme
- Ramalkan konsekwensi dari alternatif
- Teliti nilai positi dan negatif tiap konsekwensi
- Pilih konsekwensi yg meramalkan nilai paling positif atau
yg terbaik bagi yg terbanyak

Lanjutan
Pendekatan deontologi (hak/kewjiban/alasan)
a.
Identifikasi prisip moral yg relevan
b.
Bandingkan alternatif dgn prinsip moral
c.
Bandingkan ke prinsip moral tingkat yg lebih tinggi
jika terdapat konflik

Lanjutan keputusan
4. Menentukan dan mengevaluasi
a. Tindakan apa yang terbaik dan tepat
secara
moral ?
b. Berikan alasan etis terhadap keputusan anda ?
c. Apa alasan etis dari keputusan anda
d. Bagaimana anda merespon terhadap
penalaran
keputusan anda ?

To make appropriate
ethical decisions:
The manager must use a
professional approach
that eliminates trial and
error and focuses on
proven decision-making
models or problemsolving processes.

The MORAL Decision Making Model (Crisham,

1985)

MMassage the dilemma.

OOutline options.
RReview criteria and resolve.
AAffirm position and act.
LLook back. Evaluate the
decision-making.

Murphy and Murphy (1976) Approach to Ethical

Problem Solving
1. Identify the problem.
2. Identify why the problem is an ethical problem.
3. Identify the people involved in the ultimate decision.
4. Identify the role of the decision maker.
5. Consider the short- and long-term consequences of each alternative.
6. Make the decision.
7. Compare the decision with the decision makers
philosophy of
ethics.
8. Follow up on the results of the decision to establish a
baseline for future decision making.

Another error made by

managers in ethical
problem solving is
using the outcome of
the decision as the sole
basis for determining
the quality of the
decision making.

Ethics in Action

In an era of markedly
limited physical, human,
and fiscal resources, nearly
all decision making by
nursemanagers involves
some ethical component.

If a structured approach to
problem solving is used, data
gathering is adequate, and
multiple alternatives are
analyzed, even with a poor
outcome, the manager should
accept that the best possible
decision was made at that time
with the information and
resources available.

The following forces ensure that ethics will become an

even greater dimension in management decision
making in the future:

increasing technology, regulatory pressures, and

competitiveness among healthcare providers;
national nursing shortages;
reduced fiscal resources;
spiraling costs of supplies and
salaries;
and the publics increasing distrust
of the healthcare delivery system and
its institutions.

Accountability of Nursing
Nurse is answerable, responsible, & liable for the
services he or she provides or makes available.
State licensure
Nurse Practice Act
Patients Bill of Rights
Code of Ethics for Nurses

Nursing Research

Patients Bill of Rights

Informed Consent

Other Ethical Issues

Quality of life vs. Sanctity of Life

Euthanasia
Withholding or withdrawing Tx.
Abortion
Allocation of Resources
Restraints
Informed Consent
Confidentiality

Preventive Ethics

Advance Directives
*Living Will
*Durable Power of Attorney for

Institutional Ethics Committees

Patient Care Conferences

Ethics Literature

Health Care

Definitions
HIV/AIDS-Related Stigma:
a process of devaluation of people either living with or
associated with HIV/AIDS. (UNAIDS)
HIV/AIDS-related Discrimination: Discrimination follows
stigma and is the unfair and unjust treatment of an individual
based on his or her real or perceived HIV status. (UNAIDS)
Relations?
Stigma (marking/labelling) Discrimination (action)

Why Study HIV-related Stigma and

Discrimination in Asia?

Stigma and discrimination described as the greatest

barriers to effective epidemic control

Asia described as the next battlefield for AIDS

Research gap

Aim

To provide a systematic situation

analysis of structural forms of HIV
related discrimination in selected
sites in six countries:

China (Beijing)
India (Trivandrum)
Indonesia (Bali & Jakarta)
Philippines (Manila)
Thailand (Bangkok)
Vietnam (Hanoi)

Terimakasih
Wassalam