VALUE BASED ETHICS

Agus Purwadianto
 Indikasi Pilar Keputusan Klinis/PH sehari2
Biomedik medik
Keputusan
Medis VALUE

BIOKULTURAL

-
Keputusan
etis
Info-
medik

Mindset non medis pilihan pasien

Struktur Psiko- kualitas hidup
Sosio-budaya fitur kontekstual
 HIGHER EDUCATION AS KNOWLEDGE
AND CULTURE GENERATORS

HIGHER EDUCATION
UNIVERSITY ?
PROCESS EDUCATION/
TO PRODUCE TYPHICAL
SCIENCE OR LEARNING
NEW TRUTH PROCESS
INVENTION

SCIENTIST CIVILIZED & PROFESSIONAL

SCHOLAR HUMAN RESOURCES

NEW MANAGEMENT
NEW PARADIGM
NEW SYSTEM
??? GLOBAL ECONOMY
 INTI EVIDENCE BASED MEDICINE modifikasi Sudigdo S

Saintifikasi Jamu
Physicians competence
IDI
KOLEGIUM nakestrad

INTI RIs
BALITBANGKES JAMUOLOGY
Kolegium peneliti LEADING TO
BIOCULTURAL MED

Valid evidence
Patients values
FROM STUDIES
PATIENTS PREFERENCE
inter-subyektivitas
(bukan obyektivitas) JAMU DIPAKAI & BERMANFAAT
(Riskesdas 2010)
Akuntabilitas publik : papan nama + RM
 EBM
THE CARE OF INDIVIDUAL PATIENTS SHOULD
INVOLVE : the conscientious, explicit and judicious
use of current best evidence
Cochrane collaboration as officially pooler of
published SCIENTIFIC research
Improve clinicians knowledge & reading habit & computer
literacy
Provides framework of teaching
Democratization : juniors as best partners, >>
communication Dr-Pat, >>> use of resources
EBM : EMBEDDED PATIENTS VALUE
IDENTIFY : The best evaluated methods of health care > useless >
harmful methods
Enables Dr Pat make better informed CHOICE & CONSENT decision

HOW FAR VBM PENETRATE

HEALTH CARE SERVICES W/
EBM ?
 The objectives & trilogy of
CLINICAL MANAGEMENT
1. To relieve his or her symptoms,
2. To make him or her comfortable again.
3. To restore his or her sense of well-being.
a. diagnosis (to identify the cause of symptom and
to decide on the natural of the illness );
b. treatment; and
c. prognosis (estimate of how long the patient will
be ill due to present condition with or without
treatment).
(Curran, W, J., 1982)
Physician act as (only) AMPLIFIER (IN VITRO APPROACH) of
THE CARTEL industry producing of EBM SCIENTISTS +
LEGALLY POSITIVISTIC MODERN REGULATORS ?

WHAT ABOUT DRS

SOUVEREIGNTY (TOTAL
INTEGRITY), AS THE
PATIENTS HERO?
 VALUE ..
DECENCY ALTRUISM
KINDNESS SACRIFICE
SYMPATHY LOVE
EMPATHY
CARING .other GOODNESS
DEVOTION
SERVICE
GENEROSITY
 COMPONENT OF MEDICAL
DECISION MAKING
(ian Kerridge, 1998)

SCIENTIFIC EVIDENCE (ebm)

PERSONAL EXPERIENCE
PERSONAL BIASES & VALUES
ECONOMIC & POLITICAL
CONSIDERATIONS
PHILOSOPHICAL PRINCIPLES
bioethical principles
 THE ROOT of MEDICAL SCIENCES
UU DIKDOK no 20 th 2013
Patients individual/ Human suffering
Healthy (bedside)
Community
& publics
prepathogene
sis Diagnosis Treatment Prognosis

2. Clinical 4. Medical
3. Public Health
Sciences Humanities

1. Biomedical
Sciences
PHARMACEUTICALS/DEVICES as HOLISTIC MEDICINE #
PRODUCTS HEGEMONY, bench Science & arts # T&CM
Key characteristics of COMPREHENSIVENESS
good services delivery
WHO Health System ACCESSIBILITY
Strengthening
COVERAGE
CONTINUITY
QUALITY

PERSON-
CENTEREDNESS
CONTINUATION

ACCOUNTABILITY
& EFFICIENCY
 Phenomenology of Medicine
Patients perception Drs details of life-world
Finitude & dying Emphaty (of idiographic
Imagination events)
Human personhood Uniqueness

Hope Interpretation

Embodiement hermeneutics
Emotive structure of
Illness
abstract knowledge
Emotive structure of
Freely profess ability to
abstract knowledge
heal
 HEALTH & HUMAN RIGHTS
WHO Constitution: "the enjoyment of
the highest attainable standard of health
is one of the fundamental rights of
every human being..."
"The world needs a global health
guardian, a custodian of values, a
protector and defender of health,
including the right to health." Dr
Margaret Chan, Director-General, WHO.
SETIAP ORANG BERHAK ATAS KESEHATAN ps 4 UU Kes No. 36/2009
 MEDICAL EDUCATION
EBM VBM
FORMAL CURRICULUM ESPECIALLY HIDDEN
CURRICULUM
ORIENTATION
SKILLS
EDUCATION (INQUIRY,
TRAINING
(TRANSMISSION OF ADAPTABILITY,
SPECIFIC SKILLS FOR FLEXIBILITY, BE
THE PREDICTABLE COMPASSIONATE &
SOLUTION, ABILITY TO CARING DR)
DOMINATE FACTS)
MEDICINE AS SCIENCE MEDICINE AS ART
Dekadensi - nilai
 VBM consideration
Tony Hope, J.Med.Ethics, 1995
Health care purchasing
EBM as a tool to cut funding only highly relevant valid
evidence = reason to purchase
Critic to systematic bias into purchasing
Amount of effort of previous research
Drug as OBJECTIVE WEAPON after being FUNDED
Ease quantification of desired outcome
Acute relieves : > dramatic than chronic disease
Public health perspective >< individual Patients choice
best buy logic > most effective treatment
 VBM > EBM
EBM : > Drs centered bias
Hierarchical evidence : RCT, DB, MA
Consumers section of Cochrane Collab
Objectivity
& rationality behind the medical data ..
Who determined the research question ?

Fact
: Value driven question behind the research
question !!!
Why some hospital units had a high infection rate ? >
than : Do all women who undergo SC should be given an
antibiotic prophylaxis ?
 Patients Involvements
ClinicalPractice Guidelines (CPG) as the
Drs monopoly ?
No !!! Patient & Public Involvement
Program
Patients, consumers & public
Involvement : communication, consultation,
participation
>>> in Scandinavian countries
 VBM on patients side :
BALLANCING the benefit harm
Patients decision aids presenting options
Individualised risk assesment
Probabilities of benefits & downsides
supporting choices of preference
sensitive decisions (of mass screening)
 Patients rationality
3 MUs : mujarab, mudah, murah
Accountability : Effective & Quality
Accessible
Affordable
WHICH VALUES INFLUENCING HEALTH PROFESSION :
EXISTENCY, CLINICAL SETTING, RELIGION, CULTURE,
HUMAN DIGNITY

HUMAN VALUES
 Existency of Values :
7 THREATS TO ETHICS
The Death of God
Relativism
Egoism
Evolutionary Theory
Determinism & Futility
Unreasonable demands
False consciousness

Simon Blackburn, 2001

 Clinical Setting Advantages
More humane
Full
of phenomenology Merleau Ponty
Responsibility precedes the freedom - Levinas
Emancipating power Juergen Habermas
Plenty of contextualities point of hermeneutics
Elective
vs emergency, social vs individual, East vs
West, EBM vs VBM, biosafety vs biosecurity
Melting pot of theories/perspectives/paradigm
Biomedic vs infomedic Foss & Rothenberg
Ethicolegal system - AP
Agent of change & iatrogenicity par excellence

Agus Purwadianto, 2009

 3 Ihsans components
Ikhlasun niyat : melakukan pekerjaan dg motif yg
bersih, murni krn Allah = profesi luhur = tak ada
sengaja misconduct/WCC .
Itqanul amal : rapi dalam bekerja patut, teliti,
hati2, sesuai indikasi medik & standar, spy mujarab
Jaudatul ada : melakukan dan menyelesaikan
pekerjaan hingga tuntas : komprehensif : D/ Th/ s/d
Prognosis, mujarab, murah, mudah.
 Abdallah S. Daar and A. Khitamy CMAJ January 9, 2001; 164 (1)

VALUEs origin :
SECULAR vs Islamic Ethics
Western bioethics = rights-based, with a
strong emphasis on individual rights,
Islamic bioethics is based on duties and
obligations (e.g., to preserve life, seek
treatment), although rights (of God, the
community and the individual) do feature
in bioethics, as does a call to virtue
(Ihsan).
 Values source : Human dignity
Intrinsic value of every human being, equal
for all humans
Because of the sole fact that he/she is human
Ricoer 1988, De Koninck, 1995
Respect for the inherent value of every
human being and of humanity
respect for autonomy + spiritual
dimension of human existence
Lenoir & Mathieu 1998
Human : > biological & genetic level
 2 aspect of human dignity
Individual
Foundation of all rights & freedom
Promoting self-determination & protect
against any inhuman/degrading treatment
Collective
wholistic incl future
generations
Society have a solidarity rights : society have
an intrinsic value as well (in a derivative way
from individual perspective)
 Value - Norm
Value
Not concrete (no empirical-observational facts)
subjective
(basic/motivation
of will, idea, hope and internal
judgment/mind of human behavior/action explicitly or
tacitly

Norms
Concrete
Value objectivation
 Values
Pre-moral
Not
refered to specific concrete norm of
human action
Moral
Imperative of human to conduct or to refer
specific action of concrete norm;
 Value
Triad : Choosing, Prizing, Acting
Cantbe taught, but can be experienced
As basic cause of conflict

Category :
Value in itself (intrinsic value)
Pleasure
Happiness

Instrumental value (extrinsic value)

Good/right if the goal have been achieved
 NORMS (:modernity)
Ethics (narrow interpretation)
Goals of the goodness of personal life or clearness/purity of
conscience (intra-personal principles).
Law
Goals of peaceful social life (inter-personal principles) after
socializing & enforcing determined-norms
Etiquette
Goals of harmony of social life, esp. physical aspect (inter-personal
principles)
Religion/beliefs
Goals of akhlak/good behavior purification & celestial (world +
heaven) (intra-personal principles)
 Ethical justification

Claims of rights (goal oriented)

Claims of conscience (process oriented)
Distinguishing morality & ethics
 Rights
= justified claims that a person can
make on others or on society
often controversy : individual vs
society, individual vs individual;
society vs society
 Conscience
= self-reflection + judgment about
whether an action is right or wrong
= build a sense of wholeness or
integrity & responsibility, not to feel
ashamed & guilty
 Meaningful Life - theory
Love incorporated to God (Plato, sufi-ism
Islam, Kejawen)
Pleasure-based (eudamonia)
Virtue Ethics (Aristotle)
Pain-hindrances feeling (Epikurus)
Individual voluntariness incorporating with
Natural Law as Gods Law/sunatullah
(Stoa)
 Meaningful Life theory (2)
Love of God (Agustinus)
Follow the natural law (Love to God + virtue)
Not having, but being (Erich Fromm)
Freedom/autonomy of subject as moral
resources (Kant)
World view/lebenswelt (Habermas)
etc
 NILAI dlm Kode Etik Dokter RI

Kemurnian niat = sikap moral tanpa

pamrih, rela berkorban/menolong
Kesungguhan kerja = ketuntasan
tindakan baik & adil, teliti hati2
Kerendahan hati = santun
Integritas ilmiah & sosial
kesesuaian kata-perbuatan/pikiran-sikap-
tindak-perilaku = martabat profesi luhur
(hormat diri sendiri & adil)
VBE FRAMING THE AGENTS
ETHICAL THEORY
MEANINGFUL LIFE
FIDUCIARY RELATION
AGENT : VIRTUE

Golden rule
ACTS : DEONTOLOGI Kantian
Plural

ENDS : TELEOLOGICAL Goal-based

CONSEQUENCES : CONSEQUENTIALIST
(UTILITARIAN)
 RELEVANCY OF VBM
CATCHING DRS IDENTITY & CHARACTER

COGNITIVE ETHICS CULTURAL ETHICS

GOOD DOCTORS DRS WHO DO GOOD
ETHICAL DR DRS WHO ACT
ETHICALLY
INTEGRATED ETHICS
ISOLATED ETHICS
(INDEPENDENT OF ITS (FUNCTION AS
PRACTITIONERS & INTEGRAL PART OF
EXTERNAL TO THE DRs IDENTITY)
PROBLEM AT HAND)
GOOD = SENSITIVE/CARING DR
GOOD APPLICANT DR BAD = INSENSITIVE DR
 SOCIALIZATION
MERTON, READER, KENDALL, 1957
PROCESS BY WHICH PEOPLE ACQUIRE
THE VALUES & ATTITUDES, THE
INTERESTS, SKILLS & KNOWLEDGE
=THE CULTURE, IN THE GROUPS OF WHICH
THEY ARE, OR SEEK TO BECOME, A MEMBER
VBM= AS AN VALUE APPLICATION to the
STUDENT during SOCIALIZATION
Aboutrightness/wrongness within overall culture
of medicine
 Self reflection
Are you a virtuous student ?
Do you understand the ambiguity of
medicines culture ?
Are you preparing to act rightly while
maintaining your natural good character ?
 Self-reflections vigilance
Are you preparing to act rightly while maintaining
your natural good character ?
after internalize the hidden value which you got at
the place between the :
blackboard pen (not at the formal curriculum) ?
ward A ward B (at corridors of the clinical ward, not
bedside)?
Lab C lab D (at locker s room, not bench)
Health centre A posyandu B (at market, not health
care facilities)
 Good doctors
combine individual

clinical expertise
and best available

external
evidence; they are
thoughtful,
evidence based
practitioners
 Good doctors

use "intangible personal
resources" in the care of
their patients; . attaches
to vocationalism in
medicine and to the
personal qualities
required of its practitioners,
including truthfulness
 Good
reflective turn of mind doctors

open to audit
and to learning from
mistakes ....
personal qualities more
prominently than
proficiency in
knowledge and
technical skills.
 CONCLUSION
Value based ethics (VBE) is a tool to balance & to
criticized EBM by raising the whats behind
question
Drs VALUE as the subjective core of meaningful
life basis should be balance with Patients & Public
Involvements forming the virtuous
association/institution
VBE as a source of norms, are incorporated &
embedded in every article Code of Medical Ethics
& Other health professionals
Agus Purwadianto