ISSU ETIS DALAM

KEPERAWATAN
Pipit Feriani, S.Kep, MARS.
 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. Mendefinisikan etik dan etika keperawatan
2. Mengidentifikasi dilema etis yg sering terjadi
3. 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 penentuan 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, dilema moral, ketidak pastian moral, distres
moral
 Dilema terjadi konflik yg nyata antara dua atau lebih prinsip
moral yg saling berkompetisi “ the lesser of two evils”
 Contoh Px sakit parah mentaati prosedur perpanjangan
hidup, orang 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 saya menderita
kanker ? Dokter, kluarga tidak menginformasikan
Ethical Theories
 Teleology - the value of a situation is determined by its consequences.
 Deontology - the intrinsic significance of an act it self 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. Teleologi
2. Deontologi
3. Etik kebajikan
4. 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 more 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
berkembang 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
1. 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
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. Memberikan perawatan berkesinambungan

2. Tidak memandang penyakit /status sosial
3. Bertangung jawab
4. Bertindak sesuai kode etik profesi
Jenis masalah etis keperawatan
1. Kerahasiaan
2. Restrein
3. Hubungan saling percaya
4. Kematian dan sekarat
5. Menolak perawatan
Ethical Dilemma
 Defined as making a
choice between two or
more equally
undesirable alternatives
Lanjutan
1. 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.
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
client’s death.
 Assisted suicide is a form of active euthanasia.
 Passive euthanasia is the omission of an action that would
prolong dying.
 Discontinuing the client’s tube feedings is a form of passive
euthanasia.
Refusal of Treatment
 The client’s right to refuse treatment is based on the
principle of autonomy.
 A client’s 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
andof
theclaims;
actions
parties
ethical
actions;dilemma
Generation of“Were the actions
alternatives ethical?”the dilemma;
for resolving
“Whatofwere
Consideration 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

Priest,
Minister
Soul Rabbi

Person Mind Psychologist

Psychiatrist ENT
Ophthalmologist
Body Doctor Urologist
Oncologist
 Appendix 2
Stakeholders in the Decision-making Process

Patient’s
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
A SSES S M ENT
Determinationof claimsandparties

AN A LY SIS&D IAGNO S IS
Identificationof problem :Statement of ethicaldilemma

P LAN N ING
C onsiderationof prioritiesof claims
Considerationof consequencesof alternatives

IMPLE M EN TATION
Carryingout selectedm oral actions

EV ALUATION
Evaluationof outcomeof m oralactions
"Weretheactionsethical?""What weretheconsequences?"
 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
4. Menentukan dan mengevaluasi keputusan
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 problem-
solving processes.
The MORAL Decision Making Model (Crisham,
1985)

 M—Massage the dilemma.

 O—Outline options.
 R—Review criteria and resolve.
 A—Affirm position and act.
 L—Look 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 maker’s 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 nurse–managers
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 public’s 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
Patient’s Bill of Rights
Code of Ethics for Nurses
Nursing Research

 Patient’s 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 Health
Care

 Institutional Ethics Committees

 Patient Care Conferences

 Ethics Literature
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