PRINSIP MORAL DAN ETIKA

Ns Nur Anisah S.Kep.,M.Kep.Sp.KJ

 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
 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. 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 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 umum
- 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
8. Paternalisme
Lanjutan
- 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
and
of
theclaims;
actions
parties
ethical
actions;dilemma
Generation of“Were
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
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
ASSESSMENT
D e te rm in a tio n o f c la im s a n d p a rtie s

A N A L Y S IS & D IA G N O S IS
Id en tific ation o f p ro b le m : S tatem en t of eth ic al d ile m m a

P L A N N IN G
C on s id era tio n of p riorities of c la im s
C o n s id e ration o f c on se q u en c e s o f a lte rn atives

IM P L E M E N TA TIO N
C a rryin g o u t s elec te d m o ra l a ctio n s

E V A L U A TIO N
E valu ation o f o u tc om e of m ora l a c tio n s
"W e re th e ac tion s eth ic al? " "W h at w ere th e c o n s e q u e n c es ? "
 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 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
To provide a systematic situation Aim
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