KAIDAH DASAR BIOETIKA &

PRIMA FACIE



Yuli Budiningsih & Agus
Purwadianto, 2013.



Definition:
THE DISCIPLINE DEALING WITH WHAT IS
GOOD AND BAD AND WITH MORAL DUTY
AND OBLIGATION (Websters).
ETHICS OFFERS CONCEPTUAL TOOLS TO
EVALUATE AND GUIDE MORAL DECISION
MAKING
MEDICAL ETHICS IS A DISCIPLINE /
METHODOLOGY FOR CONSIDERING THE
IMPLICATIONS OF MEDICAL TECHNOLOGY /
TREATMENT AND WHAT OUGHT TO BE (Univ
of Washington School of Medicine)
Ethics can be described as a sub-branch of
applied philosophy that seeks what are the
right and the wrong, the good and the bad
set of behaviours in a given circumstance

Bioethics is a quasi-social science that offers
solutions to the moral conflicts that arise in
medical and biological science practice.

The Four Principles of Bioethics in 13
th
Century Muslim Scholar Maulanas
Teachings,Sahin Aksoy,Faculty of Medicine,Dept Med Ethics & History of
Medicine,Turki.
Ethics is :
the study of morality careful and
systematic reflection on and analysis of
moral decisions and behaviour, whether
past, present or future.

Morality is :
the value dimension of human decision-
making and behaviour.
Since ethics deals with all aspects of
human behaviour and decision-making, it
is a very large and complex field of study
with many branches or subdivisions.

Medical ethics is the branch of ethics
that deals with moral issues in medical
practice.

Medical ethics is closely related, but not
identical to, bioethics (biomedical ethics).
Medical ethics focuses primarily on issues
arising out of the practice of medicine.


Bioethics is a very broad subject that is
concerned with the moral issues raised by
developments in the biological sciences
more generally.
The study of ethics prepares medical
students to recognize difficult situations
and to deal with them in a rational and
principled manner.

Ethics is also important in physicians
interactions with society and their
colleagues and for the conduct of medical
research.
From Hippocrates came the concept of
medicine as a profession, whereby
physicians make a public promise that
they will place the interests of their
patients above their own interests.

In recent times medical ethics has been
greatly influenced by developments in
human rights.

In a pluralistic and multicultural world,
with many different moral traditions, the
major international human rights
agreements can provide a foundation for
medical ethics that is acceptable across
national and cultural boundaries.
Moreover, physicians frequently have to
deal with medical problem resulting from
violations of human rights, such as forced
migration and torture.

Medical ethics is also closely related to
law.
In most countries there are laws that
specify how physicians are required to
deal with ethical issues in patient care
and research.
In addition, the medical licensing and
regulatory officials in each country can
and do punish physicians for ethical
violations.

Different ways of approaching
ethical issues:

Non rational :
1.obedience
2.imitation
3.feeling
4.intuition
5.habit
Rational:
1.Deontology
2.consequentialism
3.principlism
4.virtue ethics
Principles of Bioethics
= Kaidah Dasar Bioetik:
Consist of 4 principles:
1. Beneficence
2. Non Maleficence
3. Autonomy
4. Justice
Derivative principles : confidentiality, truth
telling, informed consent, privacy,
promise keeping, honesty.

Context
Beneficence : do good, altruism, the best
practice for the patient
Non maleficence: do no harm
Autonomy: right to self determination
Justice: fairness, equality
The World Medical Assembly in 1999:
Physicians gathered there, representing
medical associations from around the world,
decided, to strongly recommend to Medical
Schools worldwide that the teaching of
Medical Ethics and Human Rights be included
as an obligatory course in their curricula.
Modern healthcare has given rise to
extremely complex and multifaceted ethical
dilemmas. All too often physicians are
unprepared to manage these competently.
This subject is specifically structured to
reinforce and strengthen the ethical mindset
and practice of physicians and provide tools
to find ethical solutions to these dilemmas. It
is not a list of rights and wrongs but an
attempt to sensitise the conscience of the
physician, which is the basis for all sound
and ethical decision-making.
As physicians, we know what a privilege it is to
be involved in the patient-physician relationship,
a unique relationship which facilitates an
exchange of scientific knowledge and care within
a framework of ethics and trust.
In recent times, this relationship has come
under pressure due to resource constraints and
other factors, and it shows the necessity of
strengthening this bond through ethical
practice.
The module of ethics helps prepare medical
students and physicians to better navigate
through the many ethical challenges we face in
our daily practice and find effective ways
TO PUT THE PATIENT FIRST.
According to these definitions, ethics is
primarily a matter of knowing whereas
morality is a matter of doing.

Their close relationship consists in the
concern of ethics to provide rational criteria for
people to decide or behave in some ways
rather than others.
WHY STUDY MEDICAL ETHICS?
Ethics is and always has been an essential
component of medical practice. Ethical principles
such as respect for persons, informed consent
and confidentiality are basic to the physician-
patient relationship.
However, the application of these principles in
specific situations is often problematic, since
physicians, patients, their family members and
other healthcare personnel may disagree about
what is the right way to act in a situation.



Medicine is both a science and an art.
Science deals with what can be observed and
measured, and a competent physician recognizes
the signs of illness and disease and knows how to
restore good health.

But scientific medicine has its limits, particularly
in regard to human individuality, culture, religion,
freedom, rights and responsibilities.
The art of medicine involves the application of
medical science and technology to individual
patients, families and communities, no two of
which are identical.

By far the major part of the differences among
individuals, families and communities is non-
physiological, and it is in recognizing and dealing
with these differences that the arts, humanities
and social sciences, along with ethics, play a
major role. Indeed, ethics itself is enriched by
the insights and data of these other disciplines.
The ethical directives of medical associations
are general in nature;they cannot deal with
every situation that physicians might face in
their medical practice. In most situations,
physicians have to decide for themselves what
is the right way to act, but in making decisions,
it is helpful to know what other physicians
would do in similar situations.

Medical codes of ethics and policy statements
reflect a general consensus about the way
physicians should act and they should be
followed unless there are good reasons for
acting otherwise.
Fact:

Physicians in clinical decision-making tend to
only take the medical decisions while
ignoring the ethical aspect.
Medical or ethical case?
Tergopoh-gopoh spt ini, benar atau tidak ?
Kalau yang ini 1 dari ratusan
korban tsunami, lumpur panas ?? (di luar RS >>)
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;
Moral philosophy :
Normative ethics : the answer of
how we value the most legitimate norm in the
cluster of norms?
Whats behind (the foundation of) legitimate norm
(de jure) as well as existing norm (de facto)
Praxis E. : the answer of
what is the means/instrumental to human action,
whatever his condition is?


Morality = basic moral attitude
The paradigm of the good/truth in the
community/society
The most fundamental of basic and
strongest law
The doing rights as maxim (principle)
No deliberation
Example of morality :

a. Beliefs/religion norms
Consist of teaching for human to be a wise n
understandable man (virtue ethics)
b. Prophetic Religion norms (theonomic
ethics).
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)

Etika (ethics)
normative (reflective/prescriptive E.,
deontological, das sollen, E as
science, moral philosophy)
what should I do?
= ought
consicence
Praxis (teleological E, das sein, ethics
as action/behaviour)
my action good or bad?
= is
rights
Bioethics (F. Abel)

Interdisciplinary study of (ethical)
problems which arised from biological and
medical science & technological
development.
Specific characteristic of
morality

Very fundamental norm/principles : value
> any other consideration/judgment.
Universal law (valid to whoever, whatever,
wherever etc) .
Rational & objective norms
Related with the happiness of others
eg : Golden Rule principle.
All human have morality.


Check list (Observation Sheets)

Beneficence Criterion Yes No
Promoting altruism
Guaranteeing human dignity
Viewing patient/family not as profit
objects
Maximize agregat net benefit
Compassionate paternalism
Guaranteeing minimal life of patient
Restricting goal based approach
Maximize patient satisfaction
Tutors name
Group No.
Check list (Observation Sheets)

Beneficence Criterion (2) Yes No
Maximize overall highest happiness
Continuing professional
development
Giving effective-low priced medicine
Applying Golden rule principle
Promoting patients best interest
etc
Tutors name
Group No.
Check list (Observation Sheets)

Non Maleficence Criterion Yes No
Helping emergency patient
Treating vulnerable patients
Not killing patient (no euthanasia)
Not humiliating/abusing patient
Not respect patient as object
Treating unproportionally
Not preventing patient from danger
Avoiding misrepresentation to P
Tutors name
Group No.
Check list (Observation
Sheets)

Confidentiality Criterion Yes No
Not disclosing to friends/relatives
Careful waivers : duty/permission to warn
Careful relation about public figures
Prudent ommiting sensitive
information from medical record
Prudent action to 3
rd
parties &
public officials
Prudent action of partner
notification

Tutors name
Group No.
Check list (Observation
Sheets)

Justice Criterion Yes No
Apply everything universally
Taking last portion when dividing
something
Giving P-with same position, similar
opportunity
Respect Ps rights : affordability,
equality, accessibility, availability,
quality)
Respect Ps legal rights
etc
Tutors name
Group No.
Check list (Observation
Sheets)

Justice Criterion Yes No
Respecting others rights
Caring the vulnerables (the least
advantage people)
Not abusing/discriminating
Wise in macro-allocation
etc
etc
Tutors name
Group No.
Check list (Observation
Sheets)

Autonomy Criterion Yes No
Respecting self-determination
rights, supporting of Ps dignity
Not intervening decision making
process of the P (elective condition)
Truthfullness
Respect privacy
Confidentiality etc
Supporting Ps rationality
Compassionate informed consent
Tutors name
Group No.


-
Keputusan
Medis
Keputusan
etis
Pilar Keputusan Klinis sehari2

-
Keputusan
Medis
Keputusan
etis
Pilar Keputusan Klinis sehari2
Biomedik
Info-
medik
Indikasi
medik
pilihan pasien
kualitas hidup
fitur kontekstual
Mindset non medis
Struktur Psiko-
Sosio-budaya
Micro level
Clinical medicine
The Scope of ethics in Medicine
Macro level
Politics of Health
Meso level
Health services delivery
Macho level
Health care teams
consci
ence
rights
ethics
self
reflection
justification
Deduction
= logic
Induction
= casuistry
bioethics
Concrete
Daily living
Principles-based ethics
Prima Facie
T.Beauchamp & Childress (1994) & Veatch (1989)
Beneficence
Non Maleficence
Autonomy
Justice
Contextual features
Quality of life
Clinical Decision
Making
Patients preference
Medical indication
Value-based medicine
EBM
= Deductive logic
Beneficen
ce
Non Maleficence
Autonomy Justice
Combination of
Its characteristics = Patients Context
Method = ballancing of specification
= Logic + creative thinking =
critical analysis + wisdom
Medical
Indication
rules
Particular/
Concrete case
principles morality
Norms
(ballanced-
specific rules)
Method of justification
bioethics
VALUE-based = INTRINSIC MORALITY
theory of ethics
PRIMA FACIE = TRUMP
= change into .......
Beneficen
ce
Non Maleficence
Autonomy Justice
Medical
Indication
pihak II
Umum
BAIK
kranjang
Sampah
pihak II
kesakitan/
menderita,
gadar,pra-cacat
Distress
Rentan
uzur,
terjepit
tanpa pilihan
Miskin
bodoh.
capable
person
bebas
Elektif
rentang >>
hak pilih a
// DRnya
pihak III
Non pasien
wakil/wali
kluster pop
Komunitas
Penyandang
dana
Berpotensi
Dirugikan/
Paling krg
diuntungkan
ENRICHMENT OF
JUSTIFICATION
Beneficen
ce
Non Maleficence
Autonomy Justice
Not stipulated in the text =
Patients Context
Medical
Indication
DEDUCTIVE
LOGIC
PRIMA
FACIE
CETERIS PARIBUS
CREATIVE THINKING
(NEW) ILLAH = actual duty = contextuality
OPPOSITION
VALUE
CONFORM
>< : DETECT
DEVIATION

TERGANTUNG . BERUBAH MENJADI
Etika Dokter RI

n Kemurnian niat = sikap moral tanpa
pamrih ?
n Kesungguhan kerja = tindakan baik &
adil ?
n Kerendahan hati = sopan
n Integritas ilmiah & sosial
= martabat profesi luhur (hormat diri
sendiri & adil)

Insight
Core Problem
Keywords
Basic
Moral
Principle
Beneficence
Nonmaleficence
Autonomy
Justice
Metode AP
Prima Facie
Principle
Context vs Text
Choose 1-2 out
of 4 most
relevan
(problem
solving)
Ethics
Theory
Virtue - eudamonia
Duty - deontologist
Utilitarian
teleologist eg
happiness
Metode AP
Ethical
Relativism
Culture
Custom
Ethical
Dilemma
Science &
technology
determinant
Societal &
capital
determinant
Metode AP
Ceteris
Paribus
Choose 1 most
influential
principle
Ethical
Problem
Solving
Consistency
Coherent
Corespondency
Pragmatic
Metode AP
Legal
Option
Administrative
Penal
Civil
Metode AP