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 13th 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 decisionmaking 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 :
Rational:
1.obedience
1.Deontology
2.imitation
2.consequentialism
3.feeling
3.principlism
4.intuition
4.virtue ethics

5.habit

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 physicianpatient 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 nonphysiological, 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 (interpersonal 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
Group No.

Tutors name

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

Group No.

Tutors name

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
Group No.

Tutors name

Check list (Observation

Sheets) Criterion
Confidentiality

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 3rd parties & public
officials
Prudent action of partner
notification
Group No.

Tutors name

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

Group No.

Tutors name

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
Group No.

Tutors name

The patients contexts for prima facies choice

(Agus Purwadianto, 2004)

Time

Gen eral b en efi t

resu lt, mo s t o f
p eo p le,

Elect iv e, ed u c at ed ,
b read -win n er, ma tu re
p erso n

Beneficence

Autonomy

Non
maleficence

Justice

Vu ln erab les,
emerg en cy, lif e
sav in g , min o r

> 1 p erso n , o th ers

similari ty, co mmu n ity /
so cial s rig h ts

Keputusan
Medis

Pilar Keputusan Klinis sehari2

Keputusan
etis

Indikasi
Biomedik
medik
Keputusan
Medis

Pilar Keputusan Klinis sehari2

Keputusan
etis

Infomedik

pilihan pasien
kualitas hidup
fitur kontekstual

Mindset non medis

Struktur PsikoSosio-budaya

The Scope of ethics in Medicine

bioethics
rights
justification
conscie
nce

self
reflection

ethics

Macro level
Politics of Health

Deduction
= logic

Meso level
Health services delivery
Macho level
Health care teams
Micro level
Clinical medicine

Induction
= casuistry

Concrete
Daily living

Principles-based ethics
Prima Facie

T.Beauchamp & Childress (1994) & Veatch (1989)

Patients preference
Beneficence
Non Maleficence

Contextual features
Quality of life
Value-based medicine

Autonomy
Justice

Clinical Decision
EBM
Making

VALUE-based = INTRINSIC MORALITY

theory of ethics

Medical
Indication

Beneficen
ce

Non Maleficence

bioethics

principles
rules

Autonomy

Justice
morality

Method = ballancing of specification

= Logic + creative thinking =
Norms
critical analysis + wisdom
(ballancedspecific rules)

Particular/
Concrete case

Combination of
Its characteristics = Patients Context

= Deductive logic

Method of justification

PRIMA FACIE
Medical
Indication
=
change into .......
= change into .......

Beneficen
ce

pihak II
Umum
BAIK
kranjang
Sampah

Non Maleficence

pihak II
kesakitan/
menderita,
gadar,pra-cacat
Distress
Rentan
uzur,
terjepit
tanpa pilihan
Miskin
bodoh.

= TRUMP

Autonomy

capable
person
bebas
Elektif
rentang >>
hak pilih a
// DRnya

Justice

pihak III
Non pasien
wakil/wali
kluster pop
Komunitas
Penyandang
dana
Berpotensi
Dirugikan/
Paling krg
diuntungkan

Medical ENRICHMENT
Indication
JUSTIFICATION
Beneficen
ce

Non Maleficence

OF

Autonomy

Justice

(NEW) ILLAH = actual duty = contextuality

PRIMA
FACIE
CETERIS PARIBUS
DEDUCTIVE >< : DETECT
LOGIC
DEVIATION
OPPOSITION

VALUE
CONFORM

CREATIVE THINKING

Not stipulated in the text =

Patients Context

The patients contexts for prima facies choice

(Agus Purwadianto, 2004)

Time

Gen eral b en efi t

resu lt, mo s t o f
p eo p le,

Elect iv e, ed u c at ed ,
b read -win n er, ma tu re
p erso n

Beneficence

Autonomy

Non
maleficence

Justice

Vu ln erab les,
emerg en cy, lif e
sav in g , min o r

TERGANTUNG .

> 1 p erso n , o th ers

similari ty, co mmu n ity /
so cial s rig h ts

BERUBAH MENJADI


Kemurnian niat = sikap moral tanpa
pamrih ?

Kesungguhan kerja = tindakan baik &

adil ?

Kerendahan hati = sopan

Integritas ilmiah & sosial

= martabat profesi luhur (hormat diri
sendiri & adil)

Etika Dokter RI

Insight
Basic
Moral
Principle

Core Problem
Keywords

Beneficence
Nonmaleficence
Autonomy
Justice

Metode AP

Prima
Facie
Principle

Metode AP

Ethics
Theory

Context vs Text
Choose 1-2 out
of 4 most
relevan
(problem
solving)

Virtue - eudamonia
Duty - deontologist
Utilitarian
teleologist eg
happiness

Metode AP

Ethical
Relativism
Ethical
Dilemma

Culture
Custom

Science &
technology
determinant
Societal &
capital
determinant

Ceteris
Paribus
Ethical
Problem
Solving

Choose 1 most
influential
principle

Consistency
Coherent
Corespondency
Pragmatic
Metode AP

Metode AP

Legal
Option

Administrative
Penal
Civil