Case No. Ethical Problem1. Places 2 patient beds in his medical spractice room which are divided by a

curtain.2. The first 3 patients came with common cold. Then Tenar gave three of them

their medicine, with advice: having enough rest, drinking plain water and

consuming fruits.

3. Tenar gave a presenting letter to her for the laboratory examination. Tenar referred her to a laboratory namely: "Titrasi Cepat" Clinical Laboratory, where he usually did, not far away from his practical place.

4. From this clinical laboratory he received “cake present”, in which if he evaluated, the amount was equal with the number of patients he has sent there

5. The young man didn't follow the queuing number because he confessed that he was Tenar's junior high school's friend, so that Tenar's assistant took him to the left room, the room for the special patients

6. Without telling Ms.Menor what the content of her head scanning result, Tenar gave her a referral letter to the neurological department of a hospital.

7. Mrs.Modis, without receiving blood pressure measurement, got a prescription letter for her urinary tract infection that she has suffered for the last 5 years. Tenar examined her shortly and just copied prescription from her medical record that was given by his assistant.

8. He ordered his assistant after having convincing the security man for being

hospitalized.

(Information and reference letter)

9. He helped Mr. Malthus first for about 45 minutes, meanwhile Rana was alone because Tenar's assistant was also busy assisting Tenar to cope with the bleeding problem of Mr. Malthus in the left side room. Tenar didn’t have any chance to talk with Miss.

10. Tenar was rather stunned to answer the innocent question of her, "Oh, just abdominal discomfort", answered by Tenar, gently

11 He give an envelope containing Rp.25.000,- money for the security. "For your transport, Mr. Tala. Recover soonly

12 By sweating, Tenar at last listened to Miss. Rana's symptoms

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Case No. Alternative Based On Values System1. Beneficence

1. should maximize patient’s satisfactionAutonomy1. should respect to patient’s privacy2. should keep confidentiality

Non maleficence1. should cure proportionally

Justice1. fair to every patient2. appreciate human autonomy3. give same contribution to every patient

2 Beneficence1. should check goal-based specifically

Autonomy1. should informed about disease to patient

Nonmaleficence1. should not assume patient as an object2. should cure proportionally3. should not put the patient in danger condition because of misconduct4. prevent patient from danger

Justice1. should asking patient participation according patient capability

3 Beneficence1. should put altruism on priority

Non maleficence1. should not assume patient as an object

Autonomy1. should respect to patient autonomy2. should not intervention on decision making

Justice1. should appreciate patient’s law2. should responsible to distribute the benefits and maleficence fairly

4 -5 Beneficence

1. should maximize patient’s satisfaction 2. should do golden rule principle

Non maleficence1. should priority on patient’s benefit2. Should cure proportionally

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Autonomy1. –

Justice1. Fair to every patient2. appreciate another person autonomy3. shouldn’t differ the treat to the patient

6 Beneficence1. paternalism responsibility2. minimize the negative effect

non maleficience1. should not put the patient in danger condition because of misconduct

Autonomy1. Veracity2. should Informed

Justice1. appreciate human autonomy to health2. should asking patient participation according patient capability

7 Beneficence1. insure human live quality2. minimize negative effect

Non maleficience1. should cured the patient2. should prevent patient from harm3. should cured the patient proportionality4. should not put the patient in danger condition because of misconduct

Autonomy1. should informed

Justice1. Respect to the patient’s right to health

8 Beneficence1. Should minimize bad effect2. Paternalism and responsibility to the patient3. Maximize patient’s satisfaction4. Should Help emergency patient5. Should respect patient’s right6. Based on golden rule principle

Non maleficience1. Should help emergency patient2. Prevent patient from harm3. Should treat patient proportionally4. should not put the patient in danger condition because of misconduct

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Autonomy1. Should respect patient’s dignity2. Not do intervention or disturb patient’s autonomy3. Build relationship to patient

Justice1. Respect human’s autonomy2. Give contribution based on patient’s need3. Not treat patient with different way based on social status

9 Beneficence 1. Should duty to help emergency patient

Non maleficience1. should not put the patient in danger condition because of misconduct2. Prevent patient form harm3. help emergency patient

Autonomy1. Should informed

Justice1. Respect to the patient’s right to health

10. Beneficence1. enhances the dignity of human2. should respect to patient’s right

Nonmaleficence1. avoid patient’s misrepresentation2. should do medical conduct effectively

11. Beneficence1. Enhances the dignity of the patients2. Respect to the overall patient’s right

Non maleficience1. should not put the patient in danger condition because of misconduct2. Should prevent the patient from dangerous3. should cured the patient proportionality4. should cured the patient

Autonomy1. Should inform to the patient2. Keep contract

Justice1. Respect to the patient’s right to health2. Should fair to patient

12. Beneficence1. Respect patient/family/things not only to get profit from patient2. Maximize the high patient’s satisfaction3. Based on Golden rule principle

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Non maleficience1. Should treat proportionally2. should not assume patient as an object

Autonomy1. Should respect patient’s dignity2. Should keep relationship

Justice1. Shouldn’t differ social status

Case no. Alternative Decision1. - The room will be better if it has one bed only

- Build wall to divide the room if it really necessary to use 2 beds

2. -Every patients have to examined well and specifically -Giving prescribe should be suitable with the disease not only from the general symptoms

3. -Give right to patients to choose the laboratory for their lab examinations-the doctor can give the information about the labs, but the doctor mustn’t give suggestion for one lab only.

4. -doctor shouldn’t receive the “cake present” as a “thank you” for the patients he sent there.

5. - The doctor should treat the patients according to queuing number- If its emergency case it is fine to treat him first.

6. -the doctor should informed the patient about the result from the head scanning.-The doctor make the negotiation with the patient about the next treatment.

7. -The doctor must examine depend on the standard operational procedure and give the prescriptions according to her condition

8. -he should inform the disease of the patient-give patient reference letter to be threatened more intensive on the hospital

9. -the doctor should ask his assistant to tell miss rana that he has emergency patient.-the doctor should inform miss rana that he has emergency patient.

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10. -the doctor did the right thing with keep patient confidentiality.

11. -the doctor has good charity to other.

12. -the doctor should tidy him self before meet the patient-the doctor at least clean the sweat.

Case No. Self Assessment1. He just put 2 bed that divided by curtain

2 He has Check 3 patient in same way and give same advice

3 He suggest the patient to the laboratory

4 He get the present from laboratory

5 He receive the patient that don’t follow the queuing

6 He gave Mrs. Menor referral letter without informed

7 He assume the patient have same condition

8 He order Garputala go to hospital sonly

9 He help Malthus first than Miss. Rana that comes first

10. He keep patient confidentiality

11. He gave amount of money

12. He didn’t prepare himself first

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Case NO Verification1 Utilitarian

He think that he can treat many patients easily without thinking about the maximal satisfaction for patients

2 UtilitarianBecause he doesn’t want to waste the time for knowing more about patient’s condition deeply

3 UtilitarianBecause he think about the distance’s advantages for patient

4 UtilitarianBecause he accepted the profit from what his done

5 UtilitarianBecause he doesn’t want have bad relationship with his friends

6 DeontologyBecause he wants the best treatment to Mrs. Menor so Mrs. Menor heal completely.

7 UtilitarianBecause he thing it will be useless if he check up the patient

8 UtilitarianHe only think the best for other personCommunitarianBecause he think to help another people is the responsibility with otherDeontologyBecause he has pure intention to help each otherFeminismBecause he want to best

9 UtilitarianDeontologyCommunitarianFeminism

10 DeontologyCommunitarian

11 DeontologyCommunitarian

12 DeontologyFeminism

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Case No. Reason1. The room will be better if it has one bed only, because the patient has

privacy and the doctors should appreciate patient autonomy.

2. Every patients have to examined well and specifically which is standardized

by SOP and the prescribe should be suitable with the disease, not only from

the general symptoms, because every symptoms has a different type of

disease.

3. -the doctor can give the information about the labs, but the doctor mustn’t give suggestion for one lab only, because it’s contradict with the patient autonomy to choose the lab.

4. -doctor shouldn’t receive the “cake present” as a “thank you” for the patients he sent there, because it will consider as a collusion.

5. - The doctor should treat the patients according to queuing number, If it is emergency case it is fine to treat him first, because it’s the doctor should obey the rule of humanity.

6. the doctor should informed the patient about the result from the head scanning and doctor should make the negotiation with the patient about the next treatment, because knowing the result and the information about the treatment is patient right and doctor should respect it.

7. -The doctor must examine depend on the standard operational procedure and give the prescriptions according to her condition, because

8. give patient reference letter to be threatened more intensive on the hospital and also give an information about his disease, because it is patient right to get the information about his disease.

9. the doctor should ask his assistant to tell miss rana that he has emergency patient, because if the doctor didn’t tell the condition, so it’s look like the doctor neglected miss rana.

10. The doctor did the right thing with keep patient confidentiality, because the patient confidentiality is very important and prohibited to speak up in public.

11 The doctor has good charity to other, because the charity is needed to be a good doctor.

12 The doctor should tidy him self before meet the patient, because the doctor must respect the patient with polite and tidy.

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Dr. Tenar, Ethics and Act

Dr. Tenar who opens up a private medical doctor practice is a general practitioner that

work everyday , especially on every Saturday and Sunday many patient come to him. In order to

give service to all the attended patient , he divided in his practice room by putting two bed and

bordered it with a curtain. He thinks with this way all of the patient can get the treatment without

waiting too long time. Its means, he can spend less time and get same fee.

But, this way are unethical because the patiens certain have secret about their illness in

which can hear by other patients. So, The physician should keep the patient confidentiality and

privacy, can you imagine if you talk about your secret in one room and you find out that you

shared the room? the others can hear your secret and no guarantee that they will keep it as a

secret too. dr. Tenar should make the room more comfortable for the patient, like put the real

screen to prevent the leaking of information or just make it one full-room. With this way the

patients can fully open to the physician. Physician get clearly information of the patient and the

patient can tell the disease clearly. So, both of them get the benefit.

In other cases we found that dr. Tenar give the same advice and medicine to three patient

who come first with only estimated the disease. As a physician, dr. Tenar should examine and

established the procedure before conclude the patient disease. Its no guarantee that they have

same resistance, maybe one of them has a allergic to certain drugs or the drugs may be not

proper. So, dr. Tenar should examined his patient and give advice to the patient based on their

real condition.

In third case, dr. Tenar referred his patient to clinical laboratory, maybe his way are

reasonable but not for the intention. His true intention is to get prize from the laboratory. Ethic as

judgment in self-conscience playing his role in this case, whether it’s action appropriate or not,

his intention are failed. As a doctor, dr. Tenar should not influenced and involved in any

commercial cycle. The producent of drug, clinical laboratory and others are often use the ‘cake-

present’ as a trap for the physician. Physician are bounded with commercial intention which is

to find benefit as much as he can to pay his / her ‘debt’, but actually he / she just used by the

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producent. This cycle will redundant if the physician not think about their true – nature which is

to service the humanity.

And the other case, dr. Tenar prioritize his friend than other patient, as we know the

justice as a principle of the bioethics is obligatory for the physician. This may be allowed in

emergency situation, but not on this case. Where’s the patient not following the rule. Moreover,

Tenar placed in him in special room. However, the doctor should established the principle –

include queuing rule . He shall not discriminate the patient and act deceitfully to the patient.

And do the best for the patient.

Besides should keep the patient confidentiality, the physician should give the right

information to the patient. This problem was happen when one patient who forget something

tried to ask dr. Tenar, but he only saw a man re-wearing his underwear. The patient become

disgusted with white-yellowish discharge in man undewear and afraid that she will be contagious

too. Physician as a secret-keeper of the patient, should keep the patient privacies from the start,

which not allowed other person enter the room. But because it’s too late, he must give clear

explanation to the patient that feel disgusted, so she can calm down and put the trust to the doctor

explanation.

In miss Modis case, only read the medical record and gave the prescription based on her

latest medical record. This way, violate the procedure of the treatment. Medical record only

record what she suffered before, not now condition. Which it can’t be a reference of patient

current condition. In this case, dr. Tenar should perform the examination in order to know the

real condition of the patient. we can say that he violate the beneficence of the patient principle,

by not applied the high-standard in his treatment procedure.

In other side, besides mrs. Menor scan result, mrs. Menor need to be hospitalized because

she had suffered space occupying lesion on her head. In this point, role of the physician are very

crucial, which is to give the explanation and suggest the patient. but, dr. Tenar didn’t do it. He

just gave referred him to hospital neurology department without telling her what the content of

her head scanning result. Its mean, as a doctor dr. Tenar are not respected the right and

autonomy of the patient.

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In Mr. Garputala case, he shouted to his assistant to take the patient to the hospital by the

bajaj. With hasty and rash way like this, the patient will be more upset about his condition and it

will affect his condition too. dr. Tenar are showed a very bad attitude toward the patient. From

the text, we conclude the way that used by dr. Tenar are lack of empathy. However, as a doctor

should avoid this way to communicate to the patient.

As a doctor, dr. Tenar should always clean and tidy in every situation. Meeting patient

with inappropriate condition usually will bring bad judgment to the doctor. In this case, Tenar

meet his patient with body full of sweat. This can be accepted by the patient or not. So the

physician must aware of their physical appearance when meet the patient, because it will affect

the view and trust from the patient. Except in emergency case that need the physician to perform

immediate treatment and first aid without consider his / her appearance.

And the final, Based on Hippocratic Oath and Indonesian Physician Oath, the physician

should not perform abortion and euthanasia. dr. Tenar, know that if he help miss. Rana. He will

get the respect from her father then he agreed to the abortion that performed by miss Rana

friends – also agreed upon her action to stole money. This attitude not reflected the good doctor

attitude. In this case, dr. Tenar shouldn’t show his sympathy or agreement toward the case of

miss Rana. Miss Rana are totally wrong, she stole her father’s money and spend it for helping

her friend to perform abortion. Thus, dr. Tenar don’t have to agree, even help with miss Rana

condition, dr. Tenar authority is only to make the patient more comfortable and not interfere it

with intentional cause.

Like all of the problem that happen in dr. Tenar , there was so many problems that

someone faced as a doctor but don’t make it as a great obstacle but make it as the lesson to be a

doctor. As a physician should put the patient’s interest as first priority. The right of patient must

be highly-respected by the physician. If no, the physician will get the title ‘ unethical ‘ by the

society. Highly standard procedure are absolutely needed to fulfill the patient’s need and sake.

The ethical point of view determine his act as a violation. However, as the physician, dr.Tenar,

should be more consider to all of the ethical aspect and patient needs, because from that aspect,

the physician can develop themselves along with the beneficence of the patient, and the

coherence relationship can be achieved by both , the doctor and the patient.

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