The Norm of Medical Practice

The Norm of Medical Practice

Dr H Tatang Kartawan

TA 2008/2009

The Norm of Medical Practice is Ethics and Law


TA 2008/2009

1. Consequently, ethics refers to :

a. moral values and norms that are to be guide for a people or a society in regulating their conduct. In brief, it refers to value system.

b. a set of moral principles or values; in term it is ethic code.

c. the science of badness and goodness

2. MORAL

The term “moral” etimologically has the similar meaning to “ethic”, though they derived from different languages, thus it refers to values or norms to be the guideline for someone or a group in regulating their conduct. Amoral means violating the current ethic values or norms that are valid in a certain society.

MORAL AND RELIGION

Inevitably religion has close relationship to moral.

In daily life, religion brings about the most important and strongest motive for moral behaviour.

In spontaneous reply to the question whether the conduct is permissible or impermissible

(forbidden?), it is based on favourability/prohibition in religion.

There would appear : I am a religist and my religion forbides me to do it.

Any religion contains moral study to be a guide as the way of life for every believer.

Different religions may have slight different moral doctrines; however, in general, they are non-

significant.

The truth of faith is not necessarily proved (rationally), but believed. The truth comes from The

God/Allah (absolute truth).

The relationship between religion and ethic bring about motivation and inspiration in order that all

followers obey the accepted faith-based values and norms.

MORAL AND LAW

As in the close relationship between moral and religion, there has been similar relationship between moral and law.

Law requires moral.

In Roman Empire, there was a phrase saying that “Quid leges sine moribus” meaning “what is a constitution if it is not with morality”

Law may be less meaningful when it is not inspired by morality; without morality, law is nonsense.

On the other side, moral also requires law. Moral will be only a daydream when it is not described definitely and institutionalized in society as the same way to law.

In consequence, law can enhance morality and social impact. Appreciating other people’s properties,for example, is one of the most important moral principles that led to the elicitation of intelectual property rights.

At least there are 4 differences between law and moral

1. Law has been more codified than moral did; it has been systematically written and arranged within legislation book; yuridical norms are much more certain, in contrast, moral norms are subjective and more intruded regardingto ethical or non-ethical. In law, there are a few uncertainty, but in moral , it is found much more.

2. Both law and moral regulate human conduct; however, law requires legality and limits itself to the physical behaviour, whereas moral involves attitude.

3. Sanctions in law is different from those in morality. Law is underlined by social desire, then by the state’s desire; for example, a traditional law to be considered as a valid law, it should be acknowledged/legislated by the state.

4. In contrary to law, morality is based on norms. Hence, a society may alter a law, but not a moral norm.

The International and National (Indonesian) Medical Ethics


TA 2008/2009

A. Indonesian Medical Ethics

1. Introduction

2. The Problems of Medical Ethics in Indonesia

3. Indonesian Medical Ethic Code

4. The Challenge in Indonesian Medical Ethic Code

1. INTRODUCTION

The discussion scope was both national and international, especially and emphatically on the curriculum of Bioethics and Humaniora for Faculty of Medicine, Padjadjaran University.

One of the constraints that has been disclosed here is about Human Resources Development, the experts are still very scarce.

Nevertheless, the seminarists have successfully construct the network of bioethics and humaniora in Indonesia.

In this chance, Indonesian Medical Ethics will be discussed here.

KODE ETIK KEDOKTERAN KODE ETIK KEDOKTERAN LATAR BELAKANG (1)LATAR BELAKANG (1)

• Abad XXV sM Kode Eik pertama di BabyloniaAbad XXV sM Kode Eik pertama di Babylonia• Abad V sM Sumpah HippopcratesAbad V sM Sumpah Hippopcrates• Abad XI M kembali ke Sumpah HippocratesAbad XI M kembali ke Sumpah Hippocrates• Nuremberg Code 1948Nuremberg Code 1948• International Code of Medical Ethics : International Code of Medical Ethics : -> WMA 3-> WMA 3rdrd London (England) Oct 1949 London (England) Oct 1949

-> WMA 22-> WMA 22ndnd Sydney Aug 1968 Sydney Aug 1968• KODEKI SK Menkes No 434/1983 Okt 1983KODEKI SK Menkes No 434/1983 Okt 1983• KODEKI dan Pedoman Pelaksanaannya MKEK KODEKI dan Pedoman Pelaksanaannya MKEK

IDI tahun 2001IDI tahun 2001

KODE ETIK KEDOKTERANKODE ETIK KEDOKTERANLATAR BELAKANG (2)LATAR BELAKANG (2)

Beberapa Deklarasi untuk menyempurnakan Beberapa Deklarasi untuk menyempurnakan permasalahan Etik :permasalahan Etik :

1.1. Deklarasi Helsinki (1964) tentang Penelitian dengan Deklarasi Helsinki (1964) tentang Penelitian dengan Subyek Manusia.Subyek Manusia.

2.2. Deklarasi Sydney (1968) dan Venice (1983) tentang Deklarasi Sydney (1968) dan Venice (1983) tentang Kriteria Mati dan Penyakit Terminal dikaitkan dengan Kriteria Mati dan Penyakit Terminal dikaitkan dengan Transplantasi Organ.Transplantasi Organ.

3.3. Deklarasi Oslo (1970) tentang Pengguguran Kandungan.Deklarasi Oslo (1970) tentang Pengguguran Kandungan.4.4. Deklarasi Munich (1973) tentang Penerapan Teknologi Deklarasi Munich (1973) tentang Penerapan Teknologi

Administrasi.Administrasi.5.5. Deklarasi Tokyo (1975) tentang Penggunaan Obat Deklarasi Tokyo (1975) tentang Penggunaan Obat

Terlarang.Terlarang.6.6. Deklarasi Brussel (1985) tentang Bayi Tabung.Deklarasi Brussel (1985) tentang Bayi Tabung.7.7. Deklarasi Madrid (1989) tentang Euthanasia dan Deklarasi Madrid (1989) tentang Euthanasia dan

RekayasaRekayasa Genetik. Genetik.

KODE ETIK KEDOKTERANKODE ETIK KEDOKTERANPERUBAHAN DARI WAKTU KE PERUBAHAN DARI WAKTU KE

WAKTUWAKTU

Terjadi karena :Terjadi karena :• Perubahan sosio-kultural masyarakat.Perubahan sosio-kultural masyarakat.• Kemajuan Ilmu dan Teknologi Kemajuan Ilmu dan Teknologi

Kedokteran.Kedokteran.• Perubahan Hubungan Dokter-Pasien Perubahan Hubungan Dokter-Pasien

(ada pihak ketiga).(ada pihak ketiga).• Kompleksitas masalah kesehatan.Kompleksitas masalah kesehatan.• Kompleksitas masalah Moral. Kompleksitas masalah Moral.

ASAS ETIK KEDOKTERAN ASAS ETIK KEDOKTERAN (UNIVERSAL)(UNIVERSAL)

• Asas menghormati otonomi pasien Asas menghormati otonomi pasien (Principle of Respect of the Autonomy).(Principle of Respect of the Autonomy).

• Asas kejujuran (Principle of Veracity).Asas kejujuran (Principle of Veracity).• Asas perilaku beramal dan berbudi luhur Asas perilaku beramal dan berbudi luhur

(Principle of Beneficence).(Principle of Beneficence).• Asas Keadilan (Principle of Justice).Asas Keadilan (Principle of Justice).• Asas tidak menyakiti atau merugikan Asas tidak menyakiti atau merugikan

(Principle of Non-maleficence, Primum non (Principle of Non-maleficence, Primum non Nocere).Nocere).

• Asas kerahasiaan(Principle of Asas kerahasiaan(Principle of Confidentiality)Confidentiality)

KODE ETIK KEDOKTERAN KODE ETIK KEDOKTERAN INDONESIAINDONESIA

FUNGSI KODEKIFUNGSI KODEKI

1.1. Sebagai kode etik “umum” Sebagai kode etik “umum” Memuat Memuat Kaidah Dasar Bio-Etika.Kaidah Dasar Bio-Etika.

2.2. Sebagai kode etik “Spesialis” Sebagai kode etik “Spesialis” Karena Karena spesialistik keilmuannya membawa kadar spesialistik keilmuannya membawa kadar etika tanggung-jawab lebih besar.etika tanggung-jawab lebih besar.

3.3. Memuat etiket sopan santun (antar Memuat etiket sopan santun (antar sejawat).sejawat).

4.4. Merupakan acuan untuk disiplin Merupakan acuan untuk disiplin kedokteran (setelah verifikasi keterangan kedokteran (setelah verifikasi keterangan saksi ahli) saksi ahli) Pedoman memberikan Pedoman memberikan sanksi kepada sesama anggota profesi.sanksi kepada sesama anggota profesi.


CIRI-CIRI TINGGINYA MORALITAS CIRI-CIRI TINGGINYA MORALITAS KODEKIKODEKI

• Berani berbuat sesuai tuntutan Berani berbuat sesuai tuntutan profesi (Etika Epikurian).profesi (Etika Epikurian).

• Sadar akan kewajibannya (Etika Sadar akan kewajibannya (Etika Kantian).Kantian).

• Memiliki idealisme tinggi (Etika Memiliki idealisme tinggi (Etika Aristotelian)Aristotelian)

Secara eksplisit tidak Secara eksplisit tidak

tercantum dalam KODEKI.tercantum dalam KODEKI.

2. THE PROBLEMS OF MEDICAL ETHICS IN

INDONESIA

Terminology

The origin of ethics is from two Latin words : Ethos and Mores

Here they involve mores of community and ethos of people, respectively.

The problem that develops in ethic is ethic deviation, that is, the evaluation is based on which one is right and which one is wrong. Consequently, this perception is very difficult and complex; because the perception is overviewed from each individual points of view.

2. THE PROBLEMS OF MEDICAL ETHICS IN

INDONESIA

Terminology

Referring to “Tantangan Etika Kedokteran di Indonesia” (The Challenges of Medical Ethics in Indonesia) (Samil,2001), there are some points to take attention :

What are to be the goodness and to be the badness

What are to be wisdom and to be crime

What are to desire and to reject

Further, three causes leading to the development of medical ethics : Research, The evelopment of medical science and technology, and moral fundamental crisis; considered to be dilemma in making decision.

The problems to ethics actually do not stand solely, some of them are : the relationship among doctors, patients, producers (manufacturers) of medical equipments, Laws of Health or regulation are so strict that some doctors hesitate to act, etc.

Saving life is a good ethical action, however, which quality of life should be saved (?).

Qualified life, of couse, spends high cost; then, what next? This consideration will lead the doctors to their own conflicts. The problems that are not less important are as follows :

The pluralism of Indonesian nation with its characters and cultures

The uneven distribution of health servicesTendency to ethic deviation The deviation in informed consentThe deviation in medical recordingsThe deviation in medical researches

There are 2 aspects of ethic in medicine should be noticed :

1. Medical ethics (Etik Jabatan Kedokteran)

2. Ethics of medical care (Etik Asuhan Kedokteran)

1. Medical ethics

Involving the problem concerning the doctor’s attitude against colleagues, assistants, and people.

Every profession possesses each ethics, such as : journalist ethics, justice ethics, etc.

2. Ethics of the medical care

Tends to ethos, however, the two words are related each other.

INDONESIAN MEDICAL ETHICS CODE

HISTORY

The earliest ethic code in medical practice was published by Mesopothamian tribe (Babylonian) about 2500 BC.

Hammurabi’s Ethic code was a code of conduct, i.e. a regulation for attitude urged by doctor profession. Hippocratic oath itself , declaring the doctor conduct, is appreciated by doctors.

This oath was accepted in the glory of Greek about in the fifth century BC.

Hippocratic oath protects the rights of patient and give rise a deep and holy feeling of doctors without sanction or punishment for doctor.

The most profound contribution to the history of medical ethic after Hippocrates was a British philosophist Thomas Percival who published Code of Medical Ethics in 1803.

The first Indonesian Medical Ethic Code was arranged during Musyawarah Kerja Susila Kedokteran in Jakarta in1969. The References were from The International Medical Ethic Code. It had been completed in 1968 on The 22th Congress of The World Association of Doctors.

The Indonesian Medical Ethic Code also underwent modification in “Musyawarah Kerja Nasional Etik Kedokteran Ke-2” in Jakarta. In 1983 , it was acknowledged that The Ministry Decree No.434/Menkes/SK/ conscience /1983 dated October 20th, 1983 based on its commitment to be 20 articles.

In general, it can be differ into five parts :

1. General duty of doctor(9 articles)

2. The doctor’s duty on patents (5 articles)

3. The doctor’s duty on colleagues (2 articles)

4. The doctor’s duty on him/herself (2 articles)

5. Closure

KODE ETIK KEDOKTERAN INDONESIAKODE ETIK KEDOKTERAN INDONESIAMKEK IDI 2001MKEK IDI 2001

MUKADIMAHMUKADIMAH

• Sejarah KedokteranSejarah Kedokteran

• FalfafahFalfafah

• Prinsip-prinsipPrinsip-prinsip

• Komitmen profesiKomitmen profesi

KODE ETIK KEDOKTERAN INDONESIAKODE ETIK KEDOKTERAN INDONESIAKEWAJIBAN UMUM (1)KEWAJIBAN UMUM (1)

• Tentang Sumpah DokterTentang Sumpah Dokter• Tentang Profesi DokterTentang Profesi Dokter• Perbuatan yang bersifat memuji diriPerbuatan yang bersifat memuji diri• Perbuatan yang melemahkan daya Perbuatan yang melemahkan daya

tahan pasientahan pasien• Tentang penemuan baruTentang penemuan baru• Tentang kebenaran Tentang kebenaran

keterangan/pendapatketerangan/pendapat

KODE ETIK KEDOKTERAN INDONESIAKODE ETIK KEDOKTERAN INDONESIAKEWAJIBAN UMUM (2)KEWAJIBAN UMUM (2)

• Tentang pelayanan medisTentang pelayanan medis• Bersikap jujurBersikap jujur• Tentang hak-hakTentang hak-hak• Kewajiban melindungi hidup insaniKewajiban melindungi hidup insani• Kepentingan masyarakatKepentingan masyarakat• Kerjasama dengan pihak lainKerjasama dengan pihak lain


KEWAJIBAN DOKTER TERHADAP PASIENKEWAJIBAN DOKTER TERHADAP PASIEN

• Bersikap tulus ikhlasBersikap tulus ikhlas• Kesempatan pasien untuk Kesempatan pasien untuk

berhubungan dengan berhubungan dengan keluarga/penasihatnyakeluarga/penasihatnya

• Kerahasiaan pasienKerahasiaan pasien• TentangTentang Pertolongan darurat.Pertolongan darurat.


KEWAJIBAN DOKTER KEWAJIBAN DOKTER TERHADAP TEMAN SEJAWATTERHADAP TEMAN SEJAWAT

• Tentang perlakuanTentang perlakuan

• Tidak boleh mengambil alih pasien Tidak boleh mengambil alih pasien dari teman sejawat dari teman sejawat


KEWAJIBAN DOKTER TERHADAP DIRI SENDIRIKEWAJIBAN DOKTER TERHADAP DIRI SENDIRI

• Tentang memelihara kesehatan diriTentang memelihara kesehatan diri

• Mengikuti perkembangan Ilmu Mengikuti perkembangan Ilmu Pengetahuan dan Teknologi Pengetahuan dan Teknologi Kedokteran/KesehatanKedokteran/Kesehatan

THE CHALLENGES OF

INDONESIAN MEDICAL ETHICS

The human thinking pattern is always continously changing from year to year.

The advances in medical science and technology to enhance the quality of living influences the development of medical science and profession.

It induces the development of various problems including high cost of medical care.

The changes in social value system from common in the past time to be uncommon at present.

The society is becoming more critisizing and urging doctors and medical centers to deliver their services better; and part of the fact that a doctor can be accused in court.

• In anticipating the unexpected issue, medical profession requires the guidelines of attitude and behaviour for doctors. The guidelines is so-called Medical Code of Ethic.

• To implement the medical ethic, a doctor requires education in religion including moral and good characters in human interaction.

• The most important is the necessity to comprehend fully and entend the the code of ethic.

• By guidance of ethic code, expectedly a doctor can perform his profession well, in consequence, the professional dignity can be kept maintained.

B. INTERNATIONAL MEDICAL ETHICSInternational ethic code is used as main reference for every

country.International ethic code has several times undergone

completion; the last was in The 22th Congress of World Medical Association in Sydney, Australia in 1968.

In order to add and complete consistent to the advances in medical science and technology,Worl medical Association has made declarations as follows :

a. Helsinki Declaration (1964): The study on Human Subjectsb. Sydney Declaration (1968) and Declaration of Venice

(1983) : Criteria of death and Terminal Diseases related to Organ Transplantation.

INTERNATIONAL MEDICAL ETHICSc. Oslo Declaration (1970): Abortusd. Munich Declaration (1973) : The adoption of

Technology in Administratione. Tokyo Declaration (1975) : The Drug Abusef. Brussel Declaration (1985) : Bayi tabungg. Madrid Declaration (1987) : Euthanasia and Genetic

Engineering

The medical ethic code and other documents on ethics and medical laws had ever been published internationally, mostly by Word Medical Association. Some of the important are :

1. Hippocratic Oath (century 4 BC)

Eventhough, the Greek Hippocrates is considered as The Father of Medicine, the Hippocratic oath was thought not composed by Hippocrates himself; but based on history, it was possibly by the surrounders of Hippocrates. This oath is known to be the oldest on medica ethics and suprisingly long-standing great influence the professional ethos of medicine along its history.

(Free-)Citation : “I swear in the name of Apollo and Asklepios and Hygycia and Panaceia and all Gods and Godess, with their witness, that I will meet my swear and decree in accordance to my capability and consideration.”

2. The Constitution of World Health Organization (WHO) 1946.

In The International Health Conference in New York, 61 representatives of each country signed the preambule of The constitution of WHO established in 1948, then, to be controversial. Definition of Healthy : a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity; and the acknowledgement of being healthy as one of basic human rights.

3. Nurenberg Code (1947)After Second World War (1945), eventually it was

known that the doctors in Germany undertook violence in their medical researches on prisoners (mostly Jewish ethnic).The World condemned these experiments and the related doctors were taken into allied court in Nurenberg. The judiciary elicited The Nurnberg Code (1947) describing about ethics of biomedical research.In the 10-item document, a number of basic principles must be kept. The longest description is the first article containing voluntary agreement of the human subjects involved in biomedical studies; this principle, in fact, is frequently violated in practice.

4. The Geneva Code (World Medical Association, 1948).

It was revised in 1968 and 1983.

It has humanitarian target of medical profession as the reaction to criminal of German medical doctors.

The Geneva Declaration can be viewed as modern version.

5. International Code of Medical Ethics 1949

It was revised in 1968 and 1983.

This code of ethic was based on The Geneva Declaration and codes of ethic from various modern countries trying to formulate the principles of medical ethic code that have been most common. In fact, the national ethic code refers to it.

6. The Helsinki Declaration (WMA 1964).

It was revised in 1975, 1983, 1989, and 1996. There are many principles of ethic for biomedical experiments with human subjects presented in it.

7. The Sidney Declaration (World Medical Association, 1968)

The understanding of life aid in ICU results in the traditional understanding about death must be reviewed. In fact, a patient can rebreath and the blood circulation may still be running on in his body on the assistance of very sophysticated technology. Consequently, there a novel term so-called brain dead.It is very important to determine the timing of death appropriately, especially in a patient as an organ donor.Since the time of the first heart transplantation happenedin 1967, The 22th General Congress of WMA in Sydney has been facing the new situation; leading to establishing electroencephalography as the important method for detemining the brain death.

8. The Oslo Declaration (about therapeutical abortion, WMA, 1970).

In the end of 1960s, some countries has begun to legislate abortus provocatus, such as Britain with The Abortion Act (1967), USA did it someyears later (1973).In anticipating this new situation of medical profession, WMA with its Statement on Therapeutic Abortion, without clear suggested definition, permitted medical doctors to perform therapeutical abortion with regarding to local medical association commitment.

9. The Tokyo Declaration (1975)This declaration was accepted by The 29th Congress

of WMA in Tokyo. The objective was to present some guidelines for medical doctors concerning non-humanitarian tortures and other actions that are unhumanistic and humiliating through arrest and imprisonment.This guideline is required because many doctors were involved in such practices.

10. The Belmont Report (1978)The principles and guidelines of ethic for protecting human

subjects participating in studies (The National Commission for Protecting Human Subjects from biomedical and behavioral experiments).It was one of the documents yielded by The National Commission for Protecting Human Subjects from biomedical and behavioral research established by USA in 1974.During its 5-year existence, the reports contained the guidelines of researches involving fetus, child, prisoner, mental-disabled people, etc.The final report formulated the principles of general ethic in reseach involving human subjects.Beside the concised introduction, this report also consisted of 3 parts :1. Boundaries between practice and research.2. Basic ethical principles3. Applications

11. The Lisbon Declaration on Patient’s Rights (WMA,1981)

This right is related to the state of ill patients who require health services. USA is the first country which possesses it, called “A Patient’s Bill of Rights” (1973).The Lisbon Declaration indeedly provided International Code of Medical Ethics (1949) that merely talked of the doctor obligations. This declaration said about the doctor obligation to patient but on the orher side patients also have their own rights.

12. The Declaration on Medical Doctor Independence and The Profession Freedom (WMA, 1986)

This declaration had been approved by The Congress of WMA in California, USA.It described and detailed point (b) of The Lisbon Declaration (1981). Unlike The Lisbon Declaration was about the patient’s rights, the declaration here highlightened the independence of medical profession and medical profession freedom, in order that doctor will side with patientconcern.The regulation of health service costs.

Documents

The Norm of Medical Practice