Bs Ethical Decision Making

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  • ETHICAL DECISION MAKINGBUDI SAMPURNA

  • CIRI-CIRI PROFESI DALAM MEMBUAT KEPUTUSANKEBEBASAN PROFESIINDEPENDENIMPARTIALOBYEKTIFREASONABLE MEDICAL CERTAINTYETIS

  • KEPUTUSAN ETISMEMPERTIMBANGKAN NILAI-NILAI YANG HIDUP DI DALAM MASYARAKAT, PROFESI DAN PASIENMEMPERTIMBANGKAN:TEORI ETIKAPRINSIP MORALKETENTUAN MORALKEPUTUSAN KHUSUS PADA KASUS

  • HIRARKIETHICAL THEORIES

    PRINCIPLES

    RULES

    PARTICULAR JUDGMENT & ACTIONS

  • BAGAIMANA MENENTUKAN SESUATU PERBUATAN ITU BENAR ATAU SALAH, BAIK ATAU BURUK ?

  • TEORI ETIKAACUAN YANG PALING TINGGI DALAM MENILAI BENAR-SALAHNYA (SECARA ETIK) SUATU TINDAKAN

  • TEORI ETIKA BERGANTUNG KEPADAAGENT: VIRTUE

    ACTS: DEONTOLOGI

    ENDS: TELEOLOGICAL

    CONSEQUENCES: CONSEQUENTIALIST (UTILITARIAN)

  • TEORI BERDASARKAN AGENTFIDUCIARYBERDASARKAN VIRTUE (NILAI KEUTAMAAN)JUJUR, BAIK HATI, RAMAH, WELAS-ASIH, PERHATIAN, DLLHUBUNGAN DOKTER PASIEN HARUS BERDASARKAN KONSEP INI, JANGAN HANYA BERDASARKAN HUKUM

  • TEORI BERDASARKAN ACTDEONTOLOGIDEON = DUTYBENAR SALAHNYA INHEREN KEPADA TINDAKANNYAPemuka: Immanuel KantJudgment benar-salah diambil dari agama, hukum alam, hukum benar-salah (penalaran manusia)WD Ross : Intuisi dan common sense : cukup

  • TEORI BERDASARKAN HASILTELEOLOGI: BENAR SALAHNYA BERGANTUNG KEPADA HASIL AKHIRCONSEQUENTIALIST: BENAR SALAHNYA BERGANTUNG KEPADA KONSEKUENSINYA / AKIBATNYADavid Hume, Jeremy Bentham, John Stuart MillYANG MENONJOL: UTILITARIAN (AZAS MANFAAT)

  • UTILITARIANBUKAN SEKEDAR TUJUAN MEMBENARKAN CARAGREATEST GOOD FOR THE GREATEST NUMBERTETAPI JUGA : POSSITIVE BALANCE OF VALUE OVER DISVALUEMEMAKSIMUMKAN BENEFIT, MEMINIMUMKAN RISK & COST

  • TEORI LAINNATURAL LAW (Aristoteles, St Thomas Aquinas)RAWLSS THEORY (John Rawls)CASUISTRY (Jonsen and Toulmin)VIRTUE ETHICS (Pellegrino & Thomasma)ETHICS OF CARE (Carol Gilligan)EMOTIVISM, LEGALISM, CULTURAL RELATIVISM, FIDEISM, REASONED ANALYSIS (ORourke)

  • PILIH TEORI MANA?TERGANTUNG KEPADA:KONSISTENSI DAN KOHERENSIKESEDERHANAANLENGKAP DAN KOMPREHENSIFKAPASITAS MEMPERHITUNGKAN PENGALAMAN MORAL KITA

    TAK ADA YG MEMUASKAN

  • PRINSIP-PRINSIP MORAL / KAIDAH DASAR MORALHIRARKI KEDUA (DI BAWAH TEORI) DALAM MENENTUKAN BENAR-SALAHNYA SUATU TINDAKAN

  • PRINSIP MORALKAIDAH DASAR:AUTONOMY :Self determination, Truth telling, Confidentiality, PrivacyBENEFICENCEProviding benefit, Balancing the benefit and harmsNON MALEFICENCEPrimum non nocere, Above all do no harmJUSTICE : fairnessEqual treatment of equals, Unequal treatment of unequal

  • Prinsip AUTONOMYMENGHORMATI HAK PASIEN UNTUK MENENTUKAN APA YANG BOLEH DILAKUKAN TERHADAP DIRINYA

  • PRINSIP AUTONOMYSELF GOVERNANCE, LIBERTY RIGHTS, INDIVIDUAL CHOICESKANT : TIAP ORANG MEMILIKI KAPASITAS UNTUK MEMUTUSKAN NASIBNYA SENDIRIMILL : KONTROL SOSIAL ATAS INDIVIDU HANYA SAH APABILA TERPAKSA UNTUK MELINDUNGI HAK ORANG LAIN

  • ELEMEN INFORMED CONSENTTHRESHOLD ELEMENTS (PRECONDITIONS)COMPETENCE (TO UNDERSTAND & DECIDE)VOLUNTARINESS (IN DECIDING)INFORMATION ELEMENTSDISCLOSURE (OF MATERIAL INFORMATION)RECOMMENDATION (OF A PLAN)UNDERSTANDING (OF 3 AND 4)CONSENT ELEMENTSDECISION (IN FAVOR OF A PLAN)AUTHORIZATION (OF THE CHOSEN PLAN)BEAUCHAMP & CHILDRESS, 1994

  • PRINSIP NON MALEFICENCETIDAK BOLEH MELAKUKAN SIKAP / TINDAKAN YANG MEMPERBURUK KEADAAN PASIEN

  • PRINSIP NON MALEFICENCEPRIMUM NON NOCEREABOVE ALL DO NO HARMSATU CONTINUUM DG BENEFICENCENOT TO INFLICT EVIL OR HARMPREVENT EVIL OR HARMREMOVE EVIL OR HARMDO OR PROMOTE GOOD

  • PRINSIP NON MALEFICENCE-2PRINSIP DOUBLE EFFECT TINDAKAN YG MERUGIKAN TIDAK SELALU DIANGGAP TINDAKAN YG BURUKBILA TINDAKAN TSB SECARA INTRINSIK TIDAK SALAH (SETIDAKNYA NETRAL)BILA NIATNYA MEMPEROLEH AKIBAT BAIK (AKIBAT BURUK BOLEH FORESEEN & TOLERATED)BILA AKIBAT BURUK BUKAN CARA UNTUK MENCAPAI AKIBAT BAIKBILA PERIMBANGAN YG LAYAK ANTARA AKIBAT BAIK DENGAN AKIBAT BURUK

  • PRINSIP BENEFICENCESETIAP SIKAP / TINDAKAN HARUS BERORIENTASIKAN KEPADA KEBAIKAN PASIEN

  • PRINSIP BENEFICENCETERDIRI DUA PRINSIP:PRINSIP POSITIVE BENEFICENCEPREVENT EVIL OR HARMREMOVE EVIL OR HARMDO OR PROMOTE GOODPRINSIP BALANCING OF UTILITY / PROPORTIONALITYBALANCING OF BENEFIT AND HARM

  • PRINSIP BENEFICENCE-2PRINSIP OF UTILITY = BALANCING OF COST-RISK-BENEFITCOST BENEFIT ANALYSIS:DIPERHITUNGKAN DALAM HITUNGAN UANGCOST EFFECTIVENESS ANALYSIS:DIPERHITUNGKAN BUKAN DALAM UANGRISK ASSESSMENTPROBABILITAS DAN BESARNYA RISIKO

  • PRINSIP JUSTICEKEADILANKETERBUKAANKEJUJURAN

  • PRINSIP JUSTICETERDAPAT DUA ISTILAH:JUSTICE ; FAIRNESSSESEORANG MENERIMA YANG SELAYAKNYA DIA TERIMADISTRIBUTIVE JUSTICEDISTRIBUSI SUMBER DAYA DALAM MASYARAKAT

  • PRINSIP JUSTICE-2TEORI TENTANG JUSTICEEGALITARIAN:EQUAL ACCESS TO THE GOODSLIBERTARIAN:RIGHTS TO SOCIAL AND ECONOMIC LIBERTY (fair procedure and system)UTILITARIAN:KOMBINASI KEDUA DI ATASMEMAKSIMALKAN PUBLIC UTILITY

  • KETENTUAN MORAL TURUNANVERACITYPRIVACYCONFIDENTIALITYFIDELITY

  • MORAL RULESVERACITY: telling the truthBagaimana bila informasi tsb memperburuk?Bagaimana bila pasien menolak ?PRIVACY & CONFIDENTIALITYDerivat dari hak otonomiTujuan: menjaga kepercayaan Apa pengertian rahasia kedokteran ?FIDELITYPromise keeping

  • BAGAIMANA MENGGUNAKAN PRINSIP DAN RULES?SEBAGAI RULES OF THUMBPrinsip yang hanya untuk disebut, sama sekali tidak mengikatSEBAGAI ABSOLUTPrinsip yang tak dapat diabaikan, sangat mengikatSEBAGAI PRIMA FACIEPrinsip dipakai sebagai pedoman, tetapi tidak mengikat. Prinsip dapat dikalahkan oleh prinsip lain yang terbukti lebih benarGUNAKANLAH SEBAGAI PRIMA FACIE !!

  • MASALAH IMPLEMENTASITAK ADA PEDOMAN TENTANG BOBOT MASING-MASING KAIDAH DASAR MORAL DAN KAIDAH TURUNANNYATIAP KAIDAH DIANGGAP SAMA BOBOTNYA, DAPAT SALING MENGALAHKAN

  • CLINICAL ETHICS PENDEKATAN PRAKTIS PENGAMBILAN KEPUTUSAN

  • THE FOUR TOPICSINDICATION FOR MEDICAL TREATMENTPREFERENCES OF PATIENTSQUALITY OF LIFECONTEXTUAL FEATURES

  • MEDICAL INDICATIONSWHAT IS THE PATIENTS MEDICAL PROBLEM? HISTORY? DIAGNOSIS? PROGNOSIS?IS THE PROBLEM ACUTE? CHRONIC? CRITICAL? EMERGENT? REVERSIBLE?WHAT ARE THE GOALS OF TREATMENT?WHAT ARE THE PROBABILITIES OF SUCCESS?WHAT ARE THE PLANS IN CASE OF THERAPEUTIC FAILURE?IN SUM, HOW CAN THIS PATIENT BE BENEFITED BY MEDICAL AND NURSING CARE, AND HOW CAN HARM CAN BE AVOIDED? PERTIMBANGKAN PULA ADAKAH KONTRA-INDIKASI

  • PATIENT PREFERENCEIS THE PATIENT MENTALLY CAPABLE AND LEGALLY COMPETENT? IS THERE EVIDENCE OF INCAPACITY?IF COMPETENT, WHAT IS THE PATIENT STATING ABOUT PREFERENCES FOR TREATMENT?HAS THE PATIENT BEEN INFORMED OF BENEFITS AND RISKS, UNDERSTOOD THIS INFORMATIONS, AND GIVEN CONSENT?IF INCAPACITATED, WHO IS THE APPROPRIATE SURROGATE? IS THE SURROGATE USING APPROPRIATE STANDARDS FOR DECISION MAKING?

  • PATIENT PREFERENCE (2)HAS THE PATIENT EXPRESSED PRIOR PREFERENCES, E.G. ADVANCED DIRECTIVESIS THE PATIENT UNWILLING OR UNABLE TO COOPERATE WITH MEDICAL TREATMENT? IF SO, WHY?IN SUM, IS THE PATIENTS RIGHT TO CHOOSE BEING RESPECTED TO THE EXTENT POSSIBLE IN ETHICS AND LAW?

  • QUALITY OF LIFEWHAT ARE THE PROSPECTS, WITH OR WITHOUT TREATMENT, FOR A RETURN TO NORMAL LIFE?WHT PHYSICAL, MENTAL, AND SOCIAL DEFICITS IS THE PATIENT LIKELY TO EXPERIENCE IF TREATMENT SUCCEEDS?ARE THERE BIASES THAT MIGHT PREJUDICE THE PROVIDERS EVALUATION OF THE PATIENTS QUALITY OF LIFE?

  • QUALITY OF LIFE (2)IS THE PATIENTS PRESENT OR FUTURE CONDITION SUCH THAT HIS OR HER CONTINUED LIFE MIGHT BE JUDGED UNDESIRABLE?IS THERE ANY PLAN AND RATIONALE TO FORGO TREATMENT?ARE THERE PLANS FOR COMFORT AND PALLIATIVE CARE?

  • CONTEXTUAL FEATURESARE THERE FAMILY ISSUES THAT MIGHT INFLUENCE TREATMENT DECISIONS?ARE THERE PROVIDER (PHYSICIANS AND NURSES) ISSUES THAT MIGHT INFLUENCE TREATMENT DECISIONS?ARE THERE FINANCIAL AND ECONOMIC FACTORS?ARE THERE RELIGIOUS OR CULTURAL FACTORS?

  • CONTEXTUAL FEATURES(2)ARE THERE LIMITS ON CONFIDENTIALITY?ARE THERE PROBLEMS OF ALLOCATION OF RESOURCES?HOW DOES THE LAW AFFECT TREATMENT DECISIONS?IS CLINICAL RESEARCH OR TEACHING INVOLVED?IS THERE ANY CONFLICT OF INTEREST ON THE PART OF THE PROVIDERS OR THE INSTITUTION?

  • PERANAN HUKUMDAPAT MEMBANTU MENYELESAIKAN MASALAH ETIKDAPAT MEMBATASI PILIHAN ETIKDAPAT MENCIPTAKAN KONFLIK ETIK

  • CONTOH KASUS

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