1

ISSU ETIS DALAM KEPERAWATAN

Mei Vita Cahya Ningsih

� Isu-isu etik khusus : hidup dan mati, mempertahankan/mengakhiri pemberian makanan dan minuman, mengakhiri bantuan kelangsungan kehidupan, AIDS, AI (Avian Influenza) alokasi sumber-sumber kesehatan

2

Definisi istilah

1. Etika versus moralitas

- Etika studi filosofi moralitas berdasarkan teori formal, aturan, prinsip dan kode prilaku untuk menentukan bagian yg benar suatu tindakan

- Etika studi lebih formal, sistematik dari keyakinan moral

- Moralitas menggambarkan komitmen pribadi thd nilai yg sering dipengaruhi norma dan pengharapan masyarakat

- Moralitas ketaatan thd nilai personal informal

Pendekatan thd etik

1. Etika non normatif

- Meta etik : konsep dan terminologi linguistik dalam etika :

“Baik , Kebajikan, Benar”

Contoh informed concent

- Etika deskriptif : Mengidentifikasi prilaku dan keyakinan etis tanpa melakukan penilaian

(bersifat netral : Contoh antropologi, sosiologi)

3

Lanjutan

2. Etika normatif

- Filosofi moral yg “seharusnya/ sebaiknya”

- Proses penetuan tindakan moral dalam menjawab “apa yang seharusnya saya lakukan dalam situasi seperti ini”

- Disebut juga etika normatif umum

- Jika dilakukan pada disiplin yg lebih spesifik disebut etika terapan

Situasi moral

Kata lain :

� Situasi moral, delema moral, ketidak pastian moral, distres moral

� Delema terjadi konflik yg nyata antara dua atau lebih prinsip moral yg saling berkompetisi “ the lesser of two evils”

� Contoh Px sakit parah mentaati kesucian hidup, orag lain menganggap memperpanjang penderitaan

4

Ketidak pastian moral & moral distress

� Delema perawat ketidak pastian moral

- Lansia dg pembedahan tidak mengalami kemajuan

- Px tidak siap dipulangkan

� Distress moral

- Kebijakan RS, Px menanyakan Apakah sayan menderita kanker ? Dr, kluarga tidak menginformasikan I

Ethical Theories

� Teleology - the value of a situation is determined by its consequences.

� Deontology - the intrinsic significance of an act itself as the criterion for the determination of good.

� Situational Theory - holds that there are no set rules or norms. Each situation must be considered individually.

� Caring-Based Theory - focuses on emotions, feelings, and attitudes.

5

6

7

Teori Etik Klasik

1. Teleologi

2. Deontologi

3. Etik kebajikan

4. Etik pluralisme

1. Teleologi

� Telos (yunani) = akhir, yang penting memperhatikan hasil akhir/konsekwensi dari tindakan ( Konsekuensialisme)

a. Utilitarisme (kemanfaatan) terbaik bagi yg terbanyak

- John Stuart Mill “ prinsip kebahagian terbesar”

8

The Kantian Model

� Central insight: people cannot be treated like mere things.

� Key notions:

� Autonomy & Dignity

� Respect

� Rights

2. Deontologi

� Deon (yunani) tugas/hak/ kewajiban (formalis)

� Pembenaran tindakan moral lebih penting dari pada konsekwensi

� Imanual Kant(1785/1983) Moralitas dibangun niat baik

� Contoh seorang perawat yg lalai memberikan obat dan melaporkan hanya karena takut tindakan hukuman jika kesalahan tsb diketahui ketimbang kawatir efek yg membahayakan maka perawat tidak bertindak dalam perspektif moral

� Perspektif kan disebut monistik/ imperatif moral

(ketaatan satu prinsip (rasionalitas)

� Golden Role (memperlakukan orang lain seperti memperlakukan diri sendiri.(respek kemanusiaan)

9

3. Etika kebajikan

� Sifat karakter individu (Aristotle dan Plato bahwa prilaku morla berjembang sesuai perkembangan prilaku kabijakan.

� “Saya harus menjadi apa” dari pada “Apa yang harus saya lakukan”

� Contoh kebajikan Keyakinan, harapan, cinta dan amal dalam keagamaan”

� Mewarnai etika normatif (kemurahan hati, kejujuran, keadilan)

4. Etik Pluralisme

� Tergantung konteks “ lebih baik dari yang lain” dengan mempertimbangkan beragam kerangka kerja

Pluralisme

� WD. Ross (Inggris, 1930) Prima facie (kondisional atau semua hal lain yg serupa) dan eksistensi aktual(keberadaan)

� Contoh secara moral berkata bohong itu salah, namun kadang membenarkan tindakan ini lebih mendesak karena menghindari bahaya orang lain.

10

Prinsip etika secara mum

- Otonomi -Kemurahan hati

- Kerahasiaan -Efek ganda

- Kesetiaan -Keadilan

- Non maleficence(tidak membahayakan)

- Paternalisme -Respek Individu

- Kemulian hidup -Kejujuran

Ethics in Health Care

� Bioethics is the application of ethical principles to health care.

� Ethics affects every area of health care.

� Ethics helps provide structure by raising questions that ultimately lead to answers.

11

Prinsip etika umum

1. Otonomi :

- Peraturan diri, hak individu, privacy, pilihan, kemampuan membuat pilihan yang bebas dari ekternal

2. Kemurahan hati

- Melakukan hal yang baik, penuh kebajikan, kebaikan dan kemurahan

3. Kerahasiaan

- Privasi, tidak menyebarkan utk org lain

Lanjutan 4. Efek ganda

- Tindakan dapat menghasilkan efek positif dan nengatif dg kriteria :

a. Tindakan itu ssecara moral baik

b. Secara tulis berniat efek yang baik(efek buruk diramalkan tapi tidak diminati)

c. Efek baik tidak diraih dg cara efek buruk

d. Terdapat keseimbangan proporsional yg baik dan buruk

5. Kesetiaan :

- Menepati janji (komitmen)

12

Lanjutan 6. Keadilan :

- Memperlakukan sesuai hak dan kewajiban individu dan sosial antara lain (Kesetaraan, kebutuhan, upaya, kontribusi masyakarakat, kebaikan, legal)

7. Non malificence :

- tidak membebankan utk mencegah danmenyingkirkan bahaya

8. Paternalisme

- Bekerjasama utk kemurahan hati, kesejahteraan / kebutuhan orang lain, mencegah keburukan

Lanjutan 8. Paternalisme

- Bekerjasama utk kemurahan hati, kesejahteraan / kebutuhan orang lain, mencegah

keburukan

9. Respek utk individu :

- Mengotimalkan dan memampukan orang lain membuat pilihan

10. Kemuliaan hidup :

- Eksistensi biologis harus lebih penting diatas kriteria ekternal

11. Kejujuran

- Kewajiban mengatakan yg benar, tidak bohong, tidak menipu orang lain

13

Domain etika keperawatan

1. Memberikan perawatan berkesinambungan

2. Tidak memandang penyakit /status sosial

3. Bertangung jawab

4. Bertindak sesuai kode etik profesi

Jenis masalah etis keperawatan

1. Kerahasiaan

2. Restrein

3. Hubungan saling percaya

4. Kematian dan sekarat

5. Menolak perawatan

14

Ethical Dilemma

�Defined as making a choice between two or more equally undesirable alternatives

Lanjutan

1. Kerahasiaan

- Informasi Dx. Medis, keperawatan, diskusi Px ditempat tertutup

2. Restrein (penggunaan pengikat)

- efek keselamatan, agitasi/bingung, menanyakan anggota kluarga /relawan

3. Hubungan saling percaya

- Kejujuran, tidak berbohong kepada pasien, informasi yg jelas prosedur dan diagnosa keperawatan, mengkomunikasikan pada kluarga dan dokter permintaan pasien akan informasi.

15

Ethical Decision Making

� Ethical Reasoning

� Thinking through what one ought to do in an orderly, systematic manner

� Justification of actions based on principles

Trial-and-Error Decision Making

Reflect for a minute on how you make decisions…

16

Ethical Decision Making

� Framework for Ethical Decision Making

� Which theories are involved?

� Which principles are involved?

� Who will be affected?

� What will be the consequences of the alternatives?

� What does the client desire?

Ethical Decision Making

� Steps of Ethical Analysis

� Gathering of relevant data to identify the problem

� Consideration of all the people involved

� Selection of a course of action

� Evaluation of the resolution process

17

Ethical Issue

� Euthanasia

� Refusal of Treatment

� Scarce Resources

Euthanasia

� “Good or gentle death”

� Mercy killing (deliberate ending of life as a humane action)

18

Euthanasia

� Active euthanasia is taking deliberate action that will hasten the client’s death.

� Assisted suicide is a form of active euthanasia.

� Passive euthanasia is the omission of an action that would prolong dying.

� Discontinuing the client’s tube feedings is a form of passive euthanasia.

Refusal of Treatment

� The client’s right to refuse treatment is based on the principle of autonomy.

� A client’s right to refuse treatment and the right to die challenge the values of some health care providers.

19

Scarce Resources

� The availability of specialists and organs, is contributing to a scarcity of resources.

� The use of expensive services is influenced by social and political forces.

� Health care reform is needed to ensure services to all.

Ethics and Nursing

� Professional nurses’ actions are both legal and ethical.

� Sound nursing practice involves making ethical decisions.

� Ethics affects nurses in every health care setting.

20

Ethics and Nursing

� Ethics Committees

� One approach for facilitating dialogue regarding ethical dilemmas

� Nurse as Client Advocate

� Nurses are accountable for protecting the rights and interests of the client.

Ethical Decision-Making Model

Assessing the outcome of moral actions;

“Were the actions ethical?”

“What were the consequences?”

EVALUATION

Carrying out selected moral actions

IMPLEMENTATION

Consideration of priorities of claims;

Generation of alternatives for resolving the dilemma;

Consideration of the consequences of alternatives

PLANNINGANALYSIS AND DIAGNOSIS

Problem identification: Statement of the ethical dilemma

ASSESSMENT

Determination of claims and parties

21

Web Resources,2

� Before I Die

� With Bill Moyers

�http://www.pbs.org/wnet/bid/

What is a good death?

Jeremy Bentham.Hedonistic utilitarians: a good death is a painless

death.

Eudaimonistic utilitarians: a

good death is a happy death.

John Stuart Mill

22

Appendix 1From whole to parts

Person

Soul

Mind

Body

Priest,MinisterRabbi

Doctor

Psychologist

ENTOphthalmologist

UrologistOncologist

Psychiatrist

Appendix 2Stakeholders in the Decision-making Process

� End-of-life decisions involve more than the patient and the physician.

PatientPhysician

Patient’s

Family

Insurer/

HMO

23

Lanjutan

4. Kematian dan sekaratul maut Tidak ada yg dapat dilakukan lagi

� Teknologi akan memperpanjang hidup perlu biaya tinggi

� Fokus peran asuh

� Resustiasi

a. Dukungan hidup

b. Makanan dan cairan

c. Kontrol nyeri

Lanjutan

5. Menolak perawatan

- Konflik nilai

- Takut cedera

- Keterasingan

- Takut biaya

24

Pembuatan keputusan etis

1. Pengkajian :

Situasi etis/moral dari masalah

a.Dimensi etis, hukum, profesional

- Apakah situasi mengandung masalah moral (konflik prisip etis dan kewajiban profesional)

- Apakah ada konflik prosedural (siapa yg harus membuat keputusan, apakah ada konflik pemberi asuhan, kluarga, px)

- Identitas orang terpenting yg terlibat dan mempengaruhi keputusan

Ethical Decision Making

EVALUATION

Evaluation of outcome of moral actions

"Were the actions ethical?" "What were the consequences?"

IMPLEMENTATION

Carrying out selected moral actions

PLANNING

Consideration of priorities of claims

Consideration of consequences of alternatives

ANALYSIS & DIAGNOSIS

Identification of problem: Statement of ethical dilemma

ASSESSMENT

Determination of claims and parties

25

An Exciting Timefor Ethics

� New technologies

� Policy vacuums

� Ethical & legal quandaries

Lanjutan 2. Perencanaan :

Kumpulkan informasi :

a. Fakta medis, pilihan pengobatan, Dx. Keperawatan, data legal, nilai, keyakinan, komponen keagamaan

b. Buat perbedaan antara faktual dan nilai / keyakinan

c. Validasi kepastian pasien atau kurang kapasitasa membuat keputusan

d. Indentitas informasi lain yg relevan

e. Identifikasi isu etis/ moral dan klaim persaingan

26

Lanjutan 3. Implementasi

a. Urutkan alternatif

Bedakan alternatif dg prinsip etis yg dapat diterapkan dan kode etik profesi, dapat memilih salah satu atau keduanya bandingkan :

Pendekatan utilitarisme

- Ramalkan konsekwensi dari alternatif

- Teliti nilai positi dan negatif tiap konsekwensi

- Pilih konsekwensi yg meramalkan nilai paling positif atau yg terbaik bagi yg terbanyak

Lanjutan

Pendekatan deontologi (hak/kewjiban/alasan)

a. Identifikasi prisip moral yg relevan

b. Bandingkan alternatif dgn prinsip moral

c. Bandingkan ke prinsip moral tingkat yg lebih tinggi jika terdapat konflik

27

Lanjutan

4. Menentukan dan mengevaluasi keputusan

a. Tindakan apa yang terbaik dan tepat secara moral ?

b. Berikan alasan etis terhadap keputusan anda ?

c. Apa alasan etis dari keputusan anda

d. Bagaimana anda merespon terhadap penalaran keputusan anda ?

To make appropriateethical decisions:

The manager must use a professional approach that eliminates trial and error and focuses on proven decision-making models or problem-solving processes.

28

The MORAL Decision Making Model(Crisham, 1985)

� M—Massage the dilemma.

� O—Outline options.

� R—Review criteria and resolve.

� A—Affirm position and act.

� L—Look back. Evaluate the

decision-making.

Murphy and Murphy (1976) Approach to Ethical Problem Solving

1. Identify the problem.

2. Identify why the problem is an ethical problem.

3. Identify the people involved in the ultimate decision.

4. Identify the role of the decision maker.

5. Consider the short- and long-term consequences of each alternative.

6. Make the decision.

7. Compare the decision with the decision maker’s philosophy of ethics.

8. Follow up on the results of the decision to establish a baseline for future decision making.

29

Another error made by

managers in ethical

problem solving is

using the outcome of

the decision as the sole

basis for determining

the quality of the

decision making.

Ethics in Action

� In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse–managers involves some ethical component.

30

�“If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with a poor outcome, the manager should accept that the best possible decision was made at that time with the information and resources available.”

The following forces ensure that ethics will become an even greater dimension in management decision making in the future:

� increasing technology, regulatory pressures, and competitiveness among healthcare providers;

� national nursing shortages;

� reduced fiscal resources;

� spiraling costs of supplies and

salaries;

� and the public’s increasing distrust

of the healthcare delivery system and

its institutions.

31

Accountability of Nursing

Nurse is answerable, responsible, & liable for the services he or she provides or makes available.

State licensure

Nurse Practice Act

Patient’s Bill of Rights

Code of Ethics for Nurses

Nursing Research

� Patient’s Bill of Rights

� Informed Consent

32

Other Ethical Issues

� Quality of life vs. Sanctity of Life

� Euthanasia

� Withholding or withdrawing Tx.

� Abortion

� Allocation of Resources

� Restraints

� Informed Consent

� Confidentiality

Preventive Ethics

� Advance Directives

*Living Will

*Durable Power of Attorney for Health Care

� Institutional Ethics Committees

� Patient Care Conferences

� Ethics Literature

33

DefinitionsHIV/AIDS-Related Stigma:

“a ‘process of devaluation’ of people either living with or associated with HIV/AIDS”. (UNAIDS)

HIV/AIDS-related Discrimination:“Discrimination follows stigma and is the unfair and unjust treatment of an individual based on his or her real or perceived HIV status”. (UNAIDS)

Relations?

Stigma (marking/labelling) �Discrimination (action)

Why Study HIV-related Stigma and Discrimination in Asia?

� Stigma and discrimination described as ‘the greatest barriers’ to effective epidemic control

� Asia described as “the next battlefield for AIDS”

� Research gap

34

AimTo provide a systematic situation analysis of structural forms of HIV related discrimination in selected sites in six countries:

� China (Beijing)

� India (Trivandrum)

� Indonesia (Bali & Jakarta)

� Philippines (Manila)

� Thailand (Bangkok)

� Vietnam (Hanoi)

35

36

Terimakasih

Wassalam