PERANGKAT PENGAJARAN BIOETIKA-HUKUM KEDOKTERAN- KESEHATAN&HAM DI FK/FKGAGUS PURWADIANTO FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA

ASPEK ETIKOLEGAL INFORMED CONSENT Agus PurwadiantoIKF-FKUI Pelatihan Etikolegal NARKOBA, IDI-IKF-Polda Metro Jaya, 30 September 2000 RELEVANSI

Skm gatra

Too many Humiliating criticsFrom CommunityRELEVANSIRELEVANSI

Sukma Ayus (movie star) case medical futility, similar with Karen Quinlan caseRELEVANSI

head-line Warta Kota, 6 Februari 2005RELEVANSIRELEVANSI

PROFIL DR DIADUKAN KE MKEK (DKI 2005)CABANG KEAHLIAN :OBSTETRI GINEKOLOGI12BEDAH10DOKTER UMUM 8PENYAKIT DALAM 6ANESTESI 4ANAK, JIWA, THT 3KARDIO, MATA, PARU 2BO, BP, BS, F, R, U 1

RELEVANSI

DokterMKEK MDTKTRANSISI MKDKIPeradilan PersBPSK-KesehatanKomite Etik/MedikRS setempatPN Pidana PN Perdata

Risiko Dokter Diadili/diperiksa pasca UU PradokMAKERSIPs 66 (3)Merasa dirugikanAdverse event = malpracticesisa langgar etis MKDKIPS 55

PS 68RELEVANSI

The world is changing rapidly Population expansion Urbanization Increase in international travelSocial changes - New knowledge New risks Rapid and widespread communication

RELEVANSIHAM & KES

If the IHR were a lighthouse.

NATIONAL SURVEILLANCE AND RESPONSEWHO ALERT AND RESPONSE SYSTEMTHREAT-SPECIFIC CONTROL PROGRAMMESINTERNATIONAL TRAVELS AND TRANSPORTSIHR(2005) a solid foundation and four light beamsGLOBAL PARTNERSHIP Broader range of risks

Broader range of risks

NEWRELEVANSIHAM & KES

Ethics/morality= natural law

Legal=PositivelawEthicolegal Perspectives

Ethico-legal= moral principlesHukum bisa cacat moral bila >< dgn deklarasi universal bioetikaatau moralitas umumPENDEKATAN TEORI

Methodological Schedule ScenariosAs an example, we will use the methodological schedule shown below:Country: Comment: *Note: This is a presentation/explanation about the legal system of the country. If an official explanation or website is available, this should always be referred.*Note: For each theme, applicable declaration articles are limited to those listed in the schedule.*Note: Further clarifications in next slide.

Bioethical ThemeArticles UNESCO DeclarationsLegal InstrumentsDescriptionMedical research with human beingsUniversal Declaration on Bioethics and Human Rights

BIO3 Art.3BIO4 Art.4BIO5 Art.5BIO6 Art.6, b) c)BIO7 Art.7BIO8 Art.8BIO9 Art.9BIO10 Art.10BIO11 Art.11(cont.)TreatiesConstitutionsDomestic lawsAuthoritative case lawsGuidelinesInstrumentTitle: Year of adoption:Year of official publication:Year of entering into force:

Section/ArticleThe (translated) text in quotation marks

CommentIf required:Comment of technical-legal natureWeb links to interpretative comments related to the section/article

LiabilityProfessionalDignityBonafideProfessionalismcompetencyMaintain technicalexpertiseSelf-regulationCollege CME/CPDProf organizationCode of ethics/peer reviewRespectable statusProf insurance/MDU/MPSDiscipline =accountabilityPersonal responsibilityGoal ofMedicinePatientsSafetyElements of Ethicolegal SystemAgus Purwadianto, 2006

KEKUATAN etis UU PRADOK Tujuan normatif patient safety = protecting the people (berpihak pd publik/rakyat) krn kesehatan = HAM Pemberdayaan org prof = subsidiaritas ruh disiplin DR (jeruk makan jeruk) kesempatan self regulating utk kehormatan/keluhuran profesiPedoman DR = Melindungi DR (baik) dari non DR (peniru DR) dg serangkaian hak2 praktik yg diatur/dijamin negara > obyektif : unsur masyarakat ikut atur DR (via KKI)

AccountabilityDisciplineEthico-legal SystemAgus Purwadianto, 2005

Patients Safety Law as social engineering

LiabilityValue ofHealth

Patient/ClientFamilyHealth PersonnelHealth FacilitiesHealth systemMedical GoalsResponsibilityEthics

ProfessionalDignityPROFESSIONALISMSOCIAL CONTRACTPUBLIC TRUSTBEST INTEREST, PREFERENCES,MEDICAL INDICATIONCONTEXTUALITYBALLANCINGCONFLICT OF INTERESTCommunitySociety QUALITY OF LIFE

AccountabilityDisciplineEthico-legal System & Politic of HealthAgus Purwadianto, 2007

Patients SafetyIHR WHO 2005 GEObsLAW

LiabilityBEHAVIOR VBM-BASED

Patient/ClientFamilyTECHNOLOGISM(NANO)EBMMedical GoalsResponsibilityEthics

ProfessionalDignitySOCIAL ETHICS as FARDHU KIFAYAHCHECK & BALLANCESPUBLIC TRUSTECOSOC RIGHTS, RIGHT TO HEALTHMEDICAL INDICATIONCONTEXTUALITYBALLANCINGCONFLICT OF INTERESTINTERNATIONALCommunitySociety SOLIDARITY = GLOBAL JUSTICECRITICAL MASS

Tujuan Pendidikan Dokter

Dokter yang mampu menyelenggarakan pelayanan, pendidikan dan penelitian di bidang kedokteran dan kesehatan sesuai dengan perkembangan ilmu pengetahuan dan teknologi kedokteran mutakhir, kebutuhan dan tuntutan kesehatan masyarakat serta kebijakan pemerintah yang mampu bersaing secara global

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIAPasal 2 Kebijakan SAF FKUI 04BAGAIMANA MENCAPAINYA DI SISI HULU ?

Profil produk dokter KINI Care providerDecision makerCommunicatorCommunity leaderManager, + Researcher (FKUI)

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIASISI HILIR = OUTPUT

KOMPETENSI DOKTER FKUIKompetensi UtamaKomunikasi efektifKeterampilan klinik dasarIlmu dasar dalam praktik kedokteranPengelolaan masalah kedokteran dan kesehatanTeknologi informasiMawas diri dan belajar sepanjang hayatEtika, moral dan profesionalisme dalam praktikKompetensi PendukungRisetPengelolaan kegawat-daruratan kedokteran dan kesehatanManajemen pelayanan kesehatanKEPMENDIKNAS RI No. 045/U/2002

6 Areas of competence

Patient care ( clinical reasoning)Medical knowledgePractice-based learning & improvement ( info mngmnt)Interpersonal & communication skillsProfessionalismSystem-based practice ( health economics & teamwork)

Dimensions of Prof. Competence

CognitiveTechnicalIntegrativeContextRelationshipAffective/moralHabits of Mind

TAHAP PEMBELAJARAN (Miller)KNOWSMENDAPATKAN PENGETAHUAN/ORIENTASIKNOWS HOWKETERAMPILAN MENERAPKAN IP PADA MASALAH KLINIKSHOWSPENERAPAN KETERAMPILAN PADA SIMULASI/SKILLS LABDOESPENERAPAN PADA PASIEN

LEARNING PYRAMID IN MEDICINE

Teach other Practice by doing Group discussion Demonstration Audiovisual Reading Lecture80 %75 %50 %30 %20 %10 % 5 %

PERSYARATAN AKADEMIKSTAF PENGAJAR/MEDICAL TEACHERStaf pengajar Fakultas Kedokteran mempunyai:Kepakaran dalam suatu cabang ilmu (Subject expertise)Kemampuan manajemen pendidikan (educational management)Keterampilan menyusun Rancangan Pengajaran (Instructional design skills)Keterampilan melaksanakan Rancangan Pengajaran (Instructional delivery skills) pemberi kuliah, fasilitator, pembimbing praktikum dllKeterampilan melakukan evaluasi (Evaluation skill)

Etik Dan HumanioraGuiding Principles :Ethics contributes to high quality patient and professional behavior.Knowledge of ethics enables medical trainee to become better practitioner of medicine.Ethics can be taught, learned, and evaluated along with the general corpus of medical knowledge.

Etik Dan Humaniora (conts)Goals :To incorporate ethical concerns and issues into all phases of the education medical students.To help prepare students to understand their own values and be ethically aware medical practitioners.To provide students with the knowledge, skills, and attitudes required to be clinically competent in medical ethics and to be able to make ethically-informed medical decisions.

Etik Dan Humaniora (conts)Implementation :To expose students to the major ethical principles and issues in their preclinical and clinical training.To provide students with a knowledge of and approach to common ethical problems in medicine.To include ethical concerns in all aspects of medical training from large class sessions to problem-based small group seminars to bed-side teaching.To encourage and support students in their self directed effort to improve their understanding of ethics and to improve ethics teaching in the curriculum.To include ethics in the various forms of students evaluation and to develop new ways of evaluating students in ethics.To ensure that medical faculty are also conversant with the principles of ethics.

ETHICAL PRINCIPLISM(PRINCIPLE-BASED APPROACH) POSITION

CategoryDomain Phase 1 Phase 2 Phase 3 Phase 4

MoralityPracticalEthicsNormativeEthicsMoral justificationCriticalReasoningConduct

Code of Ethics

KNOWS

MODUL(4)KNOWS

HOWMODUL(19)SHOWS

ClinicalPracticeDOES

IKK

OpiniMyser et al (1995) Professional skills & comprehensive education in ethics : using Principles + ethical issues/topicPellegrino et al (1990)the teaching of ethics, like anyother subject in a medical school, gets its ultimate justification from its contribution to the care of the sickmedical ethics education widely acceptable focus on the ethics of patient care

PENTINGNYA TOOLS

Schwartz andGibson (1981)medical education must focus on the substance of these issues, andphysicians must arm themselves with the intellectual tools necessary to directpublic discussions of the philosophical, ethical, and legal dimensions of theirprofession with the same degree of confidence, expertise, and facility withwhich they diagnose and treat medical conditions.

ETHICSTHE 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 MAKINGMEDICAL ETHICS IS A DISCIPLINE / METHODOLOGY FOR CONSIDERING THE IMPLICATIONS OF MEDICAL TECHNOLOGY / TREATMENT AND WHAT OUGHT TO BE (Univ of Washington School of Medicine)

Why using PBE =Principle-based Ethics (Basic Moral Principle)(Ethical Principlism)

= kaidah dasar bioetika = KDB???

JENIS KAIDAH DASAR BIOETIKABeneficenceNon MaleficenceAutonomyJusticeCiri = Keputusan EtikMenyatu Dgn HukumBerkonteks PasienCara = Pembenaran Moral (Deduktif Logis)MedicalIndication

Relevancy of PBE/KDBActual to & match with clinical ethics setting (Jonsen & Siegler Method)DR need a solution as well as guidance use critical reasoning analysis tools close to the work of Ethical Reviewing Board (R. Veatch method)In line with student rationality completing power to analysis preserving the logics (deductive method of Henry Richardson)

Relevancy of PBE/KDB (2)

Match with the MET method to achieve its objectives = cognitive developmental approach : + affective dev. app : > cultural transmission In line with ethico-legal approach very useful to achieve defend argumentation against the wrong & abuses legal arguments (Agus P method 2002)More practical ethics to analyze tightly coupled ethics-discipline-legal case of every professional misconduct relevant with Medical Practice Act 2004

Relevancy of PBE/KDB (3)A previous step to value clarification method (Howard Brody)Fertilizer to prima-facie-ism (AP 2004) relevant to multiculturalism issues and critics to globalization as homogenization power to universal bioethics norm (Komisi Bioetika Nas)Connecting with Asian values : ethics of love (Darryl Macer UNESCO Bangkok)

Consensus of a minimal core objective of the General Medical Council students should acquire a knowledge and understanding of "ethical and legal issues relevant to the practice of medicine" and an "ability to understand and analyze ethical problems so as to enable patients, their families, society and the doctor to have proper regard to such problems in reaching decisions".J of Med Ethics 1998, BMJ Teaching medical ethics Teaching and assessing ethics and law within medical education: a model for the UK core curriculum Consensus statement by teachers of medical ethics and law in UK medical schools

Our own (Dr. Tenars) cases COMPACT MODULE as tools

Select from 67 cases= . tutors

Group Presentation Plennary Session

Individual/Group : Take home task/examRole playPRINCIPLESBASED ETHICSWHO-SEARO casesOther toolPRIMA FACIEOF CONTEXTPINGUINA/I CASESOCIAL ETHICS

DR TENARS TOOL & LEARNING PYRAMID IN MEDICINE

Teach other Practice by doing Group discussion Demonstration Audiovisual Reading Lecture80 %75 %50 %30 %20 %10 % 5 %2-4 hHand outsSlide 4 xCheck listsTake home Cross checkOpposing viewPlenaryPrima facieEarly clinical exposure (smt I) popular (solo GP setting)Multi-paradigmFoundation of critical reasoningSubstantial for communication skill&CPD by ethicolegal app

Check list (Observation Sheets)

Tutors nameGroup No.PENGENDALI KEPUTUSAN ETIS

Beneficence CriterionYesNoPromoting altruismGuaranteeing human dignityViewing patient/family not as profit objectsMaximize agregat net benefitCompassionate paternalismGuaranteeing minimal life of patientRestricting goal based approachMaximize patient satisfaction

PINGUINA/IS TOOL & LEARNING PYRAMID IN MEDICINE

Teach other Practice by doing Group discussion Demonstration Audiovisual Reading Lecture80 %75 %50 %30 %20 %10 % 5 %

Hand outsSlide 2 xRole play Role playPlenaryDilema EtikClinical exposure (smt III ) popular (H.C. TEAM setting)Multi-paradigmFoundation of inter-professional communicationSubstantial for health care team + ethicolegal approach

Micro levelClinical medicineThe Scope of ethics in MedicineMacro levelPolitics of Health

Meso levelHealth services delivery

Macho levelHealth care teamsDr Tenars toolInspiringGuidingEnablingRelevancy - prominencyPinguina/is tool

Direct one to oneDr Patient RelationshipMedical ethics & BioethicsSetting health policyStrategic & Operational Planning

Management of hospitalPrimary carePublic health services

Professional practiceInterprofessional relationships Bio/nanotechnology Environmental issuesHealth = ECOSOC Civil & PoliticRightsProfessionalism+ Patient Safety+Medical error+Litigious Society+Defensive Medicineissues BioethicsLegal Human RightsStandard of :PerformancePersonalFacilitiesDisciplineDr Tenars toolPinguina/is tool

organizational prerequisites (1) as emerging academic discipline with intrinsic and rigorous standards provisional adequacy : 1 full time senior academic with relevant professional and academic expertisestudents to meet their own professional and legal responsibilities when working with patientsfeatures of the whole curriculum, begin early and be reinforced throughout the course (full integrated)

PENGORGANISASIAN MODUL

organizational prerequisites (2)provision of courses and workshops for teachers, including house officersformal assessment = any other core subjecthave sufficient curriculum time and resources explicitly allocated.

BIOETHICSJenning B, Kahn J, Mastroianni A, Parker LS. Ethics and public health : Model curriculum. HRSA-ASPH-The Hasting Center. Juli 2003:3-4 EVALUATION EVALUASI MODULACGMEAccreditation councilFor Graduate Med EduLevel ofcompetenceEvaluationmethod

Basic Moral PrinciplesCommon morality theories (Utilitarianism, Kantianism, etc)The 4 basic moral principle and the Prima Facie ObligationInternational and national standard on ethicsTeaching the Basic Moral Principle to undergraduate studentKnows how, shows and doesSP, 360 global rating, checklist,OSCE1a,5

Highest Norm of Medical Ethics ETHICSSUMMUM BONUM(HIGHEST GOOD)VIRTUE & DEONTIC OF NOBLE PROFESSION PRINCIPLE BASED ETHICS & ETHICOLEGALAPPROACHSELF-DIGNITY &PROFESSI-ONALISMAP 2003Epilog :Bagi Kedokteran, bukanlah supremasi hukumnamun supremasi etik (di tangan DR bijak)

KESIMPULAN PBE/KDB = metode pengajaran etik sbg penjernih logika & peningkat daya kritis mhsw dlm menyeimbangkan keputusan etis thd keputusan medis di klinikAnalisis etikolegal = pelengkap utama PBE/KDB yg berguna utk membina sikap tanggungjawab, kesadaran hukum & profesionalisme DR kelakModul (sbg perangkat) = alat praktis permudah pemahaman etika, hukum & HAM dlm aplikasinya di Kurikulum Berbasis Kompetensi