International Programme Faculty of Medicine Gadjah Mada University

BIOETHICS
Prof.DR.Dr. H Soewadi, MPH, SpKJ (K)

Definition
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Bioethics in the systematic study of the moral dimensions including moral vision, decisions, conduct and policy-of life sciences and health care, employing a variety of ethical methodologies in an inter-disciplinary setting. (Kuganse and Sheldon, 2000)
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Basic Moral / Ethical Principle

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1. Respect for Others

(autonomy, dignity, privacy, confidentiality, self-determination) 2. Beneficence, Non Maleficence, do no harm 3. Justice (threat each people morally right and proper)
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Bioethics Health Ethics Medical Ethics Clinical Ethics Ethics in

Services Research Education

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Disciplines, Departments, Field of Studies

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Medicine, Health, Nursing, Midwifery, etc Sociology, Anthropology, Psychology, Philosophy, etc.

American College of Physician, 2000

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Principles : - Beneficence - Non-maleficence - Autonomy truth telling

- disclosure - inform consent

Manual of Ethics
I. II. III.

Patient and Physician The Physician and Society The Physicians Relationship to other clinician
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I. Patient and Physician

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1. Initiating and discounting Patient 2. 3. 4. 5. 6. 7.

Physician Relationship Confidentiality The Patient and the Medical Record Disclosure Informed Consent Decisions about Reproduction Genetic Testing
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8.
9. 10.

11.
12.

13.
14. 15.

16.

Medical Risk to Physician and Patient Alternative Treatment Disability Certification Care of the Physicians Family, Friends and Employees Sexual Contact between Physician and Patient Care of Patients Near the End of Life Patients Need the End of Life Making Decisions Near the end of life Advanced Care of Planning 8

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17. Problems of life-sustaining Treatment With drawing or with holding Treatment Do Not Resuscitate Orders (DNR) Determination of death Organ donation Irreversible loss of Consciousness Intra venous fluids and Artificial feedings Physician assisted suicide and euthanasia
18. The ethics of practice The changing practice environment Financial arrangement Financial conflict of interest Advertising

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II. The Physician and Society

Obligation of the Physician to society Resources allocation Relations of the Physician to government Ethics Committees and Consultation Medicine and Law Expert witnesses Strike by physician
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1. 2. 3. 4.

5.
6. 7.

The physicians Relationship to the other Clinicians

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1. Attending Physicians and Physician in Training 2. Consultations 3. The impared physician 4. Peer Review 5. Conflicts among members of Health care team 6. Research 7. Clinical investigation 8. Innovative Medical Therapy 9. Scientific publication 10. Public announcement of research Discoveries
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Clinical Ethics (Forrow, et. Al, 1999)

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I.

Basic Ethical Principles 1. Fundamental Principle: A clinical intervention is justified if and only if the expected benefits outweigh the expected burdens from the perspective of the patient 2. Shared Decision Making a. Paternalism Complete patient autonomy b. Shared Decision Making 3. Two Rules: a. A competent patient 12 b. Patient is not competent

II. Medico-Legal Perspective

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1. 2.

3.
4. 5.

Competent adult, have a legal right-to accept or refuseIncompetent adult, have the same rightSurrogate decision maker (proxy or healthcare agent)Each state, country has their own judicial guidance Brain death-specific criteria-patients legally dead
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III. An Approach for Specific Cases

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1. Good decisions require good data 2. Seek out win-win solution and be

creative 3. Think about who should decide as well as what decision is best

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IV. The Ethics Work-Up

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1. 2. 3. 4. 5. 6.

FACTS = What are the important facts in the case? VALUES = What are the most important value at stake? CONFLICTS = What values, if any, are in conflict? POSSIBLE COURSES of ACTION DECISION AND JUSTIFICATION FURTHER REFLECTION Preventive ethics
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V. Resolving ClinicalEthical Disagreements

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Disagreement about : - Fact - Values - How to weigh different values - Where decision-making authority lies?

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VI. Preventive Ethics

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a. Establish a trust worthy partnership

with patient and family b. Communicate early, often and realistically about goals and end points.

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