FAKULTAS KEDOKTERAN

UNIVERSITAS MUSLIM INDONESIA Makassar, 23 october 2017

PBL REPORT
“THE DILEMMA OF ETHICS”

BY:
GROUP 14
Tasya Ardiani (11020170015)
Andi Muhammad Arya (11020170023)
Rizqie Hayyudiah Nur (11020170031)
Fitrah Putra Irwan (11020170050)
Moh. Yusril (11020170052)
Murni Aswiranti Putri Muhlis (11020170077)
Muhammad Anugrah Ramadhan (11020170117)
Nurul Fatimah (11020170132)
Nurul Atmitha Moudya Latif (11020170149)
Nurul Azizah Afdilla (11020170166)
Azimar Khatimah Zusandy (11020170170)

TUTOR : dr. Andy Visi Kartika, M.Kes,Sp.PA

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2017
 PREFACE
Praise and gratitude we pray over abundance of grace, taufik, and His
guidance so that the report of the group of 14 this tutorial resolved properly. And do
not forget also sent greetings and blessing to our master the prophet Muhammad
SAW which has brought us from a state of ignorance to a state of intelligence.
We also would like to thank all those who have helped in the creation of this
report and who have helped during the tutorial, especially to dr. Andy Visi Kartika,
M.Kes,Sp.PA Who have helped during the process PBL progress. And we also
apologize to any party if the process has been done wrong PBL both intentional and
unintentional.
May report the results of this tutorial can be beneficial to all parties who have
read this report and in particular for its own drafting team. Expected after reading
this report readers their knowledge of humanities, ethics, and professionalism.

Composer
 BLOOD TRANSFUSION
A 23-year-old man rides a motorcycle and has a very bad accident. Because of the
accident, the man had severe bleeding and lost enough blood and was unconscious.
Residents around immediately took him to the emergency room of the nearest hospital.
From the identification card found in the man’s clothing, it is known that the man is
named Muhammad A. and is now studying at a university in the city and his parents are
another city.
The doctor who handled the patient then contacted his family and asked for
permission to perform a blood transfusion to help the patient, but it turns out the patient’s
family has a understanding, that the blood transfusion law is haram. However, on the
other hand, doctors keep trying to explain the impotance of making this blood transfusion
and what risk will happen if blood transfusion is not done. Unfortunately, from the
patient’s family side still disagree. Finally, the doctor makes his own decision by still
transfused blood to the patient on the grounds if it is not done. The patient will lose his
life. After the doctor’s help, the condition of M.A becomes good.

Questions :

- Tells the central of ethics dilema on the case above.

- From the cases above, try to analsysis :
a) Basic Rule bioethics and prima facie (using the criteria table
KDB)
b) Clinical Ethics Jonsen Siegler Winslade (use clinical ethics
questions Jonsen Siegler Winslad "Four Box")
- What if the case above, we see it in the perspective of Islam (Islamic
Ethics) and medical profesionalism.
Answer :
Beneficience
 Doctors save M.A from the of dead.
 Doctors make the best efford for M.A that is blood transfusion.
 Doctors is keep trying to explain making this blood transfusion what risk of
blood transfusion is not done.
 Finally the doctor makes his own decision by still blood transfusion to the
patient.
Non-maleficience
 The man had severe bleeding and lost enough blood and was unconscious
 Doctor want this blood transfusion but the family didn’t want to do blood
transfusion
Autonomy
Not in this case because this case in a state of emergency
Justice
Not in this case because the principle of justice is done against more than one
patient.
The central of ethics dilemma on the case
The family doesn’t agree when the doctor to blood transfusion to Muhammad
Ali, while on the other hand the blood transfusion action is the most effective action
to save Muhammad Ali.
DISCUSSION OBJECTS 1 :
BASIC RULES OF BIOETHICS I ( IN ALTRUISM PRACTICE
BENEFICENCE
Criteria
1) Priority the altruism which is selfless
helping, willing to sacrifice for the
others
2) Guarantee the principal value human
dignity.
3) Looking the patients / families/
something that not only benefits for the
doctor
4) See the kindness /benefits are more
than the badness
5) Paternalism responsible /
compassionate
6) Ensure life- best- minimal for human
7) Restriction the goal-based.
8) Maximizing the satisfaction of
happiness/ patient preference.
9) Minimize the bad consequences.
Not analysis
Exist
Exist
The doctor who handled the
patient then contacted his family
 and asked for permission to
perform a blood transfusion to
help the patient
asked for permission to perform
 a blood transfusion to help the
patient
doctors keep trying to explain
the impotance of making this
 blood transfusion and what risk
will happen if blood transfusion
is not done
the doctor makes his own
decision by still transfused blood
 to the patient on the grounds if it
is not done
the doctor makes his own
 decision by still transfused blood
to the patient
the doctor makes his own
decision by still transfused blood
 to the patient on the grounds if it
is not done
- - Not in the scenario
After the doctor’s help, the
 condition of M.A becomes good.
 doctors keep trying to explain
the impotance of making this
 blood transfusion
the doctor makes his own
10) Obligation to help emergency
patients.
 decision by still transfused blood
to the patient

11) Respect the rights of patients Still do blood transfusion to

overall.
 the patient
12) Unattractive emoluments beyond Not in the scenario
- -
decency.
the patient’s family has a
13) Maximization of the highest
satisfication overall.
 understanding, that the blood
transfusion law is haram

14) Expand profession on going basis. - - Not in the scenario

15) Provide nutritious but inexpensive Not in the scenario
- -
drugs.
16) Applying Golden Rule Principle. - - Not in the scenario

DISCUSSION OBJECTS 2 :
BASIC RULES OF BIOETHICS 2 ( DO NO HARM IN THE EMERGENCY
SITUATION AND CLINICAL PRACTICE )

NONMALEFICENCE
Not analysis
Criteria Exist
Exist
1) Helping the emergency patient. The doctor who handled the
patient then contacted his family
 and asked for permission to
perform a blood transfusion to
help the patient

2) Conditions to describe these criteria  the doctor makes his own

are : the patient is in a very dangerous
or at risk of loss of something essential
(critical), doctors can prevent the harm
or loss, the medical measures proved
effective, the benefit to the patient >
decision by still transfused blood
to the patient on the grounds if it
is not done
loss doctor or experienced only
minimal risk.
3) Treating patients with wounds.  Do the blood transfusion

4) Do not kill the patient (not perform doctors keep trying to explain
euthanasia).  the impotance of making this
blood transfusion

5) Not insult / berate / harness the Not in this case

- -
patient.
6) Does not see patients only as an The patient will lose his life.
object.  After the doctor’s help, the
condition of M.A becomes good.

7) Treating the patient the doctor is proporsional

disproportionately.  because the doctor want to save
patient’s life

8) Does not prevent the patient from Because the doctor to do blood
harm.
 transfusion

9) Avoid misrepresentation of the Not in the scenario

- -
patient.
10) Do not endanger the lives of the doctor makes his own
patients due to negligence. decision by still transfused blood
 to the patient on the grounds if it
is not done

11) Does not give the spirit of life. - - Not in this scenario
12) Does not protect the patient from Not in this scenario
- -
attacks.

DISCUSSION OBJECTS 3 :
BASIC RULES OF BIOETHICS 3 (AUTONOMY OF PATIENTS IN
EVERY SITUATIONS)
AUTONOMY
Not analysis
Criteria Exist
Exist
1) Respect the right of self- the patient’s family has a
determination, respect the dignity of the understanding, that the blood
patient.  transfusion law is haram.
Unfortunately, from the patient’s
family side still disagree

2) Not intervene patients in making Not in this scenario

- -
decisions (on elective condition).
3) Be frank The doctor asked for permission
to perform a blood transfusion to
 help the patient transfusion and
what risk will happen if blood
transfusion is not done

4) Appreciate privacy. - - Not in this scenario

5) Keep confidential patient. - - Not in this scenario
6) Appreciate the rationality of the Not in this scenario
- -
patient.
7) Implement Informed consent. Because the patient was
 unconscious
8) Allowing competent adult patients Because the patient was
and make their own decisions.
 unconscious
9) Do not intervene or impede the Because the patient was
autonomy of the patient.
 unconscious
10) Prevent others from intervening the doctor makes his own
patients in making decisions, including decision by still transfused blood
the patient's own family.  to the patient although the
patient’s family side still
disagree

11) Patiently waiting for a decision to - - Not in this scenario

be taken in case of non-emergency
 patients
12) Do not lie to a patient even though Not in this scenario
- -
the patient's sake
13) Maintaining relationships Not in this scenario
- -
(contracts)

DISCUSSION OBJECTS 4 :
BASIC RULES OF BIOETHICS 4 (PRINCIPLES OF JUSTICE IN THE
CONTEXT OF RELATIONS DOCTOR - PATIENT )
JUSTICE( not in this case)
Not analysis
Criteria Exist
Exist
1) Impose everything universally. - - Not in this scenario
2) Taking the last portion of the process of Because the patient is not
dividing what he/she had done.
 healthly
3) Giving equal opportunity to the person Not in this scenario
- -
in the same position.
4) Respect for the healthy rights of patients doctors keep trying to explain
(affordability, equality, accessibility,  the impotance of making this
availability, and quality). blood transfusion
5) Appreciating the legal rights of patients. - - Not in this scenario
6) Respecting the rights of others. - - Not in this scenario

7) Keeping vulnerable groups (most Not in this scenario

- -
disadvantaged).
8) Not to misuse.  The doctor not do harm

9) Wise in the macro allocation. the doctor makes his own

decision by still transfused blood
 to the patient on the grounds if it
is not done. The patient will lose
his life
10) Contribute relatively the same as the Not in this scenario
- -
needs of the patient.
11) Requesting the participation of the Because the patient was
patient according to his ability.  unconscious
12) The obligation to distribute profits and Not in this scenario
losses (costs, charges, and penalties) are - -
fair.
13) Restore the right to its owner at the Not in this scenario
- -
right time and competent.
14) Do not give a heavy burden is not Not in this scenario
- -
evenly without valid reason / right.
15) Respect the rights of the population are Not in this scenario
equally vulnerable - -
      disease / health problems.......
16) Do not discriminate on the basis of Not in this scenario
racial patient services, social status, and - -
others.

.DISCUSSION OBJECTS 5 :
(CLINICAL ETHICAL DECISION DYNAMICS (CONCEPT PRIMA
FACIE)
General benefit result, most of people Elective, educated, bread-winner,
mature person
BENEFICENCE
AUTONOMY
The doctor save Muhammad Ali from
danger of death and doctor keep trying Nothing
to explain what the risk of this blood
transfusion. Finally, the doctor make
his own decision is still do blood
transfusion to the patient.

Vulnerables, emergency, life saving, > 1 person, others similarity,

minor community / social’s rights
NON MALEFICENCE JUSTICE
Muhammad Ali had severe bleeding Nothing
and lost enough blood and was
unconscious. The doctor still do blood
transfusion but the family didn’t want
to do the blood transfusion

CLINICAL ETHICS QUESTIONS CHECKLIST JONSEN, SIEGLER AND

WINSLADE "FOUR BOX"
 MEDICAL INDICATION PATIENT PREFERRENCES
 Diagnosis  M.A as patient which is really
The patient got accident and after emergency situation at the
that the patient got severe same time
bleeding
 He is not able to get
 Condition of patient assignment or inform consent
from the doctor to save his life
Emergency
or the patient will lose his life.
 Nature of disease
Bad Accident
 Prognosis
The patient will lose his life if he
don’t get blood transfusion
 Treatment options
Blood Transfution

QUALITY OF LIFE CONTEXTUAL FEATURES

 Who decides?  Social
The Doctor The doctor contact his family
 What Standar?  Culture
SKDI Blood transfusion is haram
KODEKI  Legal
 Suffering? The blood transfusion is legal
The patient got bad accident  Institutional
 Relationships Studying in university
The doctor trying to explain
the condition of the patient

MEDICAL INDICATION
NO ETHIC QUESTIONS ANALYZE
1 What is the patient's medical M.A is a student in university in
problems? Profile? Diagnosis? the city and his parents are in
Prognosis? another city . he get an accident
he get severe bleeding and lose
enough blood and was
unconcious .

2 Is the problem acute? Chronic? The problem can be heal by

critical ? emergency ? still curable? blood transfusion and the patient
becomes good .
3 What is the ultimate goal of the To save his life or he will lose
treatment? his life

4 How likely is success? After the doctor’s help , the

condition of M.A becomes good

5 Are there any other plans if therapy Not in this case , there is no
fails? plans
6 As an addition, how these patients The patien get the adventage.
benefit with medical care, and how The advantage is the patient still
the loss of treatment can be avoided? life . The disadvantages is the
doctors make own decision by
still transfused blood to the
patient on the ground if it is not
done , the patient will lose his
life.

QUALITY OF LIFE
NO ETHIC QUESTIONS ANALYZE
1 What are the prospects, with or With the treatment the patient still
without treatment to return to have a wish to get well , but there is
normal life? no treatment the patient will be die

2 Whether physical disorders, Can make some trauma social

mental, social and natural patient relation problem between doctor
when treatment is successful? and patient parents

3 Is there any prejudice that might Nothing

give rise to suspicion that the
service provider evaluation of the
quality of patients’ life?

4 How is the condition of the The condition of the patient after

patient's present or future, whether get blood transfusion becomes
the patient's life can then be good.
assessed as expected?
5 Is there a rational reason for the Nothing
next treatment plan?

6 Are there any plans for comfort Nothing

and palliative care?

PATIENT PREFERRENCES
NO ETHIC QUESTIONS ANALYZE
1 Whether the patient is mentally Mentally capable and competent
capable and legally competent?
whether there are circumstances
that give rise to the inability?
2 If competent, what patients say if the patient still believe that the
about the treatment options? blood transfusion is Haram the
patient will not get heal from the
doctor
3 Whether the patient has been The doctor who handled the patient
 informed about the benefits and then contacted his family and asked
risks, do or not understand the for permission to perform a blood
information provided and give transfusion to help the patient, but
consent? it turns out the patient’s family has
a understanding, that the blood
transfusion law is Haram.
4 If not competent, who should His family . But his family is not
replace him/her? Is a competent capable with standart decision
person using appropriate standards making
in decision-making?
5 Does the patient have shown Nothing
something more to his liking?
6 Whether the patient is unwilling / In this case the patient is
unable to cooperate with the emergency situation and the patient
treatment given? if so, why? unconscious

7 In addition, if the patient's right to Nothing

choose to be respected regardless
of ethnicity and religion?

CONTEXTUAL FEATURES
NO ETHIC QUESTION ANALYZE
1 Is there any family problems that His family disagree with blood
might affect treatment decisions? transfusion because that the blood
transfusion law is haram
2 Is there a problem of data sources Nothing
(clinics and nurses) that may affect
treatment decisions?
3 Are there any issues of financial Nothing
and economic factors?
4 Is there a religious and cultural There is religious factor , the
factors? family believe that blood
transfusion law is Haram
5 Is there a limit trust? There is limit trust
6 Are there issues of resource Nothing
allocation?
7 How does the law affect treatment Autonomy is not able if non-
decisions? maleficien
8 Whether the clinical research or Nothing
teaching involved?

9 Is there a conflict of interest on the Nothing

part of decision-making within an
institution?

BASIC PRINCIPLES OF ETHICS OF ISLAM

NO ETHIC PRINCIPLES ANALIYZE
1 Prinsip niat / Intention (qa'idat al Doctor have sicere intention to help
qasd) M.A, this can be seen from his
actions to do blood transfusion.

2 Prinsip kepastian / Certainty Doctor keep trying to explain the

(qa'idat al yaqeen) importance of making this blood
transfusion and what risk will
happen if blood transfusion is not
done.

3 Prinsip kerugian / Harm (qa'idat Doctor take action to prevent

al dharar) gravity or severity to Muhammad
Ali.

4 Prinsip kesukaran / Difficulty Emergency shooting legalize rights

(qa'idat al mashaqqat) violation or autonomy temporarily.
 5 Prinsip kebiasaan / Custom Doctors actions are standard
(qa'idat al 'aadat) operating procedures.

IF WE SEE IT IN THE PERSPECTIVE OF ISLAM (ISLAMIC ETHICS)

AND MEDICAL PROFESIONALISM.

Islam it self see this blood donation is something that is beneficial for the
benefit. This can be seen from the opinion of some scholars. One of them is Shaykh
Al-Allama Muhammad bin Ibrahim Aali Shaykh rahimahullah. According to Ust.
Hammad Abu Mu'awiyah in his writings, Shaykh Al-Allamah allows blood donation
activities. This is seen from three different viewpoints: the person who receives, the
donor, and who makes the referral or the doctor. According to him, the person who
receives must really need, not harm to the donor and who gives a referral is a Muslim
doctor, if nothing then it is allowed with a doctor other than muslim. Islam itself see
this blood donation is something that is beneficial for the benefit. This can be seen
from the opinion of some scholars. One of them is Shaykh Al-Allama Muhammad
bin Ibrahim Aali Shaykh rahimahullah. According to Ust. Hammad Abu Mu'awiyah
in his writings, Shaykh Al-Allamah allows blood donation activities. This is seen
from three different viewpoints: the person who receives, the donor, and who makes
the referral or the doctor. According to him, the person who receives must really
need, not harm to the donor and who gives a referral is a Muslim doctor, if nothing
then it is allowed with a doctor other than muslim

Surat Al-Baqarah ayat 173

”Sesungguhnya Allah hanya mengharamkan bagimu bangkai, darah, daging babi,
dan binatang (yang ketika disembelih) disebut (nama) selain Allah. Tetapi barang
siapa dalam keadaan terpaksa (memakannya) sedang ia tidak menginginkannya dan
tidak (pula) melampaui batas, maka tidak ada dosa baginya”. This verse refers to
the recipient or recipient of blood is a person who is really in a critical state. And we
are also forbidden to sell the blood

Sahih International

He has only forbidden to you dead animals, blood, the flesh of swine, and that which
has been dedicated to other than Allah . But whoever is forced [by necessity], neither
desiring [it] nor transgressing [its limit], there is no sin upon him. Indeed, Allah is
Forgiving and Merciful.