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Eriko Prawestiningtyas, dr, Sp.F

9/17/2014

ETHICAL DILEMMA,
CONFLICT OF
INTEREST AND
SOLUTION

LEARNING OBJECTIVES
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should be able to differentiate and explain the


principles of bioethics in practice and how to
balance these principles in practice
Understand hoe to do ethical deliberation using
several strategies
Understand to find out and make ethical
statement using several designated thingking
strategy

REVIEW
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Etika:
ilmu pengetahuan mengenai tingkah laku manusiawi
yang ingin menjawab pertanyaan dasar: bagaimana
saya harus hidup dan bertindak dengan benar?
Memberikan orientasi dan kritisi mengapa kita harus
bertindak ini dan atau itu, sehingga etika tidak
berpretensi langsung membuat manusia menjadi baik
namun memberikan pertanggungjawaban nalar
mengapa saya berbuat ini atau itu
Sehingga etika merupakan dasar berpikir tindakan
kritis dan diharapkan manusia bertindak
berdasarkan dasar itu

REVIEW
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Definition of law:
System of rule which a particular country or
community recognizes as regulating the action of
its members and which it may enforce by the
imposition of penalties (oxford dictionary online)
Rule of conduct or procedure established by
custom, agreement or authority (free dictionary
online)

REVIEW

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INTRODUCTION
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Many ethical problem in medical practice are


frequently dealt with by means of practical
reasoning, base on experience, education and
beliefs, the opinion of colleaques, law, patient
perferences and other factors
Medicine is based on amorally-demanding
fiduciary duty of physician to protect and
promote the interest of his patient
In daily, physician face with ethical problems
which require us to make ethical decision, often
result in difficults solution, as : DILEMMA
We must distinguish between ethical problem
and ethical dilemma

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CONTINOUS
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In strict sense, a dilemma has no solution an


arises when we encounter an irresolvable conflict
of duties
Dilemma or ethical difficulties that present as
dilemmas, prove on careful analysis to be
resolvable problems
Ethical dilemmas always involve disputes in
which both sides have an etical underpinning to
their position

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THE PRACTICE OF MEDICINE


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To benefit for the sick


Improving peoples health by conducting physical
and non physical intervention
Involving interpersonal relationship :
- own moral resources
- Role behaviour
- setting of objectives
Not only based on evidence, but also values

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THE FACT OF MODERN MEDICAL


PRACTICES
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No doctor can avoid having to make difficult


ethical decisions
Developing of medical sciences and technology
( e.g. life sustaining treatment, stem cell, cloning
therapy, surrogate mother. Etc)
Clinical decisions are increasingly questioned by
patients, relatives and courts
Conflict of values (physician-patients-families)

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WHERE IS THE ENTERANCE FOR


PHILOSOPHICAL THINKING?

2.
3.

Health is not a moral matter but working for


health as a moral action
When values are conflicting, to what principles
can health workers assent their answers?
How can we escape from stalemate of moral
conflict?

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THE FOUR TOPICS / BOXES


METHOD
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Learning Objectives
Differentiate personal moral code from clinical
ethics
Convey the important of conflicting principles in
bioethical decision making

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THE NIJMEGEN METHOD


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HOWARD BRODY CASCADE


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ETHICS IN EMERGENCY SITUATION


USING HOWARD BRODY CASCADE
Emergency medicine have the unique aspect

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Brought-in not deliberately >>> not patients


decision
Cant choose physician >>> less confidence and
trust
Lack of time >>> less chance to make informed
decision
No time to consult other physician >> no time for
reflection, deliberation and consultation
Less controlled environment >>> less private and
sensitive relationship with patient

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THE POSSIBLE CAUSE OF ETHICAL


PROBLEMS IN EMERGENCY
SITUATION

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WHAT ARE THE CONSEQUENCES OF


UNSOLVES ETHICAL PROBLEM?
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Immediate
- patients or families complaint >> ethical and legal
problem
- under pressure situation >> unproffesional conduct
- poor tem work >> institution performance
Long term
- moral burden
- no reference for future case
- legal consequences
- decrease community trust

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1.
2.
3.

Traditional approach
Triage
Exception to general rules
Bypass the ethical dilemmas of emergency care
altogether

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HOW DO WE APPROACH ETHICAL


PROBLEMS IN EMERGENCY
SITUATION?

Unsolved ethical problems


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STRATEGY SOLVING MEDICAL


ETHICS

Lexical
- solve the ethical problems by making priority
- make several list which have contributor to the
problem ( by different method)

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Prima facie
- solve the most critical point in ethical problem

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PROBLEM PERCEPTION
Should you give critically ill patient the
potentially upsetting information she has
requested?

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LIST ALTERNATIVES
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Tell the patient the truth


Deny knowledge of her husband condition
Lie
Iqnore the question
Use delaying statement
dont worry about that right now, just rest..

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LIST THE ETHICAL VALUES AND


IMPORTANT INTEREST AT STAKE
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Beneficence
Non-maleficence
Patient self determination
Patient well being
Self-improvement
Fidelity
fairness

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CHOSE1 ALTERNATIVES
Alternatives:
1. telling her that the husband is ok
2. deny knoledge of her husband condition

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FRAME AN ETHICAL STATEMENT

1st , answer 3 basic ethucal questions:


1. what ought to be done
2. who ought to do it
3. under what conditions ought the action to be done

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Example of ethical statement:


when critically ill patient request information
about persons who are either critically ill or dead,
and you are aware of the informatib, deny any
knowledge about other patients
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LIST CONSEQUENCES 1
1.
2.
3.

4.

Immediate consequences
Patient will not receive information she does not
really want
The patient will not be depressed ad so her
recovery will be speeded
The physician will not encounter hostility as the
bearer of bad news and so will continue to enjoy
the patients trust
The patient will not begin to adjust to the present
reality

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LIST CONSEQUENCES 2
1.
2.
3.
4.

Long range consequences


Very ill patients begin to distrust physicians
Physician will lie more frequently to patients
Legal action is taken againts physician to prevent
type of falsification
Critically ill patients will cease to ask potentially
upsetting questins just before being admitted to
surgery

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COMPARES CONSEQUENCES WITH


VALUE
TOPIC TASKS
Homework
Speed up recovery VS patients right of self
Hand writing determination
Must be collecting
maximum on
Test for consistency
Friday, september
19th 2014, before 10
Inconsistent
consistent
am
( at mas Hasan
Revised or re-do
valid ethical
office, 6th floor)

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judgement

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CASE 1
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Sirkumsisi lazim dilakukan di Indonesia karena


sebagian besar pendudukan menganut agama Islam.
(khitan atau sirkumsisi atau dorsumsisi sebenarnya
tidak hanya dilakukan oleh umat muslim, tetapi juga
agama Yahudi. Dalam ajaran yahudi, sirkumsisi
sangat dianjurkan dilaksanakan pada hari ke7
setelah kelahiran.
Saat ini keluarga muslim dan Yahudi yang tinggal di
USA merasa khawatir tidak dapat melaksanakan
ajaran agama mereka karena Surgeon general telah
memutuskan bahwa tindakan sirkumsisi adalah
tindakan yang ethical. Keputusan ini diambil
setelah mempertimbangkan berbagai aspek dari
pasien (anak). Menurut sebuah penelitian di US pada
laki-laki yang telah disirkumsisi, sebagian besar
responden mengatakan bahwa kepuasan seks
berkurang setelah sirkumsisi

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2.
3.

Apa sekiranya pertimbangan dari surgeon


general memutuskan bahwa sirkumsisi adalah
unethical prosedure?
Dalam dilemma ini, menurut saudara prinsip
apa yang bertentangan?
Bagaimana saudara bersikap terhadap dilemma
tersebut?

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CASE 2

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Dr Y adalah seorang dokter spesialis muda, memiliki


prestasi akademil luar biasa. Dia ditunjuk menjadi dosen
pembimbing klinis 3 orang koass/DM saat periode stase
bangsal. Koas-koas tersebut berkewajiban untuk follow
up pasien dan harus mengetahui perkembangan penyakit
pasiennya. Salah satu koas A malas-malasan
memeriksa pasien, bahkan ada pemeriksaan penunjang
yang batal dilakukan karena keteledoran koas A. Dr Y
menegur koas A atas perilakunyaa. Ternyata Koas A
adalah anak salah satu senior konsulen di RS tersebut
dan koas A mengadukan drY kepada ayahnya (dr K)
sehingga kemudian dr Y ditegur oleh dr K
1. Bagaimana sikap anda sebagai dr Y dalam kasus
tersebut
2. Dr Y mempunyai kewajiban membimbing koas agar
mempunyai kompetensi yang ditentukanm jika koas
dibiarkan maka khawatir akan membuat pasien menjadi
terlantar, bagaimana sikap anda menyikapi hal ini?
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FORENSI
C