ETHICAL DILEMMA,

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CONFLICT OF
INTEREST AND
SOLUTION

Eriko Prawestiningtyas, dr, Sp.F

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

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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
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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)

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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 6
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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 people’s 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?

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1. Health is not a moral matter but working for
health as a moral action
2. When values are conflicting, to what
principles can health workers assent their
answers?
3. 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

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 Emergency medicine have the unique aspect

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THE POSSIBLE CAUSE OF ETHICAL
PROBLEMS IN EMERGENCY SITUATION

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 Brought-in not deliberately >>> not
patient’s decision
 Can’t 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
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patient
WHAT ARE THE CONSEQUENCES OF
UNSOLVES ETHICAL PROBLEM?

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 Immediate
- patient’s 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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HOW DO WE APPROACH ETHICAL
PROBLEMS IN EMERGENCY
SITUATION?

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 Traditional approach
1. Triage

2. Exception to general rules

3. Bypass the ethical dilemmas of emergency

care altogether

Unsolved ethical problems

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STRATEGY SOLVING MEDICAL ETHICS

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

 Prima facie
- solve the most critical point in ethical
problem
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PROBLEM PERCEPTION

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 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

“ don’t 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

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

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FRAME AN ETHICAL STATEMENT

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 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

 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” 35
LIST CONSEQUENCES 1

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 Immediate consequences
1. Patient will not receive information she does
not really want
2. The patient will not be depressed ad so her
recovery will be speeded
3. The physician will not encounter hostility as
the bearer of bad news and so will continue
to enjoy the patient’s trust
4. The patient will not begin to adjust to the
present reality
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LIST CONSEQUENCES 2

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 Long range consequences
1. Very ill patients begin to distrust physicians

2. Physician will lie more frequently to patients

3. Legal action is taken againts physician to

prevent type of falsification
4. 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

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• Homework
Speed up recovery VS patient’s right of self
• Hand writingdetermination
• Must be collecting
maximumTest on for consistency
Monday,0ctober
5th 2015
Inconsistent consistent
(mas Hasan)
Revised or re-do valid ethical
judgement

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CASE 1
Sirkumsisi lazim dilakukan di Indonesia karena
sebagian besar pendudukan menganut agama

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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
“unethical’. 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 39
berkurang setelah sirkumsisi
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1. Apa sekiranya pertimbangan dari
surgeon general memutuskan
bahwa sirkumsisi adalah
unethical prosedure?
2. Dalam dilemma ini, menurut
saudara prinsip apa yang
bertentangan?
3. Bagaimana saudara bersikap
terhadap dilemma tersebut? 40
CASE 2
Dr Y adalah seorang dokter spesialis muda,
memiliki prestasi akademik luar biasa. Dia

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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 41
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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