Bioethics in Clinical Practice ;

Ethical Issues

Yati Soenarto
Chairs ;
-Center for Bioethics & Medical Humanities (CBMH)
-Pediatric Research Office (PRO),
Faculty of Medicine, Public Health & Nursing, UGM

Orientasi Bioetik dalam Praktek Klinis

Monday, June 24th, 2019
 Outlines

Introduction of Ethical Issues

Four Principles in Applying Ethics

Four Topics Chart

Cases
 Introduction of Ethical Issues

Ethical Issues:
A problem or situation that requires a person or organization to choose between alternatives
that must be evaluated as right (ethical) or wrong (unethical).

Clinicians must understand ethical issues such as: Clinicians mean:

• Informed consent Physicians, surgeon nurses, social
• Truth telling workers, psychologists, clinical ethicist,
• Confidentiality member of ethics committee, medical
• Privacy technicians, chaplains, and other
• The Distinction between research and clinical responsible for the welfare of patients.
care
• End-of-life care
Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical
Ethics: A Practical Approach To Ethical Decision in Clinical Medicine.
7th ed. Gavelston: Mc Graww Hill Medical.
 Respect for
Beneficence
Autonomy
A practitioner should act in the
Patient has the right to
Four
best interest of the patient
refuse/choose their treatment
Principles
In applying
Ethics in
Profession Justice
Non maleficence Concern the distribution of scarce
“first, do no harm” health resources, and the decision
of who gets what treatment

Beauchamp, Tom L and Childress James F. 2013. Principles of Biomedical Ethics. 7th ed. ed. New York. Oxford University Press.
THE FOUR TOPICS CHART
(Jonsen et al, 2010)
 Central to The Practical Application of Clinical Ethics

Reflect
Decide
and Act
Consider

Identify

Central to the practical application of clinical ethics is the ability to

identify and analyze an ethical questions and to reach a reasonable conclusion and
recommendation for action
Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
6
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suggested to
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problem
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the facts
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understand
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principles meet
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Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical Medicine. 7th ed.
Gavelston: Mc Graww Hill Medical.
 • MEDICAL INDICATION • PATIENT/ FAM. PREFERENCES

Principles of beneficence & non maleficence Principles of respect for other/ autonomy
1. Medical problems? 1. Good informed consent, understood?
1. Diagnosis 2. Goal of treatment? 2. Mentally capable, legally competent? 1. Patient
2. Treatment 3. Circumstances, medical treatment, non 3. Preferences of patients/ family stating 2. Family
indicated? 4. Patients expression before 3. Team
3. Prognosis
4. Probability of success of treatment? Appropriate surrogate
5. Benefited by medicine and nursing care, 5. Patient unwilling to medicine,
harm can be avoided? treatment?
QUALITY OF LIFE CONTEXTUAL FEATURES
Principles of beneficence, non maleficence & respect Principles of Justice & Fairness

autonomy 1. Conflict of interest?

2. Fairness preferences?
1. Medical treatment – physical, mental, social,
1. Before 3. Patient confidentiality?
deficit? 4. Financial factors? 1. Support system
2. During 2. Quality of life, before and after? 5. Allocations of scarce resources? 2. Cost availability
3. After 3. Providers evaluation? Bias? 6. Religious issues? 3. Special circumstance
4. Ethical issues & patient quality of life? 7. Legal issues?
5. Quality of life assessment – life treatment? 8. Research & education?
6. Plans & rationale? 9. PH issues?
(Jonsen, et al, 2010)
7. Legal & ethical status of suicide? 10. Interest of hospital? Effect or patient welfare?
 The Four Topics Chart
1. MEDICAL INDICATION
THE PRINCIPLE OF BENEFICENCE AND NON-MALEFICENCE:
• What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible?
Emergent? Terminal?
•What are the goals of treatment?
• In what circumstances are medical treatments not indicated?
• What are the probabilities of success of various treatment options?
• In sum, how can this patient be benefited by medical and nursing care, and how can harm be
avoided?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 1. MEDICAL INDICATION

• Medical Indications are those facts about the patients' physiological or

psychological condition that indicate which forms of diagnostic,
therapeutic, or educational interventions are appropriate.
• Beneficence and Non Maleficence are ethical principles which most
relevant to medical indications.
• Three ethical issues in which medical indications are particularly
prominent:
1. Nonbeneficial (or futile) treatment
2. Cardiopulmonary resucitation (CPR) and do-not-resucitate (DNR) orders
3. The Determination of Death
Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical Medicine. 7th ed.
Gavelston: Mc Graww Hill Medical.
 The Four Topics Chart
2. PATIENT PREFERENCES
THE PRINCIPLE OF RESPECT FOR AUTONOMY
• Has the patient been informed of benefits and risks, understood this information, and given consent?

• Is the patient mentally capable and legally competent, and is there evidence of incapacity

• If mentally capable, what preferences about treatment is the patient stating?

• If incapacitated, has the patient expressed prior preferences?
• Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 2. PATIENT PREFERENCES

• Express choices of the patient about their treatment, or the

decisions of those who are authorized to speak for the pa t i
e n t w h e n t h e p a t i e n t i s incapable of doing so.
• Reflect patients experiences, beliefs, values
• Principles of Respect for Autonomy
“Respect for persons affirms that each and every person has moral
value and dignity in his or her own right”

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 The Four Topics Chart
3. QUALITY OF LIFE
THE PRINCIPLES OF BENEFICENCE AND NONMALEFICENCE AND RESPECT FOR AUTONOMY
• What are the prospects, with or without treatment for a return to normal life, and what physical, mental and social deficits might the
patient experience even if treatment succeeds?
• On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a
judgement?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
• What ethical issues arise concerning improving or enhancing a patient’s quality of life?
• Do quality of life assesment raise any questions regarding changes in treatment plans, such as forgoing life-sustining treatment?

• What are plans and rationale to forgo life-sustaining treatment?

• What is the legal and ethical status of suicide?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 3. QUALITY OF LIFE

• Describes features of the patient’s life prior to and following

treatment.
• Refers to degree of satisfaction that people experience and value
about their lives as a whole and in its particular aspects, such as
physical health.
• Maslahat and Mudarat.
• Non maleficence shoud be considered first before Beneficence.
“The Principles of Beneficence and Nonmaleficence and
Respect For Autonomy”
Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 Diarrhea is a threat to a child’s quality of life
Updating the DALYs for diarrhoeal disease

Height Fitness I.Q.

Growth shortfalls of up to Fitness impairment scores Repeated episodes of

8.2 cm by age 7 years have are substantially reduced 4– diarrhoea in the first 2
been attributed to recurrent 6 years following recurrent years of life can lead to a
episodes of diarrhoea  episodes of diarrhoea during loss of IQ points2,3
2,3 and an

during early childhood1 early childhood2 additional 12 months of

DALY, disability adjusted life years
1. Moore et al. Int J Epidemiol 2001; 30: 1457–64; schooling by age 9 years
2. Guerrant et al. Am J Trop Med Hyg 1999; 61: 707–13;
3. Niehaus et al. Am J Trop Med Hyg 2002; 66: 590–3

Locally Rooted, Globally Respected www.ugm.ac.id

 The Four Topics Chart
4. CONTEXTUAL FEATURES
THE PRINCIPLES OF JUSTICE AND FAIRNESS
• Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?

• Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
• What are the limits imposed on patient confidentiality by the legitimate interest of third parties
• Are there financial factors that create conflicts of interest in clinical decision
• Are there problems of allocation of scarce health resoursces that might affect clinical decision
• Are there religious issues that might affect clinical decisions?
• What are the legal issues that might affect clinical decisions?
• Are there considerations of clinical research and education that might affect clinical decisions?
• Are there issues of public health and safety that affect clinical decisions
• Are there conflict interest within institutions and organizations (e.g., hospitals) that may affect clinical decisions and patient welfare

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical Medicine. 7th ed. Gavelston: Mc
Graww Hill Medical.
 4. CONTEXTUAL FEATURES

• The way in which professional, familial, religious, financial, legal, and

institutional factors influence clinical-decisions
• The principles of justice and fairness
• Justice Refers to Those moral and social theories that attempt to
distribute the benefits and burdens of a social system in a fair and
equitable way among all participants in the system.
• Fairness demands that transactions and relationship give to each
participant that which they deserve and reasonably expect. In addition,
it is obviously unfair to exploit by deceit, manipulation, or discrimination.
Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 Case: Informed Consent for HIV testing
(case by Lidwina Stefani MD, Pediatric Research Office Assistant)

CASE
Mr. H was brought to ER by his pregnant wife in unconscious
condition. The doctor in ER examined the patient and
suspected the patient had HIV-AIDS. The doctor decided to do
HIV testing immediately without any consent from the patient
and the family.
 RECOMMENDATION
WHO Consolidated Guidelines on HIV Testing Services 20151 said
that,”The 5Cs are principles that apply to all HIV Testing Service and in
all circumstances. 5Cs are: consent, confidentiality, counselling, correct
test result, and connection (linkage to prevention, treatment and care
service).”

Permenkes Republik Indonesia Nomor 74 tahun 20142

”Sekalipun dalam kondisi kritis (adanya penurunan kesadaran), tidak
dibenarkan dilakukan tes HIV tanpa persetujuan yang bersangkutan”
1. World Health Organization (WHO). HIV Testing Services: WHO Consolidated Guidelines. 2015
2. Peraturan Menteri Kesehatan Republik Indonesia Nomor 74 Tahun 2014. Pedoman Pelaksanaan Konseling dan Tes HIV
 Case Illustration (Patient Preferences)
(case by Galang Martin MD, Pediatric Research Office Assistant )

CASE
Mrs. A, a 35-year-old veiled woman, was brought to ER by her
husband and midwife with postpartum hemorrhage conditions
since 4 hours ago. Patient and her husband refused to be
examined by male medical personnel even though the
patient's condition was in an emergency. But at that time there
was no female general practitioner or specialist doctor.

20
 Recommendations
Professional ethics unequivocally supports competent adult
patients’ right to accept or decline any medical intervention,
even at risk of death.1 The clinician should assessed the legal
standards for decision-making capacity for consent to
treatment.1,2

1. Keirns CC, Goold SD. Patient-Centered Care and Preference-Sensitive Decision Making. JAMA, 2009;302(16): 1805-1806.
2. Appelbaum PS, M.D. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007;357:1834-40
 Case Illustration (Contextual Features)
(case by Yohanes Ridora MD, Pediatric Research Office Assistant)

CASE
Mr. D came into ER with a chief complaint of fever since yesterday,
without any other associated symptoms. Through a physical
examination, patient’s body temperature was 37.8°C. Since this was
not an emergency medical conditon, and the patient did not look
like a well-off person, the doctor decided to upcode the diagnosis to
Hyperpyrexia (≥41.1°C; an emergency condition), to get the health
insurance coverage for the treatment, thus the patient did not have
to pay.

*
22
 Recommendations
1. Peraturan Menteri Kesehatan RI No.27 Tahun 2014: A
hospital should not do upcoding intentionally to increase
payments to the hospital
2. Derlet RW, et al. (2016):
“Profiteering from excessive billing of our sick and injured who
seek treatment in EDs should be prohibited”

1. Peraturan Menteri Kesehatan RI No. 27 Tahun 2014

2. Derlet RW, McNamara RM, Plantz SH, Organ MK, Richards JR. Corporate and Hospital Profiteering in Emergency Medicine: Problems of the Past, Present, and Future. J Emerg Med
[Internet]. 2016;50(6):902–9
 References
• Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in
Clinical Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
• Beauchamp, Tom L and Childress James F. 2013. Principles of Biomedical Ethics. 7th ed. ed. New York. Oxford
University Press.
• World Health Organization (WHO). HIV Testing Services: WHO Consolidated Guidelines. 2015
• Peraturan Menteri Kesehatan Republik Indonesia Nomor 74 Tahun 2014. Pedoman Pelaksanaan Konseling dan Tes
HIV
• Keirns CC, Goold SD. Patient-Centered Care and Preference-Sensitive Decision Making. JAMA, 2009;302(16):
1805-1806.
• Appelbaum PS, M.D. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007;357:1834-
40
• Peraturan Menteri Kesehatan RI No. 27 Tahun 2014
• Derlet RW, McNamara RM, Plantz SH, Organ MK, Richards JR. Corporate and Hospital Profiteering in Emergency
Medicine: Problems of the Past, Present, and Future. J Emerg Med [Internet]. 2016;50(6):902–9
THANK YOU