KAIDAH DASAR BIOETIKA &

PRIMA FACIE

Yuli Budiningsih, Agus Purwadianto

Fakultas Kedokteran Universitas Kristen Krida Wacana
Definition:
 THE DISCIPLINE DEALING WITH WHAT IS
GOOD AND BAD AND WITH MORAL DUTY
AND OBLIGATION (Webster’s).
 ETHICS OFFERS CONCEPTUAL TOOLS TO
EVALUATE AND GUIDE MORAL DECISION
MAKING
 MEDICAL ETHICS IS A DISCIPLINE /
METHODOLOGY FOR CONSIDERING THE
IMPLICATIONS OF MEDICAL TECHNOLOGY /
TREATMENT AND WHAT OUGHT TO BE (Univ
of Washington School of Medicine)
 Ethics can be described as a sub-branch of
applied philosophy that seeks ‘what are the
right and the wrong, the good and the bad
set of behaviours in a given circumstance’

 Bioethics is a quasi-social science that offers

solutions to the moral conflicts that arise in
medical and biological science practice.

 The Four Principles of Bioethics in 13th Century Muslim Scholar Maulana’s

Teachings,Sahin Aksoy,Faculty of Medicine,Dept Med Ethics & History of
Medicine,Turki.
 Ethics is :
the study of morality – careful and
systematic reflection on and analysis of
moral decisions and behaviour, whether
past, present or future.

Morality is :
the value dimension of human decision-
making and behaviour.
 Since ethics deals with all aspects of
human behaviour and decision-making, it
is a very large and complex field of study
with many branches or subdivisions.

 Medical ethics is the branch of ethics

that deals with moral issues in medical
practice.

 Medical ethics is closely related, but not

identical to, bioethics (biomedical ethics).
Medical ethics focuses primarily on issues
arising out of the practice of medicine.

Bioethics is a very broad subject that is

concerned with the moral issues raised by
developments in the biological sciences
more generally.
 The study of ethics prepares medical
students to recognize difficult situations
and to deal with them in a rational and
principled manner.

 Ethics is also important in physicians’

interactions with society and their
colleagues and for the conduct of medical
research.
 From Hippocrates came the concept of
medicine as a profession, whereby
physicians make a public promise that
they will place the interests of their
patients above their own interests.
 Inrecent times medical ethics has been
greatly influenced by developments in
human rights.

 Ina pluralistic and multicultural world,

with many different moral traditions, the
major international human rights
agreements can provide a foundation for
medical ethics that is acceptable across
national and cultural boundaries.
 Moreover, physicians frequently have to
deal with medical problem resulting from
violations of human rights, such as forced
migration and torture.
 Medical ethics is also closely related to
law.
 In most countries there are laws that
specify how physicians are required to
deal with ethical issues in patient care
and research.
 In addition, the medical licensing and
regulatory officials in each country can
and do punish physicians for ethical
violations.
Different ways of approaching
ethical issues:

• Non rational : Rational:

• 1.obedience 1.Deontology
• 2.imitation 2.consequentialism
• 3.feeling 3.principlism
• 4.intuition 4.virtue ethics
• 5.habit
Principles of Bioethics
= Kaidah Dasar Bioetik:
Consist of 4 principles:
1. Beneficence
2. Non Maleficence
3. Autonomy
4. Justice
Derivative principles : confidentiality, truth
telling, informed consent, privacy,
promise keeping, honesty.
Context

 Beneficence : do good, altruism, the best

practice for the patient
 Non maleficence: do no harm
 Autonomy: right to self determination
 Justice: fairness, equality
The World Medical Assembly in 1999:
Physicians gathered there, representing
medical associations from around the world,
decided, “to strongly recommend to Medical
Schools worldwide that the teaching of
Medical Ethics and Human Rights be included
as an obligatory course in their curricula.
Modern healthcare has given rise to
extremely complex and multifaceted ethical
dilemmas. All too often physicians are
unprepared to manage these competently.
This subject is specifically structured to
reinforce and strengthen the ethical mindset
and practice of physicians and provide tools
to find ethical solutions to these dilemmas. It
is not a list of “rights and wrongs” but an
attempt to sensitise the conscience of the
physician, which is the basis for all sound
and ethical decision-making.
As physicians, we know what a privilege it is to
be involved in the patient-physician relationship,
a unique relationship which facilitates an
exchange of scientific knowledge and care within
a framework of ethics and trust.

In recent times, this relationship has come

under pressure due to resource constraints and
other factors, and it shows the necessity of
strengthening this bond through ethical
practice.
The module of ethics helps prepare medical
students and physicians to better navigate
through the many ethical challenges we face in
our daily practice and find effective ways
TO PUT THE PATIENT FIRST.
According to these definitions, ethics is
primarily a matter of knowing whereas
morality is a matter of doing.

Their close relationship consists in the

concern of ethics to provide rational criteria for
people to decide or behave in some ways
rather than others.
 WHY STUDY MEDICAL ETHICS?

Ethics is and always has been an essential

component of medical practice. Ethical principles
such as respect for persons, informed consent
and confidentiality are basic to the physician-
patient relationship.
However, the application of these principles in
specific situations is often problematic, since
physicians, patients, their family members and
other healthcare personnel may disagree about
what is the right way to act in a situation.
Medicine is both a science and an art.
Science deals with what can be observed and
measured, and a competent physician recognizes
the signs of illness and disease and knows how to
restore good health.

But scientific medicine has its limits, particularly

in regard to human individuality, culture, religion,
freedom, rights and responsibilities.
The art of medicine involves the application of
medical science and technology to individual
patients, families and communities, no two of
which are identical.

By far the major part of the differences among

individuals, families and communities is non-
physiological, and it is in recognizing and dealing
with these differences that the arts, humanities
and social sciences, along with ethics, play a
major role. Indeed, ethics itself is enriched by
the insights and data of these other disciplines.
The ethical directives of medical associations
are general in nature;they cannot deal with
every situation that physicians might face in
their medical practice. In most situations,
physicians have to decide for themselves what
is the right way to act, but in making decisions,
it is helpful to know what other physicians
would do in similar situations.

Medical codes of ethics and policy statements

reflect a general consensus about the way
physicians should act and they should be
followed unless there are good reasons for
acting otherwise.
Fact:

Physicians in clinical decision-making tend to

only take the medical decisions while
ignoring the ethical aspect.
Medical or ethical case?
Tergopoh-gopoh spt ini, benar atau tidak ?
Kalau yang ini 1 dari ratusan
korban tsunami, lumpur panas ?? (di luar RS >>)
 Value - Norm
Value
 Not concrete (no empirical-observational
facts)
 subjective
◦ (basic/motivation of will, idea, hope and
internal judgment/mind of human
behavior/action explicitly or tacitly

Norms
 Concrete
 Value objectivation
 Values
 Pre-moral
◦ Not refered to specific concrete norm of human
action
 Moral
◦ Imperative of human to conduct or to refer
specific action of concrete norm;
 Moral philosophy :
 Normative ethics : the answer of
◦ ”how we value the most legitimate norm in the
cluster of norms?
◦ What’s behind (the foundation of) legitimate norm
(de jure) as well as existing norm (de facto)
 Praxis E. : the answer of
◦ “what is the means/instrumental to human action,
whatever his condition is?”
Morality = basic moral attitude
 The paradigm of the good/truth in the
community/society
 The most fundamental of basic and
strongest law
 The doing rights as maxim (principle)
 No deliberation
Example of morality :

a. Beliefs/religion norms
◦ Consist of teaching for human to be a wise n
understandable man (virtue ethics)
b. Prophetic Religion norms (theonomic
ethics).
 NORMS (:modernity)
 Ethics (narrow interpretation)
◦ Goals of the goodness of personal life or clearness/purity of
conscience (intra-personal principles).
 Law
◦ Goals of peaceful social life (inter-personal principles) after
socializing & enforcing determined-norms
 Etiquette
◦ Goals of harmony of social life, esp. physical aspect (inter-
personal principles)
 Religion/beliefs
◦ Goals of “akhlak”/good behavior purification & celestial (world
+ heaven) (intra-personal principles)
 Etika (ethics)
 normative (reflective/prescriptive E.,
deontological, das sollen, E as
science, moral philosophy)
◦ “what should I do?“
◦ = “ought”
◦ consicence
 Praxis (teleological E, das sein, ethics
as action/behaviour)
◦ “my action good or bad?”
◦ = “is”
◦ rights
Bioethics (F. Abel)

Interdisciplinary study of (ethical)

problems which arised from biological and
medical science & technological
development.
 Specific characteristic of
morality
 Very fundamental norm/principles : value
> “any other consideration/judgment”.
 Universal law (valid to whoever, whatever,
wherever etc) .
 Rational & objective norms
 Related with the happiness of others
eg : Golden Rule principle.
◦ All human have morality.
 Check list (Observation Sheets)
Beneficence Criterion Yes No

Promoting altruism
Guaranteeing human dignity
Viewing patient/family not as profit
objects
Maximize agregat net benefit
Compassionate paternalism
Guaranteeing minimal life of patient
Restricting “goal based approach”
Maximize patient satisfaction
Group No. Tutor’s name
 Check list (Observation Sheets)
Beneficence Criterion (2) Yes No

Maximize overall highest happiness
Continuing professional
development
Giving effective-low priced medicine
Applying Golden rule principle
Promoting patient’s best interest
etc

Group No. Tutor’s name

 Check list (Observation Sheets)
Non Maleficence Criterion Yes No

Helping emergency patient
Treating vulnerable patients
Not killing patient (no euthanasia)
Not humiliating/abusing patient
Not respect patient as object
Treating unproportionally
Not preventing patient from danger
Avoiding misrepresentation to P
Group No. Tutor’s name
 Check list (Observation Sheets)
Confidentiality Criterion Yes No

Not disclosing to friends/relatives
Careful waivers : duty/permission to warn
Careful relation about public figures
Prudent ommiting sensitive
information from medical record
Prudent action to 3rd parties &
public officials
Prudent action of partner
notification
Group No. Tutor’s name
 Check list (Observation Sheets)
Justice Criterion Yes No

Apply everything universally
Taking last portion when dividing
something
Giving P-with same position, similar
opportunity
Respect P’s rights : affordability,
equality, accessibility, availability,
quality)
Respect P’s legal rights
etc Group No. Tutor’s name
 Check list (Observation Sheets)
Justice Criterion Yes No

Respecting other’s rights
Caring the vulnerables (the least
advantage people)
Not abusing/discriminating
Wise in macro-allocation
etc
etc

Group No. Tutor’s name

 Check list (Observation Sheets)
Autonomy Criterion Yes No

Respecting self-determination
rights, supporting of P’s dignity
Not intervening decision making
process of the P (elective condition)
Truthfullness
Respect privacy
Confidentiality etc
Supporting P’s rationality
Compassionate informed consent
Group No. Tutor’s name
Keputusan Pilar Keputusan Klinis sehari2
Medis

-
Keputusan
etis
 Indikasi
Biomedik medik
Keputusan Pilar Keputusan Klinis sehari2
Medis

Info-
etis
-
Keputusan
medik

pilihan pasien
kualitas hidup
fitur kontekstual

Mindset non medis

Struktur Psiko-
Sosio-budaya
The Scope of ethics in Medicine

bioethics
Deduction
Macro level = logic

rights Politics of Health

justification Meso level

consci
ence Health services delivery
self
Macho level
reflection Health care teams
ethics
Micro level Induction
= casuistry
Clinical medicine
Concrete
Daily living
 Principles-based ethics 
Prima Facie
T.Beauchamp & Childress (1994) & Veatch (1989)

Patient’s preference

Beneficence
Autonomy

Non Maleficence Justice

Contextual features Clinical Decision

Making EBM
Quality of life

Value-based medicine
 VALUE-based = INTRINSIC MORALITY
Medical
theory of ethics
Indication

Beneficen Autonomy Justice

Non Maleficence
ce
principles bioethics morality

Method = ballancing of specification

rules = Logic + creative thinking =
Norms
(ballanced- critical analysis + wisdom
specific rules)

Combination of
Particular/ It’s characteristics = Patient’s Context
Concrete case

= Deductive logic
Method of justification
 Medical PRIMA FACIE = TRUMP
= change into .......
Indication

Beneficen Autonomy Justice

Non Maleficence
ce

pihak II capable pihak III

pihak II person Non pasien
kesakitan/
Umum bebas wakil/wali
menderita,
BAIK Elektif kluster pop
gadar,pra-cacat
“kranjang rentang >> Komunitas
Distress
Sampah” hak pilih a Penyandang
Rentan
uzur, // DRnya dana
terjepit Berpotensi
tanpa pilihan Dirugikan/
Miskin Paling krg
bodoh. diuntungkan
 Medical ENRICHMENT OF
JUSTIFICATION
Indication

Beneficen
ce Non Maleficence Autonomy Justice

(NEW) ILLAH = actual duty = contextuality

PRIMA
FACIE
CETERIS PARIBUS

DEDUCTIVE >< : DETECT

LOGIC DEVIATION
“OPPOSITION”
CREATIVE THINKING

Not stipulated in the text =

VALUE
Patient’s Context
CONFORM
TERGANTUNG …….  BERUBAH MENJADI
n Kemurnian niat = sikap moral tanpa
pamrih ?
n Kesungguhan kerja = tindakan baik &
adil ?
n Kerendahan hati = sopan
n Integritas ilmiah & sosial
= martabat profesi luhur (hormat diri
sendiri & adil)

Etika Dokter RI
Insight Core Problem
Keywords

Basic Beneficence
Nonmaleficence
Moral Autonomy
Justice
Principle
Metode AP
Metode AP

Prima Facie Context vs Text

Choose 1-2 out
of 4 most
Principle relevan
(problem
solving)

Ethics Virtue - eudamonia

Theory Duty - deontologist

Utilitarian –
teleologist eg
happiness
Metode AP

Ethical Culture
Custom
Relativism

Ethical Science &

technology
determinant
Dilemma Societal &
capital
determinant
Ceteris Choose 1 most
influential
Paribus principle

Ethical
Consistency

Problem Coherent
Corespondency
Solving Pragmatic

Metode AP
Metode AP

Legal Administrative
Penal

Option Civil