issu etis dalam keperawatan

ISSU ETIS DALAM
KEPERAWATAN
M.Fathoni, S.Kep, Ns.

Isu-isu etik khusus : hidup dan mati,
mempertahankan/mengakhiri pemberian makanan
dan minuman, mengakhiri bantuan kelangsungan
kehidupan, AIDS, AI (Avian Influenza) alokasi
sumber-sumber kesehatan
Tujuan pembelajaran
1.
2.
3.
Mendefinisikan etik dan etika keperawatan
Mengidentifikasi dilema etis yg sering terjadi
Menguraikan strategi membantu dalam membuat
keputusan etis
Introduksi
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Perkembangan IPTEK mempengaruhi perkembangan hidup
manusia
Isu Perinatal : skrening genetika, fertilisasi invitro,
pengambilan dan pembekuan embrio, operasi perinatal
Awal kehidupan : bayi prematur dg bantuan alat canggih, anak
dan dewasa transplantasi organ
Mixed blessing akibat peningkatan biaya
HIV / AIDS, Degeneratif dsb.
Definisi istilah
1.
Etika versus moralitas
- Etika studi filosofi moralitas
berdasarkan teori formal,
aturan, prinsip dan kode
prilaku untuk menentukan
bagian yg benar suatu
tindakan
- Etika studi lebih formal,
sistematik dari keyakinan
moral
- Moralitas menggambarkan
komitmen pribadi thd nilai
yg sering dipengaruhi norma
dan pengharapan
masyarakat
- Moralitas ketaatan thd
nilai personal informal
Pendekatan thd etik
1.
Etika non normatif
- Meta etik : konsep dan terminologi linguistik dalam etika :
“Baik , Kebajikan, Benar”
Contoh informed concent
- Etika deskriptif : Mengidentifikasi prilaku dan keyakinan
etis tanpa melakukan penilaian
(bersifat netral : Contoh antropologi, sosiologi)
Lanjutan
2. Etika normatif
- Filosofi moral yg “seharusnya/ sebaiknya”
- Proses penetuan tindakan moral dalam menjawab “apa yang
seharusnya saya lakukan dalam situasi seperti ini”
- Disebut juga etika normatif umum
- Jika dilakukan pada disiplin yg lebih spesifik disebut etika
terapan
Situasi moral
Kata lain :
 Situasi moral, delema moral, ketidak pastian moral,
distres moral
 Delema terjadi konflik yg nyata antara dua atau lebih
prinsip moral yg saling berkompetisi “ the lesser of
two evils”
 Contoh Px sakit parah mentaati kesucian hidup, orag
lain menganggap memperpanjang penderitaan
Ketidak pastian moral & moral distress

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Delema perawat ketidak pastian moral
- Lansia dg pembedahan tidak mengalami kemajuan
- Px tidak siap dipulangkan
Distress moral
- Kebijakan RS, Px menanyakan Apakah sayan
menderita kanker ? Dr, kluarga tidak
menginformasikan I
Ethical Theories
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Teleology - the value of a situation is determined by its consequences.
Deontology - the intrinsic significance of an act itself as the criterion
for the determination of good.
Situational Theory - holds that there are no set rules or norms. Each
situation must be considered individually.
Caring-Based Theory - focuses on emotions, feelings, and attitudes.
Teori Etik Klasik
1.
2.
3.
4.
Teleologi
Deontologi
Etik kebajikan
Etik pluralisme
1. Teleologi

Telos (yunani) = akhir, yang penting memperhatikan
hasil akhir/konsekwensi dari tindakan (
Konsekuensialisme)
a. Utilitarisme (kemanfaatan) terbaik bagi yg
terbanyak
- John Stuart Mill “ prinsip kebahagian
terbesar”
The Kantian Model
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Central insight: people
cannot be treated like mere
things.
Key notions:
• Autonomy & Dignity
• Respect
• Rights
2. Deontologi
Deon (yunani) tugas/hak/ kewajiban (formalis)
 Pembenaran tindakan moral lebih penting dari pada
konsekwensi
 Imanual Kant(1785/1983) Moralitas dibangun niat baik
 Contoh seorang perawat yg lalai memberikan obat dan
melaporkan hanya karena takut tindakan hukuman jika
kesalahan tsb diketahui ketimbang kawatir efek yg
membahayakan maka perawat tidak bertindak dalam
perspektif moral
 Perspektif kan disebut monistik/ imperatif moral
(ketaatan satu prinsip (rasionalitas)
 Golden Role (memperlakukan orang lain seperti
memperlakukan diri sendiri.(respek kemanusiaan)

3. Etika kebajikan
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Sifat karakter individu (Aristotle dan Plato bahwa prilaku
morla berjembang sesuai perkembangan prilaku kabijakan.
“Saya harus menjadi apa” dari pada “Apa yang harus saya
lakukan”
Contoh kebajikan Keyakinan, harapan, cinta dan amal dalam
keagamaan”
Mewarnai etika normatif (kemurahan hati, kejujuran, keadilan)

4. Etik Pluralisme
Tergantung konteks “ lebih baik dari yang lain” dengan
mempertimbangkan beragam kerangka kerja
Pluralisme
 WD. Ross (Inggris, 1930) Prima facie (kondisional atau semua
hal lain yg serupa) dan eksistensi aktual(keberadaan)
 Contoh secara moral berkata bohong itu salah, namun kadang
membenarkan tindakan ini lebih mendesak karena menghindari
bahaya orang lain.
Prinsip etika secara mum
- Otonomi
-Kemurahan hati
- Kerahasiaan
-Efek ganda
- Kesetiaan
-Keadilan
- Non maleficence(tidak membahayakan)
- Paternalisme
-Respek Individu
- Kemulian hidup -Kejujuran
Ethics in Health Care
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Bioethics is the application of ethical principles to
health care.
Ethics affects every area of health care.
Ethics helps provide structure by raising questions
that ultimately lead to answers.
Prinsip etika umum
Otonomi :
- Peraturan diri, hak individu, privacy, pilihan, kemampuan
membuat pilihan yang bebas dari ekternal
2. Kemurahan hati
- Melakukan hal yang baik, penuh kebajikan, kebaikan dan
kemurahan
3. Kerahasiaan
- Privasi, tidak menyebarkan utk org lain
1.
Lanjutan
4. Efek ganda
- Tindakan dapat menghasilkan efek positif dan nengatif dg
kriteria :
a. Tindakan itu ssecara moral baik
b. Secara tulis berniat efek yang baik(efek buruk diramalkan
tapi tidak diminati)
c. Efek baik tidak diraih dg cara efek buruk
d. Terdapat keseimbangan proporsional yg baik dan buruk
5. Kesetiaan :
- Menepati janji (komitmen)
Lanjutan
6. Keadilan :
- Memperlakukan sesuai hak dan kewajiban
individu dan
sosial antara lain (Kesetaraan,
kebutuhan, upaya,
kontribusi masyakarakat, kebaikan, legal)
7. Non malificence :
- tidak membebankan utk mencegah dan
menyingkirkan bahaya
8. Paternalisme
- Bekerjasama utk kemurahan hati,
kesejahteraan /
kebutuhan orang lain,
mencegah keburukan
Lanjutan
8. Paternalisme
- Bekerjasama utk kemurahan hati,
kesejahteraan /
kebutuhan orang lain,
mencegah keburukan
9. Respek utk individu :
- Mengotimalkan dan memampukan orang lain membuat pilihan
10. Kemuliaan hidup :
- Eksistensi biologis harus lebih penting diatas kriteria ekternal
11. Kejujuran
- Kewajiban mengatakan yg benar, tidak bohong, tidak menipu
orang lain
Domain etika keperawatan
1.
2.
3.
4.
Memberikan perawatan berkesinambungan
Tidak memandang penyakit /status sosial
Bertangung jawab
Bertindak sesuai kode etik profesi
Jenis masalah etis keperawatan
1.
2.
3.
4.
5.
Kerahasiaan
Restrein
Hubungan saling percaya
Kematian dan sekarat
Menolak perawatan
Ethical Dilemma

Defined as making a
choice between two
or more equally
undesirable
alternatives
Lanjutan
Kerahasiaan
- Informasi Dx. Medis, keperawatan, diskusi Px ditempat
tertutup
2. Restrein (penggunaan pengikat)
- efek keselamatan, agitasi/bingung, menanyakan anggota
kluarga /relawan
3. Hubungan saling percaya
- Kejujuran, tidak berbohong kepada pasien, informasi yg
jelas prosedur dan diagnosa keperawatan,
mengkomunikasikan pada kluarga dan dokter permintaan
pasien akan informasi.
1.
Ethical Decision Making

Ethical Reasoning
• Thinking through what one ought to do in an orderly,
systematic manner
• Justification of actions based on principles
Trial-and-Error
Decision Making
Reflect for a minute on how
you make decisions…
Ethical Decision Making

Framework for Ethical Decision Making
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•
•
•
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Which theories are involved?
Which principles are involved?
Who will be affected?
What will be the consequences of the alternatives?
What does the client desire?
Ethical Decision Making
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Steps of Ethical Analysis
•
•
•
•
Gathering of relevant data to identify the problem
Consideration of all the people involved
Selection of a course of action
Evaluation of the resolution process
Ethical Issue
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Euthanasia
Refusal of Treatment
Scarce Resources
Euthanasia
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“Good or gentle death”
Mercy killing (deliberate ending of life as a humane
action)
Euthanasia

Active euthanasia is taking deliberate action that will
hasten the client’s death.
• Assisted suicide is a form of active euthanasia.

Passive euthanasia is the omission of an action that
would prolong dying.
• Discontinuing the client’s tube feedings is a form of passive
euthanasia.
Refusal of Treatment
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The client’s right to refuse treatment is based on the
principle of autonomy.
A client’s right to refuse treatment and the right to die
challenge the values of some health care providers.
Scarce Resources
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The availability of specialists and organs, is
contributing to a scarcity of resources.
The use of expensive services is influenced by social
and political forces.
Health care reform is needed to ensure services to all.
Ethics and Nursing
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Professional nurses’ actions are both legal and ethical.
Sound nursing practice involves making ethical
decisions.
Ethics affects nurses in every health care setting.
Ethics and Nursing

Ethics Committees
• One approach for facilitating dialogue regarding ethical
dilemmas

Nurse as Client Advocate
• Nurses are accountable for protecting the rights and
interests of the client.
Ethical Decision-Making Model
ANALYSIS
ASSESSMENT
AND DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
ProblemAssessing
identification:
Consideration
Determination
Carryingthe
outoutcome
Statement
selected
ofofpriorities
claims
of
moral
of
moral
and
of
the
claims;
actions
parties
ethical
actions;dilemma
Generation of“Were
alternatives
the actions
for resolving
ethical?”the dilemma;
Consideration
“Whatofwere
the consequences
the consequences?”
of alternatives
Web Resources,
2
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Before I Die
With Bill Moyers
http://www.pbs.org/wnet/bid/
Web Resources, 3
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The End of Life: Explaining Death in America
http://www.npr.org/programs/death/
What is a good death?
Eudaimonistic utilitarians: a
good death is a happy death.
John Stuart Mill
Jeremy Bentham.
Hedonistic utilitarians: a good
death is a painless death.
Appendix 1
From whole to parts
Soul
Person
Priest,
Minister
Rabbi
Mind
Psychologist
Body
Psychiatrist
ENT
Ophthalmologist
Doctor
Urologist
Oncologist
Appendix 2
Stakeholders in the Decision-making Process
Patient’s
Family
Physician
Patient
Insurer/
HMO

End-of-life decisions involve more than the patient and the
physician.
Lanjutan
4. Kematian dan sekaratul
maut Tidak ada yg dapat
dilakukan lagi
 Teknologi akan memperpanjang hidup perlu biaya
tinggi
 Fokus peran asuh
 Resustiasi
a. Dukungan hidup
b. Makanan dan cairan
c. Kontrol nyeri
Lanjutan
5. Menolak perawatan
- Konflik nilai
- Takut cedera
- Keterasingan
- Takut biaya
Pembuatan keputusan etis
1.
Pengkajian :
Situasi etis/moral dari masalah
a.Dimensi etis, hukum, profesional
- Apakah situasi mengandung masalah
moral (konflik prisip etis dan kewajiban
profesional)
- Apakah ada konflik prosedural (siapa yg
harus membuat keputusan, apakah ada
konflik pemberi asuhan, kluarga, px)
- Identitas orang terpenting yg terlibat dan
mempengaruhi keputusan
Ethical Decision Making
ASSESSMENT
Determination of claims and parties
ANALYSIS & DIAGNOSIS
Identification of problem: Statement of ethical dilemma
PLANNING
Consideration of priorities of claims
Consideration of consequences of alternatives
IMPLEMENTATION
Carrying out selected moral actions
EVALUATION
Evaluation of outcome of moral actions
"Were the actions ethical?" "What were the consequences?"
An Exciting Time
for Ethics

New technologies

Policy vacuums

Ethical & legal quandaries
Lanjutan
2. Perencanaan :
Kumpulkan informasi :
a. Fakta medis, pilihan pengobatan, Dx. Keperawatan, data
legal, nilai, keyakinan,
komponen keagamaan
b. Buat perbedaan antara faktual dan nilai /
keyakinan
c. Validasi kepastian pasien atau kurang kapasitasa membuat
keputusan
d. Indentitas informasi lain yg relevan
e. Identifikasi isu etis/ moral dan klaim persaingan
Lanjutan
3. Implementasi
a. Urutkan alternatif
Bedakan alternatif dg prinsip etis yg dapat diterapkan dan
kode etik profesi, dapat memilih salah satu atau keduanya
bandingkan :
Pendekatan utilitarisme
- Ramalkan konsekwensi dari alternatif
- Teliti nilai positi dan negatif tiap konsekwensi
- Pilih konsekwensi yg meramalkan nilai paling positif atau
yg terbaik bagi yg terbanyak
Lanjutan
Pendekatan deontologi (hak/kewjiban/alasan)
a.
Identifikasi prisip moral yg relevan
b.
Bandingkan alternatif dgn prinsip moral
c.
Bandingkan ke prinsip moral tingkat yg lebih tinggi
jika terdapat konflik
Lanjutankeputusan
4. Menentukan dan mengevaluasi
a. Tindakan apa yang terbaik dan tepat
secara
moral ?
b. Berikan alasan etis terhadap keputusan anda ?
c. Apa alasan etis dari keputusan anda
d. Bagaimana anda merespon terhadap
penalaran
keputusan anda ?
To make appropriate
ethical decisions:
The manager must use a
professional approach
that eliminates trial and
error and focuses on
proven decision-making
models or problemsolving processes.
The MORAL Decision Making Model (Crisham,
1985)
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M—Massage the dilemma.
O—Outline options.
R—Review criteria and resolve.
A—Affirm position and act.
L—Look back. Evaluate the
decision-making.
Murphy and Murphy (1976) Approach to Ethical
Problem Solving
1. Identify the problem.
2. Identify why the problem is an ethical problem.
3. Identify the people involved in the ultimate decision.
4. Identify the role of the decision maker.
5. Consider the short- and long-term consequences of each alternative.
6. Make the decision.
7. Compare the decision with the decision maker’s
philosophy of
ethics.
8. Follow up on the results of the decision to establish a baseline for
future decision making.
Another error made by
managers in ethical
problem solving is
using the outcome of
the decision as the sole
basis for determining
the quality of the
decision making.
Ethics in Action

In an era of markedly
limited physical, human,
and fiscal resources, nearly
all decision making by
nurse–managers involves
some ethical component.

“If a structured approach to
problem solving is used, data
gathering is adequate, and
multiple alternatives are
analyzed, even with a poor
outcome, the manager should
accept that the best possible
decision was made at that time
with the information and
resources available.”
The following forces ensure that ethics will become an
even greater dimension in management decision
making in the future:
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increasing technology, regulatory pressures, and
competitiveness among healthcare providers;
national nursing shortages;
reduced fiscal resources;
spiraling costs of supplies and
salaries;
and the public’s increasing distrust
of the healthcare delivery system and
its institutions.
Accountability of Nursing
Nurse is answerable, responsible, & liable for the
services he or she provides or makes available.
State licensure
Nurse Practice Act
Patient’s Bill of Rights
Code of Ethics for Nurses
Nursing Research

Patient’s Bill of Rights
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Informed Consent
Other Ethical Issues
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Quality of life vs. Sanctity of Life
Euthanasia
Withholding or withdrawing Tx.
Abortion
Allocation of Resources
Restraints
Informed Consent
Confidentiality
Preventive Ethics

Advance Directives
*Living Will
*Durable Power of Attorney for
Care

Institutional Ethics Committees
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Patient Care Conferences

Ethics Literature
Health
Definitions
HIV/AIDS-Related Stigma:
“a ‘process of devaluation’ of people either living with or
associated with HIV/AIDS”. (UNAIDS)
HIV/AIDS-related Discrimination: “Discrimination follows
stigma and is the unfair and unjust treatment of an individual
based on his or her real or perceived HIV status”. (UNAIDS)
Relations?
Stigma (marking/labelling) Discrimination (action)
Why Study HIV-related Stigma and
Discrimination in Asia?

Stigma and discrimination described as ‘the greatest
barriers’ to effective epidemic control

Asia described as “the next battlefield for AIDS”

Research gap
Aim
To provide a systematic situation
analysis of structural forms of HIV
related discrimination in selected
sites in six countries:
•
•
•
•
•
•
China (Beijing)
India (Trivandrum)
Indonesia (Bali & Jakarta)
Philippines (Manila)
Thailand (Bangkok)
Vietnam (Hanoi)
Terimakasih
Wassalam