ISSU ETIS DALAM KEPERAWATAN

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1 ISSU ETIS DALAM KEPERAWATAN
M.Fathoni, S.Kep, Ns.

2 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

3 Tujuan pembelajaran Mendefinisikan etik dan etika keperawatan
Mengidentifikasi dilema etis yg sering terjadi Menguraikan strategi membantu dalam membuat keputusan etis

4 Introduksi 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.

5 Definisi istilah 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

6 Pendekatan thd etik 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)

7 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

8 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

9 Ketidak pastian moral & moral distress
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

10 Ethical Theories 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.

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15 Teori Etik Klasik Teleologi Deontologi Etik kebajikan Etik pluralisme

16 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”

17 The Kantian Model Central insight: people cannot be treated like mere things. Key notions: Autonomy & Dignity Respect Rights The second main model for understanding the moral life comes most directly out of Immanuel Kant, an eighteenth century German philosophy who emphasized the notions of respect, autonomy, and fairness. It is precisely this moral tradition which underlies the contemporary doctrine of informed consent. As I asked you to do when considering utilitarianism, I would ask you to think about the ways in which this model applies to your thinking as a physician in regard to end of life decisions. Kant drew a distinction that is diametrically opposed to the utilitarian standpoint. There are, he said, two classes of entities in the world: things and persons. Things have a price, can be bought and sold, are objects to be used. Persons, on the other hand, are not things; they cannot be merely used as objects. They must be treated as ends-in-themselves.

18 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)

19 3. Etika kebajikan 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)

20 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.

21 Prinsip etika secara mum
- Otonomi -Kemurahan hati - Kerahasiaan -Efek ganda - Kesetiaan -Keadilan - Non maleficence(tidak membahayakan) - Paternalisme -Respek Individu - Kemulian hidup -Kejujuran

22 Ethics in Health Care 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.

23 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

24 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)

25 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

26 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

27 Domain etika keperawatan
Memberikan perawatan berkesinambungan Tidak memandang penyakit /status sosial Bertangung jawab Bertindak sesuai kode etik profesi

28 Jenis masalah etis keperawatan
Kerahasiaan Restrein Hubungan saling percaya Kematian dan sekarat Menolak perawatan

29 Ethical Dilemma Defined as making a choice between two or more equally undesirable alternatives

30 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.

31 Ethical Decision Making
Ethical Reasoning Thinking through what one ought to do in an orderly, systematic manner Justification of actions based on principles

32 Trial-and-Error Decision Making
Reflect for a minute on how you make decisions…

33 Ethical Decision Making
Framework for Ethical Decision Making 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?

34 Ethical Decision Making
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

35 Ethical Issue Euthanasia Refusal of Treatment Scarce Resources

36 Euthanasia “Good or gentle death”
Mercy killing (deliberate ending of life as a humane action)

37 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.

38 Refusal of Treatment 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.

39 Scarce Resources 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.

40 Ethics and Nursing Professional nurses’ actions are both legal and ethical. Sound nursing practice involves making ethical decisions. Ethics affects nurses in every health care setting.

41 Ethics and Nursing Ethics Committees Nurse as Client Advocate
One approach for facilitating dialogue regarding ethical dilemmas Nurse as Client Advocate Nurses are accountable for protecting the rights and interests of the client.

42 Ethical Decision-Making Model
ASSESSMENT Determination of claims and parties ANALYSIS AND DIAGNOSIS Problem identification: Statement of the ethical dilemma Carrying out selected moral actions IMPLEMENTATION Assessing the outcome of moral actions; “Were the actions ethical?” “What were the consequences?” EVALUATION Consideration of priorities of claims; Generation of alternatives for resolving the dilemma; Consideration of the consequences of alternatives PLANNING

43 Web Resources, 2 http://www.pbs.org/wnet/bid/ Before I Die
With Bill Moyers

44 Web Resources, 3 The End of Life: Explaining Death in America

45 What is a good death? Eudaimonistic utilitarians: a good death is a happy death. John Stuart Mill What is a good death? One of the issues for utilitarians has been how you measure “good consequences.” What is the standard, the yardstick, in terms of which these can be measured? What is the scale that we can employ? Two standards have vied for supremacy in utilitarianism, and these two standard compete at well in how we understand what a good death is. John Stuart Mill, whom I mentioned earlier, said that happiness is the appropriate measure of consequences. In doing so, he was breaking from the work of his immediate predecessor, Jeremy Bentham. Bentham maintained that pleasure was the appropriate measure of consequences, and those alternatives that produced the greatest amount of pleasure were the right ones. Mill, despite his personal liking for Bentham (who was in fact his godfather), called this a “pig’s philosophy.” Pleasure, he maintained, was too gross, too bodily a standard for human beings; we must instead look to what produces happiness, not mere pleasure. This is, of course, a choice we face many times a day. If I want to fix my daughter the breakfast that will give her the most pleasure, sugar and chocolate would probably be the principal components. If I want to fix her a breakfast that will give her the most happiness, presumably a nutritionally more balanced alternative will result in more happiness. Or, even more bluntly, heroin give you pleasure, but it doesn’t give you happiness. This battle about standards plays itself out in regard to end of life decisions as well. Let me indicate one way. What is a good death? Those who think in terms of pleasure identify a good death as one that is without pain. Modern medicine can do a lot to eliminate, or at least reduce, pain. Those who think in terms of happiness view a good death as more than pain-free. The work of Elizabeth Kubler-Ross was pioneering in helping us to understand the stages of dying and to see what might be involved in a good death. Today hospice often leads the way in understanding what a good death is, and it goes far beyond the mere absence of pain. It often involves developing a sense of closure about one’s life, reconciliation with family, and peacefulness. Those utilitarians who see a good death along the pleasure-pain axis are, I think, most likely to think it is better just to “end someone’s suffering,” to put them out of their misery. The crucial concern is physical pain. One of this morning’s case studies, “It’s over, Debbie,” is an example of this. The resident’s concern was simply to end Debbie’s pain. Jeremy Bentham. Hedonistic utilitarians: a good death is a painless death.

46 Appendix 1 From whole to parts
Priest, Minister Rabbi Soul Person Mind Psychologist Psychiatrist ENT Ophthalmologist Urologist Oncologist Body Doctor

47 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.

48 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

49 Lanjutan 5. Menolak perawatan - Konflik nilai - Takut cedera
- Keterasingan - Takut biaya

50 Pembuatan keputusan etis
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

51 Ethical Decision Making

52 An Exciting Time for Ethics
New technologies Policy vacuums Ethical & legal quandaries

53 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

54 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

55 Lanjutan Pendekatan deontologi (hak/kewjiban/alasan)
Identifikasi prisip moral yg relevan Bandingkan alternatif dgn prinsip moral Bandingkan ke prinsip moral tingkat yg lebih tinggi jika terdapat konflik

56 Lanjutan 4. Menentukan dan mengevaluasi keputusan
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 ?

57 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 problem-solving processes.

58 The MORAL Decision Making Model (Crisham, 1985)
M—Massage the dilemma. O—Outline options. R—Review criteria and resolve. A—Affirm position and act. L—Look back. Evaluate the decision-making.

59 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.

60 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.

61 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.

62 “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.”

63 The following forces ensure that ethics will become an even greater dimension in management decision making in the future: 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.

64 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

65 Nursing Research Patient’s Bill of Rights Informed Consent

66 Other Ethical Issues Quality of life vs. Sanctity of Life Euthanasia
Withholding or withdrawing Tx. Abortion Allocation of Resources Restraints Informed Consent Confidentiality

67 Preventive Ethics Advance Directives Institutional Ethics Committees
*Living Will *Durable Power of Attorney for Health Care Institutional Ethics Committees Patient Care Conferences Ethics Literature

68 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)

69 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

70 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)

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74 Terimakasih Wassalam