ISSU ETIS DALAM KEPERAWATAN Mei Vita Cahya Ningsih
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
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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
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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)
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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
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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
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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Teori Etik Klasik
1.
Teleologi
2.
Deontologi
3.
Etik kebajikan
4.
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”
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The Kantian Model 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)
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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)
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.
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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
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.
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Prinsip etika umum 1. 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
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)
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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, keburukan
mencegah
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
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Domain etika keperawatan
1.
Memberikan perawatan berkesinambungan
2.
Tidak memandang penyakit /status sosial
3.
Bertangung jawab
4.
Bertindak sesuai kode etik profesi
Jenis masalah etis keperawatan
1.
Kerahasiaan
2.
Restrein
3.
Hubungan saling percaya
4.
Kematian dan sekarat
5.
Menolak perawatan
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Ethical Dilemma
Defined as making a choice between two or more equally undesirable alternatives
Lanjutan 1. 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.
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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…
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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?
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
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Ethical Issue
Euthanasia Refusal of Treatment Scarce Resources
Euthanasia
“Good or gentle death” Mercy killing (deliberate ending of life as a humane action)
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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
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.
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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.
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.
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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
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Web Resources, 2 Before I Die With Bill Moyers
http://www.pbs.org/wnet/bid/
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.
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Appendix 1 From whole to parts
Soul Person
Priest, Minister Rabbi
Mind
Psychologist
Body
Doctor
Psychiatrist ENT Ophthalmologist 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.
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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
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Pembuatan keputusan etis
1.
Pengkajian : Situasi etis/moral dari masalah a.Dimensi etis, hukum, profesional - Apakah situasi mengandung masalah prisip etis dan kewajiban profesional)
moral (konflik
- 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?"
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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
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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
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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 ?
To make appropriate ethical decisions:
The manager must use a professional approach that eliminates trial and error and focuses on proven decisionmaking models or problemsolving processes.
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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.
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. of
Consider the short- and long-term consequences 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.
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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.
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“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: 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.
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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
Informed Consent
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Other Ethical Issues
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 Health Care Institutional Ethics Committees Patient Care Conferences Ethics Literature
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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) (action)
Discrimination
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
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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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Terimakasih Wassalam
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