issu etis dalam keperawatan2

ISSU ETIS DALAM ISSU ETIS DALAM KEPERAWATANKEPERAWATAN

ISSU ETIS DALAM ISSU ETIS DALAM KEPERAWATANKEPERAWATAN

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 Tujuan pembelajaran

1. Mendefinisikan etik dan etika keperawatan

2. Mengidentifikasi dilema etis yg sering terjadi

3. Menguraikan strategi membantu dalam membuat keputusan etis

Introduksi 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.

Definisi istilah 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 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 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 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 distressKetidak 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 TheoriesEthical 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.

Teori Etik Klasik Teori Etik Klasik

1. Teleologi

2. Deontologi

3. Etik kebajikan

4. Etik pluralisme

1. Teleologi 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 ModelThe Kantian Model

Central insight: people cannot be treated like mere things.

Key notions:• Autonomy & Dignity

• Respect

• Rights

2. Deontologi 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 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 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 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 CareEthics 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.

Prinsip etika umum 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 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 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 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 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 keperawatanJenis masalah etis keperawatan

1. Kerahasiaan

2. Restrein

3. Hubungan saling percaya

4. Kematian dan sekarat

5. Menolak perawatan

Ethical DilemmaEthical Dilemma

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

Lanjutan 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.

Ethical Decision MakingEthical 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 Trial-and-Error Decision MakingDecision Making

Reflect for a minute on Reflect for a minute on how how you make decisions…you make decisions…


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?


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 IssueEthical Issue

Euthanasia Refusal of Treatment Scarce Resources

EuthanasiaEuthanasia

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

action)

EuthanasiaEuthanasia

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 TreatmentRefusal 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.

Scarce ResourcesScarce 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 NursingEthics 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.

Ethics and NursingEthics 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 ModelEthical Decision-Making Model

Assessing the outcome of moral actions;“Were the actions ethical?”

“What were the consequences?”

EVALUATION

Carrying out selected moral actions

IMPLEMENTATION

Consideration of priorities of claims;Generation of alternatives for resolving the dilemma;Consideration of the consequences of alternatives

PLANNINGANALYSIS AND DIAGNOSIS

Problem identification: Statement of the ethical dilemma

ASSESSMENT

Determination of claims and parties

Web Resources,Web Resources,22

Before I Die With Bill Moyers

http://www.pbs.org/wnet/bid/




Web Resources, 3Web Resources, 3

The End of Life: Explaining Death in America http://www.npr.org/programs/death/

http://www.npr.org/programs/death/

What is a good death?What is a good death?

Jeremy Bentham.Hedonistic utilitarians: a good

death is a painless death.

Eudaimonistic utilitarians: a good death is a happy death.

John Stuart Mill

Appendix 1Appendix 1From whole to partsFrom whole to parts

Person

Soul

Mind

Body

Priest,Minister

Rabbi

Doctor

Psychologist

ENTOphthalmologist

UrologistOncologist

Psychiatrist

Appendix 2Appendix 2Stakeholders in the Decision-making ProcessStakeholders in the Decision-making Process

End-of-life decisions involve more than the patient and the physician.

PatientPhysician

Patient’sFamily

Insurer/HMO

Lanjutan 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 Lanjutan

5. Menolak perawatan

- Konflik nilai

- Takut cedera

- Keterasingan

- Takut biaya

Pembuatan keputusan etis 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


E V A L U A TIO NE va lu a tion o f ou tcom e o f m ora l ac tion s

"W ere th e ac tion s e th ica l? " "W h at w ere th e con seq u en ces? "

IM P L E M E N TA TIO NC arryin g ou t se lec ted m ora l ac tion s

P L A N N IN GC on s id era tion o f p rio rit ies o f c la im s

C on s id era tion o f con seq u en ces o f a lte rn a tives

A N A L Y S IS & D IA G N O S ISId en tifica tion o f p rob lem : S ta tem en t o f e th ica l d ilem m a

A S S E S S M E N TD ete rm in a tion o f c la im s an d p art ies

An Exciting TimeAn Exciting Timefor Ethicsfor Ethics

New technologies

Policy vacuums

Ethical & legal quandaries

Lanjutan 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 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 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

Lanjutan 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 appropriateTo make appropriateethical decisions: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.

The MORAL Decision Making ModelThe MORAL Decision Making Model (Crisham, (Crisham, 1985)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 Murphy and Murphy (1976) Approach to Ethical Problem SolvingProblem 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 ActionEthics 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 The following forces ensure that ethics will become an even greater dimension in management decision even greater dimension in management decision

making in the future: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.

Accountability of NursingAccountability of Nursing

Nurse is answerable, responsible, & liable for the services he or she provides or makes available.

State licensureNurse Practice ActPatient’s Bill of RightsCode of Ethics for Nurses

Nursing ResearchNursing Research

Patient’s Bill of Rights

Informed Consent

Other Ethical IssuesOther Ethical Issues

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

Preventive EthicsPreventive Ethics

Advance Directives*Living Will*Durable Power of Attorney for Health

Care

Institutional Ethics Committees

Patient Care Conferences

Ethics Literature

DefinitionsDefinitionsHIV/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 Why Study HIV-related Stigma and Discrimination in Asia?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

AimAim 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

issu etis dalam keperawatan2

Documents