ASPEK ETIKOLEGAL ILMU KEDOKTERAN UNTUK
PENANGGULANGAN COVID-19
Agus Purwadianto
Anggota MKDKI
Gurubesar I.K.Forensik & Medikolegal FKUI/RSCM ESB XXV KARS
29 JANUARI 2021
▪ Ketua Dewan Pertimbangan Klinis
▪ Ketua Asosiasi Peneliti Kesehatan Indonesia (APKESI)
▪ Ketua Perkumpulan Profesi Kesehatan Tradisional dan Komplementer Indonesia (PPKESTRAKI)
▪ Anggota Dewan Pakar KARS
▪ Ketua Prodi Spesialis Ilmu Kedokteran Forensik & Medikolegal FKUI/RSCM
▪ Ketua Dewan Pertimbangan ILUNI UI
▪ Wakil Ketua Komisi Bioetika Nasional
▪ Anggota Kompartemen Litbang PERSI
▪ Anggota MKDKI, MKEP Himpenindo
▪ Anggota Komnas KIPI
▪ Anggota Komnas Saintifikasi Jamu
▪ Gurubesar I.K. Forensik & Medikolegal (07)
▪ Doktor Filsafat UI (03); Msi Sosio-Kriminologi UI (00)
▪ SpF (konsultan etiko-medikolegal) (05)
▪ Diplome of For.Med Groningen Univ (02); SH (97), SpF (83), dr (79)
Agus Purwadianto
Pembahasan
• Etikolegal : perspektif & implikasinya
• Temuan lapangan & pemilahan filosofis peran RS dalam kategorisasi
permasalahan Covid-19
• Pemetaan masalah sesuai 4 pilar ilmu
kedokteran : pangkal – potensi - refleksi
• KDB dimensi makro & uraiannya
• Argumen kerumahsakitan
• Kesimpulan
Perspektif Etikolegal
• Menyorot kaitan etika dan hukum krn etika – disiplin – hukum sebagai continuum.
• Bertolak dari [panggilan tugas → suara hati insan individu & sosial] korsa kedokteran sbg penyandang trias tanggungjawab pemberi
layanan dok/kes berdasarkan keluhuran
martabat profesi dalam menggunakan semua sumberdaya untuk pelayanan prima termasuk mencegah/mengurangi kekeliruan/KTD
sehingga bermanfaat dalam praktik kedokteran lege artis ketika menghadapi kasus konkrit.
Pengertian implikatif praktis
• Medikolegal/legal (dasar yuridis)
– Gunakan peraturan yg (sudah) ada (dibuat oleh penguasa/pejabat sah masa lalu) sbg “payung hukum”
• Etikolegal
– Membuat peraturan baru berbasis etika (oleh
penguasa/pejabat sah masa kini utk kepentingan masa depan), krn peraturan lama sdh tak memadai akibat perkembangan iptek, masyarakat
dunia/lokal, kapital, dll pada saat hadapi kasus.
– Bila telah disahkan : menjadi medikolegal masa depan
Pandemic situations
• Multi-contextual, multi dimensional and moral conflict par excellence → need immediate,
simultaneous, comprehensive and best rational decision of concrete health care cases from
bureaucrats/HC facilities/practitioners and society
– Super-emergency vs elective, global vs individual, state vs citizen; national vs local; pluralism vs
singularism; e-health vs traditional health; derivative vs classical medicine; poor vs rich; (medico)legal vs ethicolegal etc
From global to local approach → best for studying THE FUTURE TREND OF ETHICS
BIOETHICAL ASPECT
ADE FIRMANSYAH SUGIHARTO, 2020 7
PROBLEMATIKA LAPANGAN
8 ADE FIRMANSYAH SUGIHARTO
Persoalan Etikolegal
• Pasien terpaksa tidak jujur sbg OTG/ODP
• Asuransi komersial menolak membayar karena alasan akan dibiayai Pem
• Perbedaan tarif RS dengan paket pemeriksaan
• Praktik telemedisin & medsos
• Pemilahan sayap pelayanan Covid vs non Covid
• Validasi terapi dan diagnostik versi
Perhimpunan
Themes of interest (1)
• Vulnerabilities & inequalities – stigma &
discrimination, social determinants of health, structural inequalities, vulnerable populations, global health justice
• Resource allocation – approaches to allocating scarce health-related resources within pandemic contexts
(including vaccines & therapeutics, personal protective equipment, and clinical care for a range of health needs)
• Political responsibilities – preparedness & public health responses, solidarity & collective interests,
individual interests & rights, policy-making, corruption
• Containment approaches – including population-wide
& targeted requirements for physical distancing, isolation
& quarantine, proposals for immunity certifications
• WHO Ethics & PHEPREN (Public Health Emergency Preparedness and Response)- 2020
Themes of interest (2)
• Surveillance & monitoring – including the use of digital technologies i.e. apps and algorithms to monitor and model population movements and COVID transmission patterns
• Engagement & communication – participatory approaches &
access to reliable information, information needs, miscommunication
& misinformation, competing discourses, social media & infodemics
• Health systems – clinical ethics, public health ethics, MEURI &
emergency use of unproven clinical interventions outside research, health-worker interests & responsibilities
• Data & sample sharing – sharing pathogen samples, genomic, pathogen, research, clinical, epidemiological & surveillance data, and research methods & outputs
• Research prioritisation & oversight – accelerated research pathways, approaches to ethical and regulatory review, including strengthening local ethics review, community & participant interests, dissemination & publication
• WHO Ethics & PHEPREN (Public Health Emergency Preparedness and Response)- 2020
Isu Etikolegal Yang Perlu Diwaspadai Manajer RS
• Epistemologi, aksiologi, ontologi RS
– Epistemologi : wadah interkolaborasi seimbang ilmu kedokteran terapan
– Aksiologi : penjunjung tinggi martabat kemanusiaan khususnya manusia yg perlu ditolong
– Ontologi : markas besar penyembuh sakit & penyakit
Agus Purwadianto, 2020
RS & 4 Pilar Ilmu Kedokteran
Patogenesis; resiliensi tubuh; komorbid, lonjakan kapasitas, solidarity trial, revisi
pedoman D/ & Th/
ARUS UTAMA KES:
PHBS+protokol;
EUA, imunisasi, klaim dana, fraud,
pulasara, dll
UU No 20 Th 2013 ttg Pendidikan Kedokteran
Virulensi Virus C- 19; mudah mutasi
& sebar; daya tahan di benda;
Ro number;
Ragam Test, herd immunity, otoritas
kesmas, Keseimbangan
[Kes – ekonomi];
Takut, stigma, Norma Perilaku
Adaptasi
Kehidupan Baru RS = integritas penolong;
“pemanusiaan” manusia Agus Purwadianto, 2020
Peran RS Mengatasi Pangkal Masalah Pandemi Covid-19
• Biomedik:
– Lab uji klinis in vitro: site of solidarity trial, pharmacovigilance EUA – Disclaimer test (penyaring vs penentu)
• Klinis:
– Pemutakhiran standar/pedoman in vivo, terkait klaim, rujukan lonjakan kapasitas
• Kesmas:
– Penjaga gawang (3T), perub perilaku 3M + IAI
• Bioetika/Humaniora-kes:
– Ekses litigious society ec marah; oligarki
Nakes/fasyankes bermasalah & konflik etikolegal
•
biomedik Dok Klinis
Bioetika / Humaniora
Kes
Kesmas/
Komunitas
Diagnosis:
• Perubahan kriteria
• Klinis vs
Mikrobiologis/patklin
• Pasca vs Pra RT- PCR/TCM
Berbahaya : OTG
PSBB/Protokol Kes: fasum, fas-vital, lokasi rentan:
• Ftatenning the curve Syarat Program kesmas:
• Data, Manajemen
Otoritas, Teknologi praktis (prevent, detect,
response)
Promkes interkolaboratif
• (investasi kes jangka panjang)
Big data sbg satu data set
• Prima facie KDB pandemik vs HAM
• Habituasi“baik”
kelelahan anomikvs
• Etikolegal / hukum
responsif/progresif vs hukum stagnan
• Perlindungan vs penugasan nakes
Biomedik
reduksionistik Biomedik
holistik
Peran RS Mengatasi Potensi Masalah Pandemi Covid-19
Agus Purwadianto, 2020
Refleksi Bioetik Ttg Covid-19 – Kategori Biomedik
Pilar Ilmu Kedoktera n
Ciri Obyek Kajian Klaster Kajian/
Refleksi
Jenis 1 Jenis 2 Jenis 3 Jenis 4 Jenis 5
1 IlmuBiomedi
k
Kedokteran Preklinik/
penunjang, Mempelajari Agen,vector, Obat dan alat In vitro
overviews and
provocation s;
“ We” Are In This Together, But We Are Not One and the Same, Rosi Braidotti
The New Fear of One Another,
Alphonso Lingis
Interview: Mourning Is a Political Act Amid the Pandemic and Its Disparities, Judith Butler and George Yancy
The Appointment in Samarra: A New Use for Some Old Jokes, SlavojŽižek
Extract
Untuk Menaklukkan Alam
Umumnya Tataran mikro,
global perspective s;
Humiliating
Whistle-Blowers:
Li Wenliang, the Response to Covid-19 and the Call for a Decent Society, Jing-Bao Nie and Carl Elliott
Rethinking the Central Role of Equity in the Global
Governance of Pandemic Response,
Oghenowede Eyawo and A.M. Viens Extract
Science at Warp Speed: Medical Research, Publication, and Translation During the COVID-19 Pandemic, Wendy
Lipworth, Melanie Gentgall, Ian Kerridge, and Cameron Stewart
Learning Lessons from COVID-19 Requires Recognizing Moral Failures, Maxwell Smith and Ross Upshur
[1]https://bioethicalinquiry.com/symposium-social-and-ethical-implications-of-the-covid-19-pandemicpart-1/ ePub ahead of print, August 25, 2020.
2IlmuKedokt
eran Klinis
Individu sakit
Penyembuh an
Pengobatan Tataran mikro
clinical implicat ions;
An Ethics
Framework for Making Resource Allocation
Decisions Within Clinical Care:
Responding to COVID-19, Angus Dawson, David Isaacs, Melanie Jansen,
Christopher
Jordens, Ian Kerridge, Ulrik Kihlbom, Henry Kilham, Anne Preisz, Linda Sheahan, George Skowronski
Building an Ethics
Framework for COVID-19 Resource Allocation:
The How and the Why, Angus Dawson
Systems of Care in Crisis:
The Changing Nature of
Palliative Care During COVID- 19, Michael Chapman, Beth Russell,
Jennifer Philip Extract
Family
Presence for Patients and Separated Relatives
During COVID- 19: Physical, Virtual, and Surrogate, Teck Chuan Voo, Mathavi Senguttuvan, Clarence C.
Tam
Refleksi Bioetik Ttg Covid-19 – Kategori Klinis/Spesialistis
[1]https://bioethicalinquiry.com/symposium-social-and-ethical-implications-of-the-covid-19-pandemicpart-1/ ePub ahead of print, August 25, 2020.
Covid – Bioetika & Humaniora Kes
• Penghargaan thd nilai kemanusiaan: segera mandiri, gubah peradaban, kawal kemajuan iptekdokkes, >< ketergantungan LN
• Isu kemanusiaan:
– Tingginya kematian Dr & nakes : >< konflik etleg – Pasien mati di kendaraan, tak bisa masuk RS – Penolakan jenazah & pukul/usir nakes RS
– Konflik larangan mudik, pembebasan napi,
pembukaan sekolah/bioskop, sebagian WFO, fenomena “semangka”, telemedisin dll
Micro level Clinical medicine
The Scope of ethics in Medicine
Macro level
Politics of Health Meso level
Health services delivery Macho level
Health care teams
Principle-based Ethics
+ approriate theory Ethics + value clarification
Social ethics Role Model
Inspiring Guiding Enabling
Cultural transmission (Role model) only, Paternalism era
New concept
Previous concept
THREE PILLARS OF MEDICAL ETHICS MANAGEMENT
PRIVATE GOODS PUBLIC GOODS
Agus Purwadianto, 2009
Substantive principles
• Utility : act so as to produce the greatest good
• Efficiency : minimize the resources needed to produce an objective; maximize the total benefit from a given level of resources
• Fairness : treat like cases alike & avoid unfair discrimination (due to irrelevant & illegitimate characteristics of person/group)
• Liberty : impose the least burden on personal self-determination necessary to achieve
legitimate goals = “do not trade all freedom for security”
Capron, 2006
Public Health Emergency Ethics i.e. Covid-19 pandemic
Moral Consideration of PH Goals
• Producing benefits
• Avoiding,.
Preventing, removing harms;
• Maximizing utility
Justficatorycondition for PH intervention
• Effectiveness
• Proportionality
• Necessity
• Least infringement
• Public Justification
Justification principles for PH interventions
• Protection of vulnerable populations
• Least restrictive / coercive
alternatives/means
• Reciprocity
• transparency
Childress et al, 2002 Childress et al, 2002 Gostin, 2005 Ability to balance Benefits – Risks of Ethical Choices & it’s Consequences of:
Officials : competent to make professional-bioethical-decisioned public policy & implementing it for public welfare
People : society which full of well informed & balance person Eubios Declaration for International Bioethics, 2005
Safeguard
Plan Guide
Agus Purwadianto, 2020
BIOETHICS principles & PH Intervention During Pandemic Covid-19
Beneficence Autonomy
Non
Maleficence
Justice
BENEFIT SHARING Human rights
General
Agus Purwadianto, 2020
Isolation Quarantine
of symptomatic Social-distance Measures
Travel restriction Border control EQUITY
FAIR PROCESS RECIPROCITY
Distributive/
Global Justice Do No Harm
UTILITY/
EFFICIENCY
PROPORTIONALITY SOLIDARITY
TRANSPARENCY Fair innings
arguments Necessity
Palliative care
Vulnerables OBLIGATION TO HCW ACCESS TO HEALTH CARE OBLIGATION OF HCW
& COUNTRIES & NGO
Modified from Nuffield Council on Bioethics:
Public Health: Ethical Issues, 2007 & Capron 2006
BIOETIKA KESEHATAN
AGUS PURWADIANTO - 2018
• Disiplin (ilmu pengetahuan campuran IPA-IPS/bud) baru pencerah, penggerak nilai, tekad SUPER-tanggungjawab
& perilaku profesional korsa TENAGA & SDM KESEHATAN, secara individual atau kolektif, dlm menyelenggarakan setiap komponen SISTEM
KESEHATAN NASIONAL sebagai pengabdian profesi yg menjamin keselamatan/ kepentingan terbaik pasien/klien, tercapainya kesehatan masyarakat ideal berkelanjutan
dan terinformasikan, ditengah kemajuan iptekdokkes dalam keseimbangan & keserasian tatanan lingkungan kehidupan setempat/nasional menuju peradaban,
kesejahteraan & perdamaian global yang abadi.
Agumen Komprehensif Kesehatan & Ekonomi dll
ILMU KEDOKTERAN : Biomedik – Klinis –
Kesmas – Bioetika &
Humaniora Kes Kesmas :
Prom-Prev-Kur-Rehab-Paliatif Politik Kes:
Pengarus-utamaan, Advokasi Upaya Kepemerintahan
Medikolegal Covid-19
Kepmenkes NOMOR HK.01.07/MENKES/413/2020 Pedoman Gah-dal Covid-19
Pandemik : the law of non composeable of law
– Pencapaian mission driven Pemerintah
• cepat tanggap menyelesaikan masalah kesehatan
& ekonomi
– Non birokrasi
– Penguatan integritas (moral based regulation, Kant)
– Perluasan kewenangan Pem namun juga mengawasi sendiri
• Mengimbangi Gugus Tugas yg eksekutif
• Guntur Hamzah, 2020
Guntur Hamzah, 2020
Kesimpulan
• Perspektif etikolegal merupakan salah
satu pendekatan penting dalam efektivitas
& efisiensi kategorisasi masalah pandemic Covid-19 yang kemudian memerlukan
regulasi responsif bidang Kesehatan.
• Manajer RS dengan bekal pemahaman
etikolegal mutakhir berbasis filosofi pilar
ilmu dan etika level makro & meso akan
mendongkrak peran etiko-medikolegalnya
sebagai pembuat kebijakan publik RS
SAYA UCAPKAN TERIMA KASIH
