Study Guide Medical Profesionalism Semester II Tayang 12 April 2016

~ CURRICULUM ~

Aims:

 Comprehend the central position of professionalism in contemporary medical practice

 Apply professionalism in the context of primary health care settings

Learning outcomes:

 Awareness of professional, moral, ethical and legal implications of medical practice  Comprehension of the significance of the three dimensions of professionalism

underlying contemporary medical practice

 Develop awareness and basic skill required to nurturing professional personal attributes: compassion, integrity, truthfulness, truth-worthiness, and lifelong commitment or habit to maintaining professional competence and standards

 Develop awareness and respect to the needs of a diverse patient population in terms of gender, belief/religion, education, ethnicity, and socio-cultural background  Differentiate between professional, moral and ethical issues

 Able to understand and explain about bioethics, bioethical theories, research ethics, clinical ethics, public health ethics, and biomedical ethics.

 Able to differentiate between ethics, discipline, and law.  Able to apply philosophy of medicine and PPKN in Bioethics.

 Apply the principles of biomedical ethics and ethical reasoning to formulate questions while making ethical-decision.

 Able to understand and explain about KODEKI and KODERSI in relation to bioethical theories and health care.

 Critically analyze ethical issues commonly encountered in medical practice.  Able to resolve ethical issues faced during common clinical scenarios.

Curriculum contents:

 Defining professional, moral and ethical issues

 The three dimensions/ components of medical professionalism

 Common educational strategies to nurture the development of affective behaviors  Basic principles and strategies of cross-cultural communication

 National and global legal systems governing medical practice

 The principles of moral and ethical reasoning, and ways to avoid pitfalls

 Skills related to applying the basic principles of professionalism in virtual or real patients

~ PLANNERS TEAM ~

NO NAME DEPARTMENT

1 dr. I.B. Alit, DFM. SpF. (Head) Forensic Medicine

2 dr. I W. Sugiritama,M.Kes (Secretary) Histology

3 Prof. Dr. dr. N. Mangku Karmaya, M.Repro Anatomy

4 Drs. Supriyadi, M.Si Psychology

5 dr. Dudut Rustyadi, Sp.F, SH Forensic Medicine

6 dr. Henky, Sp.F., M,BEth., FACLM. Forensic Medicine

7 DR. dr. Dyah Paramitha D. M.Kes Public Health

8 dr. A.A. Sagung Sawitri, MPH Public Health

9 dr. Ni Nengah Dwi Fatmawati Sp.MK, PhD Microbiology

10 dr. Kunthi Yulianti Sp.F Forensic Medicine

~ LECTURERS ~

NO

NAME DEPARTMENT PHONE

1 Prof. Dr. dr. N. Mangku Karmaya, M.Repro

Anatomy 0811387105

2 Drs. Supriyadi, M.Si. Psychology 08123606296

3 dr. A.A. Sagung Sawitri, MPH Public Health 0817340145

4 dr. Ida Bagus Alit, Sp. F Forensic Medicine 081916613459

5 dr. Dudut Rustyadi, Sp.F, SH Forensic Medicine 0818651015

6 DR. Dr. Dyah Paramitha D. M.Kes Public Health 0818357777

7 dr. Kunthi Yulianti Sp.F Forensic

8 dr. Henky, Sp.F., M,BEth., FACLM. Forensic Medicine 08123988486

9 dr. Ni Nengah Dwi

Fatmawati Sp.MK, PhD

~ FACILITATORS ~

Regular Class (Class A)

No Name Group Department Phone Venue (2nd

floor)

1 dr. I Putu Kurniyanta, Sp.An A1 Anasthesi 081805755222 2nd floor:

R.2.01

2 dr. I Putu Bayu Mayura, S.Ked A2 Microbiology 082236165801 2nd floor:

R.2.02 3 Dr. Luh Seri Ani, S.KM,M.Kes A3 Public Health 08123924326 2_R.2.03nd floor: 4 dr. Pratihiwi Primadharsini, _{M.Biomol, Sp.PD} A4 Interna 081805530196 2_R.2.04nd floor: 5 dr. I Gede Putu Supadmanaba,

S.Ked A5

Biochemistry 082146558748 2nd _floor:

R.2.05 6 dr. I Made Dwijaputra Ayustha,

Sp.Rad A6

Radiology 08123670195 2nd _floor:

R.2.06 7 dr. Ni Made Laksmi Utari, _{M.Biomed, Sp.M} A7 Opthalmology 081916513322 2_R.2.07nd floor: 8 Dr.dr. I G A Sri Mahendra Dewi,

Sp.PA(K) A8

Anatomy Pathology

081338736481 2nd _floor:

R.2.08

9 Dr.dr.Luh Made Mas

Rusyati,SpKK,FINSDV A9

Dermatology 081337338738 2nd _floor:

R.2.21 10 dr. Sari Wulan Dwi Sutanegara, _Sp.THT-KL A10 ENT 081237874447 2_R.2.22nd floor:

English Class (Class B)

No Name Group Department Phone ₍₂Venue nd _floor)

1 Dr. dr. I Wayan Putu Sutirta

Yasa, M.Si B1

Clinical Pathology

08123953344 2nd _floor:

R.2.01 2 dr. I G A Dewi Ratnayanti , _M.Biomed B2 Histology 085104550344 2_R.2.02nd floor: 3 dr. Luh Nyoman Alit Aryani, _Sp.KJ B3 Psychiatry 085737717244 2_R.2.03nd floor:

4 dr. I G A Artini, M.Sc B4 Pharmacology 08123650481 2nd floor:

R.2.04 5 dr. I Gst. Lanang Ngurah Agung

Artha Wiguna, Sp.OT (K) B5

Orthopaedy 0811388859 2nd _floor:

R.2.05 6 dr. I Made Oka Adnyana, Sp.S _(K) B6 Neurology 0817347697 2_R.2.06nd floor: 7 dr. Tjok. Istri Anom Saturti, _Sp.PD B7 Interna 081916253777 2_R.2.07nd floor:

8 dr. Herman Saputra, Sp.PA (K) B8 Anatomy

Pathology

081338981853 2nd _floor:

R.2.08

10 dr. I Made Sudipta, Sp.THT- KL B10 ENT 08123837063 2nd floor: R.2.22

~ TIME TABLE ~

DAY/

DATE _{English Class}TIME_{Regular Class} ACTIVITY VENUE CONVEYER

1

Tuesday 12-04-2016

08.00 – 08.15 08.15 – 09.15 09.15 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00

09.15 – 09.30 09.30 – 10.30 12.00 – 13.30 13.30 – 15.00 11.30 – 12.00 10.30 – 11.30 15.00 – 16.00

Introduction to the Block Lecture : Professional Personal Attribute Ind. Learning SGD Break Student Project Plennary Class room Class room -Disc. room -Class room Class room Alit Mangku K -Facilitator -Mangku K 2 Wednesday 13-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Bioethics

SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Henky Facilitator Henky -3 Thursday 14-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Bioethical Theories SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Henky Facilitator Henky -4 Friday 15-04-2016

08.00 – 09.00

09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00

10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Informed consent, confidentiality, Patient’s right & autonomy SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Alit Facilitator Alit -5 Monday 18-04-2016

08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00

09.00 – 10.00 12.00 – 13.30 13.30 – 15.00 11.30 – 12.00 10.00 – 11.30 15.00 – 16.00

Lecture : Awareness to diversity in medical practices Ind. Learning SGD Break Student Project Plennary Class room -Disc. room -Disc. room Class room D. Paramitha -Facilitator -D. Paramitha 6 Tuesday 19-04-2016

08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00

09.00 – 10.00 12.00 – 13.30 13.30 – 15.00 11.30 – 12.00 10.00 – 11.30 15.00 – 16.00

Lecture : Research Ethics Ind. Learning SGD Break Student Project Plennary Class room -Disc. room -Disc. room Class room Dwi Fatmawati -Facilitator -Dwi Fatmawati 7 Wednesday 20-04-2016

08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00

09.00 – 10.00 12.00 – 13.30 13.30 – 15.00 11.30 – 12.00 10.00 – 11.30 15.00 – 16.00

Lecture : Public Health Ethics Ind. Learning SGD Break Student Project Plennary Class room -Disc. room -Disc. room Class room Sawitri -Facilitator -Sawitri 8 Thursday 21-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Clinical Ethics

SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Henky Facilitator Henky

-9

Friday 22-04-2016

08.00 – 09.00 09.00 – 10.30 10.30 – 12.00 12.00 – 12.30 12.30 – 14.00 14.00 – 15.00

09.00 – 10.00 12.00 – 13.30 13.30 – 15.00 11.30 – 12.00 10.00 – 11.30 15.00 – 16.00

Lecture : Empathy

Ind. Learning SGD Break Student Project Plennary Class room -Disc. room -Disc. room Class room Supriyadi -Facilitator -Supriyadi 10 Monday 25-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Legal Aspect of Medical Practice SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Dudut Facilitator Dudut -11 Tuesday 26-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Medical Malpractice SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Dudut Facilitator Dudut -12 Wednesday 27-04-2016

08.00 – 09.00

09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 13.30 13.30 – 15.00

09.00 – 10.00

10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 13.00 – 14.30 14.30 – 16.00

Lecture : Legal Aspect of Medical Record, Medical Certification and Visum et Repertum SGD Plennary Break Ind. Learning Student Project Class room Disc. room Class room -Alit Facilitator Alit -13 Thursday 28-04-2016

08.00 – 09.00 09.00 – 10.00 10.00 – 11.00 11.30 – 12.00 12.00 – 14.00

09.00 – 10.00 10.00 – 11.00 11.00 – 12.00 12.30 – 13.00 14.00 – 16.00

Lecture : Medical Record

SGD Plennary Break Student Project Presentation (I,II) Class room Disc. room Class room -Class room -Kunthi Facilitator Kunthi -Lecturer

-BASIC CLINICAL SKILL 14

Friday 29-04-2016

08.00 – 09.00 10.00 – 13.00 13.00 – 15.00

09.00 – 10.00 13.00 – 16.00 10.00 – 13.00

Guest Lecture Student Project Presentation (III,IV,V) Ind. Learning Class room Class room -IDI Lecturer -15 Monday 02-05-2016

08.00 – 09.00 10.00 – 13.00 13.00 – 15.00

09.00 – 10.00 13.00 – 16.00 10.00 – 13.00

Lecture : Medical Certification and Visum et Repertum Writing Skill Training

Ind. Learning

Class room

- Forensic Team Forensic Team

Tuesday

03-05-2016 _{Preparation for Exam} Wednesday

04-05-2016 EXAMINATION _{Block Team}

Venue:

Lecture and Plenary session : Lecture Room 4.02, 4th floor

Group discussion : Discussion room of west wing 2nd _{floor, room with partitions}

~ MEETING OF STUDENT REPRESENTATIVES AND FACILITATORS

~

Meeting of student representatives and facilitators will be held on Friday 22nd _{April 2016.} This meeting will be organized by the planners and attended by lecturers, student group representatives and all facilitators. Meeting with student representatives will take place at

12.00 until 12.45 pm and meeting with the facilitators at 12.45 until 13.30 pm. The purpose of the meeting is to evaluate the teaching learning process of the Block. Feedbacks and suggestion are welcome for improvement of the Block educational programs.

~ STUDENT PROJECT ~

Student have to write a paper with topics that has been given by lecturer. The topic will be chosen randomly on day 1, each small group discussion should work one paper. Students make a paper as student project an will be presented in front of the class. The paper and the presentation will be evaluated by respectively facilitator and lecturer.

Format of the paper : 1. Cover :

Tittle Name

Student Registration Number

Faculty of Medicine, Udayana University 2016 2. Introduction

3. Content 4. Conclusion

5. References (minimal 3 refferences)

Note : 5-10 pages; 1,5 line spacing; Times new roman 12

~ ASSESSMENT METHOD ~

Cognitive assessment will be carried out on Wednesday 4th _{May 2016. The test will be} consist of 100 questions with 100 minutes provide for working. The assessment will be held at the same time for both Regular Class and English Class. SGD’s and student project’s mark will be include in the final score as describe below. The overall passing score requirement is ≥70. More detailed information or any changes that may be needed will be acknowledged at least two days before the assessment.

Skill assessment will be carried out at the end of the semester using Objective Structured Clinical examination (OSCE).

SGD will be reviewed every day by facilitator with a standard SGD assessment and it contributes 5% to final score. Student projects as a summative assessment account for 15% of the final score.

~ LEARNING PROGRAMS ~

Abstracts of Lectures

People come to physician for help with their most pressing needs-relief from pain and suffering and restoration of health and well being. They allow physicians to see, touch and manipulate every part of their bodies, even the most intimate. They do this because they trust their physicians to act in their best interests.

What constitutes a good doctor? Is technical proficiency sufficient to be a good doctor? Clearly, a physician cannot lack necessary technical knowledge and skills and still be a good doctor. Less clear is whether a technically proficient physician can lack interpersonal skills necessary to relate well to patients and still be a good doctor. The physician’s interpersonal skills are critical to establishing strong, trust-based physician-patient relationships that offer multiple benefits. Most physician-patients want a strong relationship with a primary care physician.

The quality of a patient’s relationship with a physician can affect not only a patient’s emotional responses but also behavioral and medical outcomes such as compliance and recovery. Consequently, physicians have been urged to improve their communication and patient education techniques, develop their empathetic abilities, encourage participative decision making, and convey respect and dignity.

Patients need good doctors. Good doctors make the care of their patients their first concern; they are competence, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.

Refferences :

1. Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 51-57

2. CMA. Professionalism in Medicine.2001

3. Bendapudi,N.M. et al. Patient’s Perspectives on Ideal Phsician Behaviours. Mayo Clin Proc.2006.81(3):338-344

Professional Personal Attribute

Prof. Dr. dr. N. Mangku Karmaya, M.Repro

Bioethics is the ethics of biological science and medicine. Bioethics concerns the ethical questions that arise in the relationships between biology, ecology, medicine, cybernetics, politics, law, philosophy, theology, and social science. It has a broad meaning, however in this lecture, the scope will be restricted to the areas of human life in which medicine and

the biomedical sciences can affect human well-being – for good or for ill.

Bioethics has a very long history. Ethical codes, such as the Hippocratic Oath and the Charaka Samhita Oath, has been applied in medical practice as a code of conduct since ancient times. In the nineteenth and early twentieth centuries the rapid expansion of biological sciences began to raise new questions about the possibilities for human progress and the potential conflicts between science and religion. Nevertheless, the birth and rapid development of modern bioethics came as a result of the atrocities of the Second World War, which brought us the ethics of medical research.

An even more potent influence came from the dramatic expansion of medicine’s capacity to save lives and either cure or prevent disease, through the production of a vast range of pharmaceuticals and vaccines, the refinement of life-saving medical technologies such as dialysis and heart-lung machines, and major improvements in surgical techniques. Yet, of course, every new advance brought fresh ethical problems. With the advent of organ transplantation, it became necessary to find a new definition of death – ‘brain death’ – so that the organs to be transplanted would remain viable; and the ability to keep people alive on machines did not necessarily mean that the quality of a patient’s life was improved or even maintained. Moreover, the massive commercial power of the transnational pharmaceutical and medical technology industries could also pose a major threat to health, through the medicalization of all human experience from birth to death. These phenomenon gave birth to clinical ethics.

Globally, The WHO has focused on justice in health care resources, as well as a recognition of the social determinants of ill-health – poverty, unemployment, lack of education and absence of adequate food, clean water and sanitation. The issues of breast feeding, tobacco use, HIV/AIDS, global pandemics, global warming and its detrimental effects on human health have entered into bioethical discussion as public health ethics.

Lastly, the exponential development of human genetics following the mapping of the human genome has raised some key questions about the determinants of human behavior, the potential for predicting disease and disability and the protection of human privacy. This has led to a broadening out of bioethics from a focus on health care and the clinical relationship to ‘biomedical ethics’, the study of the ethical implications of findings in the biosciences, particularly in genetics. References:

1. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

Lecture: Bioethics

Theory is an account of the world that goes beyond what we can see and measure. It embraces a set of interrelated definitions and relationships that organize concepts in a systematic way. The concept itself is defined as the terminological means by which bioethicists seek to analyse moral phenomenon, to classify the objects of the observed world, impart meaning through explanation to selected phenomena and formulate higher-order propositions of what we ought to do in given situations, what we take to be “good” or “bad”, “right” or “wrong”.

Theory is important because (1) It allows us to produce a “story” about how the moral world operates or should operate. It brings “order” to the “chaos” through generalizations and classifications of the moral, social and political universe, (2) It gives meaning and focus to moral inquiry or investigation. Theories offer a coherent strategy for thinking about moral phenomena, what we are doing or what we ought to do across time, space, and situations, (3) It sets the puzzles (“ethical dilemmas”) and standards for their solution. Once something has been identified as a bioethical dilemma or issue, theory shapes action that is taken to resolve the problem; (4) Bioethical theory seeks not only to make things intelligible, but to make them “better” by setting standards for behaviour. Ethical discourse is a codified body to abstract knowledge held by experts about the ‘good’ and ways to realize it, (5) Theory is a “box of tools” that suggest ways of looking at the world that can make the strange familiar; reveal taken-for-granted values, hidden moral premises, norms, intentions, that inform arguments and diagnosis.

Generally, bioethics focuses on normative and applied theories. In this lecture, some of popular approaches on normative and applied ethics will be disscused, including virtue theory, consequentialism, kantianism, communitarianism, libertarianism, and principlism.

References:

1. Irvine R. Critical Concepts in Bioethics (Lecture Notes). Sydney: The University of Sydney; 2013.

2. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press; 2013.

4. Hope T, Savulescu J, Hendrick J. Medical ethics and law: the core curriculum. 2nd ed. Edinburgh: Churchill Livingstone, 2008.

5. Kerridge IH, Lowe M, Stewart CL. Ethics and Law for the Health Professions. 4th ed. Sydney: The Federation Press; 2013.

6. Johnston C, Bradbury P. 100 Cases in Clinical Ethics and Law. 2nd ed. Boca Raton: CRC Press Taylor & Francis Group; 2016.

7. Kode Etik Kedokteran Indonesia (KODEKI); 2012.

Lecture: Bioethical Theories

dr. Henky, Sp.F., M,BEth., FACLM.

Base on Principles of Bioethics, Autonomy is one of principles that must be concern by the doctor. Autonomy is the rights to self determination and the patient not only the object of treatment but also has role in making decision. The doctor must respect to this rights because this rights is Human Rights for all person.

Patients are entitled to make decisions about their medical care and to be given relevant information on which to base such decisions. The physician's obligation to obtain the patient's consent to treatment is grounded in the bioethical principles of patient autonomy and respect for persons and is affirmed by Indonesian law and professional policy. A large body of research supports the view that the process of obtaining consent can improve patient satisfaction and compliance and, ultimately, health outcomes.

Physician must disclose relevant and detail information, so the patient can understand it clearly. Both elements are necessary for valid consent. Physician should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The physician’s goal is to disclose information that a reasonable person in the patient's position would need in order to make an informed decision. Therefore, physician may need to consider how the proposed treatment (and other options) might affect the patient's employment, finances, family life and other personal concerns. Physician may also need to be sensitive to cultural and religious beliefs that can affect disclosure.

The situation in which an adult lacks the capacity, for whatever reason, to make an informed decision is somewhat confused. Where a patient is suffering from a mental condition, he may be given treatment for his mental condition without consent. In emergency, such as an accident where the victim is unconscious or shocked, no permission is necessary and doctors must do as they think best for the patient in those urgent circumstance. Exceptions to the principle of informed consent also occur with regard to persons with impaired, such as children who are usually represented by a third party, such as parents or other close relatives, vis-à-vis the physician. Substitute decision-making poses two main questions: Who should make the decision for the incapable person, and, how should the decision be made? To answer these questions, physician should become familiar with the legal requirements.

Physicians are obliged to keep information about their patients secret. The understanding that the physician will not disclose private information about the patient provides a foundation for trust in the therapeutic relationship. Respect for confidentiality is firmly established in codes of ethics and in law. It is sometimes necessary, however, for physicians to breach confidentiality. Physicians should familiarize themselves with legislation governing

Informed consent, confidentiality,

Patient’s right & autonomy

the disclosure of certain kinds of information without the patient’s authorization. Even when no specific legislation applies, the duty to warn sometimes overrides the duty to respect confidentiality. The physician should disclose only that information necessary to prevent harm, and should reveal this information only to those who need to know it in order to avert harm. Whenever possible any breach of confidentiality should be discussed with the patient beforehand.

Concept of Autonomy, take place the patient in doctor - patient relationship in the proportional position. The doctor and patient have Rights and Interest that must be respected. The doctor has two kinds of duties : First the duties that caused by patient-doctor relationship (contractual bases) and second the duties that regulated by the regulations and Law (Tort Bases). Patient rights have recently become the centre of national attention in the practice of medicine. Patient rights encompass legal and ethical issues in the provider-patient relationship, including a person's right to privacy, the right to quality medical care without prejudice, the right to make informed decisions about care and treatment options, and the right to refuse treatment.

The purpose of delineating patient rights is to ensure the ethical treatment of persons receiving medical or other professional health care services. Without any exception, all persons in all settings are entitled to receive ethical treatment.

A patient's rights occur at many different levels, and in all specialties. The American Medical Association (AMA) outlines fundamental elements of the doctor-patient relationship in their Code of Medical Ethics. These rights include the following:

1. The right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives

2. The right to make decisions regarding the health care that is recommended by the physician

3. The right to courtesy, respect, dignity, responsiveness, and timely attention to health needs

4. The right to confidentiality

5. The right to continuity of health care

6. The basic right to have adequate health care

References :

 Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page 61-80

 Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page 81-96

 Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th ed. New York: Oxford University Press, 2008.

 Kode Etik Kedokteran Indonesia (KODEKI).

 Peraturan Menteri Kesehatan Republik Indonesia Nomor 290/MENKES/PER/III/2008 tentang Persetujuan Tindakan Kedokteran

 Shepherd, R. The Ethics of Medical Practice in Simpson,s Forensic Medicine. Twelfth Edition.2003. page 8-14

 Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 3-38

 Shepherd, R. The Ethics of Medical Practice in Simpson,s Forensic Medicine. Twelfth Edition.2003. page 8-14

 Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 3-38

 CMA. Professionalism in Medicine.2001

 Bendapudi,N.M. et al. Patient’s Perspectives on Ideal Phsician Behaviours. Mayo Clin Proc.2006.81(3):338-344

Culture consists of patterns, explicit and implicit, of and for behaviour acquired and transmitted by symbols, constituting the distinctive achievement of human groups. Culture is a human creation, which includes codes of behaviour, language, ritual, and systems of beliefs. The essential core of culture consists of traditional ideas and especially their attached values. So culture is learned, shared, ideas about and patterns of behaviour.

Values of culture influenced gender perspective. Unequality of gender perspective is different between countries. In higher-income countries women live longer than men. It is different conditions especially in lower-income countries, by gender discrimination, resulting in inequalities in education, income and employment, information and in access to health services. Moreover, the problems for women are especially severe in relation to sexuality and reproduction. However, although gender discrimination is more severe in low-and middle-income countries.

A society is an organized group of individuals with specific boundaries, or criteria, of membership. We will speak of both societies and cultures in terms of levels of inclusiveness (about gender as the cultural construction, values, norms, and belief). Factors inherent within a given culture are also likely to influence deeply the perception and definition of illness, and any consequent actions. Although this subject highlights the different influences on health and many of this factors are inter-related.

References:

1. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

2. Principles of Bioethics, Thomas R. McCormick, D.Min., Senior Lecturer Emeritus, Dept. Bioethics and Humanities, School of Medicine, University of Washington

3. Ross J.Taylor. et al. Health and Illness in the community. Oxford University Press. 2003

Empathy

Drs. Supriyadi, M.Si.

Awareness to diversity in medical practices

The origin of the word empathy dates back to the 1880s, when German psychologist Theodore Lipps coined the term "einfuhlung" (literally, "in-feeling") to describe the emotional appreciation of another's feelings. Empathy has further been described as the process of understanding a person's subjective experience by vicariously sharing that experience while maintaining an observant stance. Even more simply stated, empathy is the ability to "put oneself in another's shoes."

Effective empathetic communication enhances the therapeutic effectiveness of the doctor-patient relationship. Appropriate use of empathy as a communication tool facilitates the clinical interview, increases the efficiency of gathering information, improved health outcomes, better patient compliance, reduction in medical-legal risk, and improved satisfaction of clinicians and patients.

Empathy was known as "bedside manner," a quality considered innate and impossible to acquire. More recently, greater emphasis has been placed on empathy as a communication tool of substantial importance in the medical interview, and many experts now agree that empathy and empathetic communication are teachable, learnable skills.

Because empathy is such a powerful communication skill in medical practice, the clinicians would scramble to learn about and use it at every available opportunity.

Refferences :

1. Batmanabane, V.Empathy: A vital attribute for doctors. Indian Journal of Medical Ethics. 2008. 5(3) :128-129

2. Hardee, J.T. An Overview of Empathy. The Permanente Journal.2003.7 (4):51-54

Research ethics issues have been started since World War II in the Nuremberg City, Germany in 1945-1946, which introduced 10 principles that known as Nuremberg Code. The journey of research ethics were then continued by establishment of regulatory guidance documents, including the World Medical Association Declaration of Helsinki (World Medical Association); the Belmont Report share a common purpose: to protect the autonomy, safety, privacy, and welfare of human research subjects. The three primary ethical principles cited in Belmont are: autonomy, beneficence, and justice. All of the regulations agree with the same principles of research ethics protection of the research participant as paramount; independent ethical review; scientific validity of the research; fully informed and voluntary consent; and an acceptable balance of risks and benefits. In order to perform clinical research, responsibility for the interpretation and application of these ethical principles and regulations are the duties of committees comprised of scientist and non-scientists, called Institutional Review Boards for the Protection of Human Subjects (IRBs).

In doing research, the researcher should understand that they should maintain their integrity by providing reliable research data, and avoiding in doing fabrication, falsification, plagiarism, and false claims to authorship. Understanding research ethics and maintaining research integrity are keywords for researcher for their dignity in scientific field.

References:

1. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

Research Ethics

Achieving health for all is not easy. Government through the Ministry of Health

(MOH) have been conducting many health programs to increase the health status of

community. Health Program comprises several health activities that systematically

developed, being massively conducted, and usually compulsory. Health Program

uses the concepts of preventive medicine and health promotion. Preventive

medicine deals on how to prevent of control disease, while health promotion in

general is encouraging healthier life styles by persuasion, education and legislation.

Even though the goal of health program is good, to some limits there alwas

possibilities for a rising of ethical problems. This is because there is dilemma in term

of keeping the balance between the goods of society with the freedom of the

individual. Failure in balancing social justice or to fairly distributed the burdens and

benefits in society will lead to ethical issues in PH.

For example, screening program rise ethical issue due to uncertainty for the

test accuracy and whether these program should be done compulsory or optional.

Vaccination also lead to ethical issue due to some “free riders” and decision on it to

be compulsory or optional. Epidemic or pandemic control may reduce autonomy of

persons and make any harm to a lot of community members. Another example is the

implementation of “one child policy” in China, had also made serious problem not

limited to health and ethics. Despite the success of health program in making what

we think is better for human, we face another problem. One example is called

paradox of health care, a phenomena of a continuing demand following the

succesfull of one health program/activities and that outweighing the supply.

To maintain the ethical aspect in PH program, we need to distribute the

resources fairly in the macro, meso, and micro level. At the micro level, there is a

problem to prioritise fairly on who is to receive a given treatment when there are not

resources to treat everyone. Questions always rise on whether the rich person have

better access than the poor? Who should come first to access the health service?

Or Who shall live? Since health is not a luxury goods, ethical issue may rise when

we prioritise health program without un-clear concept. There are six principles to

allocate resources including equal share, according to individual choice, potential for

future life years, what they deserve, social usefulness, and their needs.

Another PH ethical issue is related to global inequity in health and the gobal

survival. The first term refer to the higher burden of morbidity and mortality in low

and middle income countries compare to the high income countries. While the global

survival questioning about the resources use by recent generation and what will be

left for the future generation.

References:

1. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

Public Health Ethics

Ethical issues are imbedded in every clinical encounter between patients and caregivers because the care of patients always involves both technical and moral considerations. The central feature of this clinical encounter is the therapeutic relationship between a physician and a patient, a relationship that is permeated with ethical responsibilities. Physicians must aim, in the words of Hippocrates, "to help and do no harm." Modern physicians approach the doctor– patient relationship with a professional identity that includes the obligations to provide competent care to the patient, to preserve confidentiality, and to communicate honestly and compassionately.

Clinical ethics is a structured approach to ethical questions in clinical medicine. Clinical ethics depends on the larger discipline of bioethics, which in turn draws upon disciplines such as moral philosophy, health law, communication skills, and clinical medicine. The scholars called "bioethicists" must master this field. However, clinicians in the daily practice of medicine can manage with a basic understanding of certain key ethical issues such as informed consent and end-of-life care. Central to the practical application of clinical ethics is the ability to identify and analyze an ethical question and to reach a reasonable conclusion and recommendation for action.

Bioethics identifies four ethical principles that are particularly relevant to clinical medicine: the principles of beneficence, non-maleficence, respect for autonomy, and justice. To these, some bioethicists add empathy, compassion, fidelity, integrity, and other virtues. The bioethical literature discusses these principles and virtues at length. In this lecture, a method to identify the ethical dimensions of patient care and to analyze and resolve ethical problems will be introduced. This method is useful for structuring the questions faced by any clinician who cares for patients. The method is called the four topics which constitute the essential structure of a case in clinical medicine, namely, medical indications, patient preferences, quality of life, and contextual features.

Medical indications refer to the diagnostic and therapeutic interventions that are being used to evaluate and treat the medical problem in the case. Patient preferences state the express choices of the patient about their treatment, or the decisions of those who are authorized to speak for the patient when the patient is incapable of doing so. Quality of life describes features of the patient's life prior to and following treatment, insofar as these features are pertinent to medical decisions. Contextual features identify the familial, social, institutional, financial, and legal settings within which the particular case takes place, insofar as they influence medical decisions

References:

1. Jonsen A, Siegler M, Winslade W. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 7th ed. New York: McGraw-Hill; 2010.

2. Campbell AV. Bioethics The Basic. Oxon: Routledge; 2013.

3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press; 2013.

4. Hope T, Savulescu J, Hendrick J. Medical ethics and law: the core curriculum. 2nd ed. Edinburgh: Churchill Livingstone, 2008.

5. Kerridge IH, Lowe M, Stewart CL. Ethics and Law for the Health Professions. 4th ed. Sydney: The Federation Press; 2013.

According to the Assembly of Indonesian Law of Health, Law of Health includes all regulation that is directly related to maintenance/services of health care and its’ application, which includes Civil Code, Criminal Code and Law of Administration. Law of Health is divided into two, direct and indirect.

Direct Law of Health is a law regulation that is directly related to maintenance of health, such as:

 Act Number. 29 Year 2004 concerns of Medical Practice  Act Number 36 Year 2009 concerns of Health

Indirect Law of Health includes all application of law regulation that is related to law specialization, such as: Civil Code, Criminal Code and Law of Administration which can be implied in maintenance/services of health care.

The purpose of Law of Health is to provide legal protection and assurance to both giving and receiving parties in health care services. Thus, Law of Health consists of:

• Medical/Dentistry Law

• Clinical Pharmacy Law

• Hospital Law

• Community Health Law

• Etc.

Medical Law is a Law of Health in a constricted meaning, which is also the core of Law of Health which regulates the medical services. The meaning of Medical Law is divided into a broad and constricted meaning.

Medical Law in the broad meaning is all the regulations in medical services, such as medical services provided by doctors, dentists, nurses, and laboratories.

Medical Law in the constricted meaning is all the regulations that only cover the doctor’s professions, such as:

• Doctor-patient relationship

• Medical Record and medical Confidentiality

• Informed Consent

• Medical malpractice

• Euthanasia

• Etc. Refferences :

1. Shepherd, R. The Ethics of Medical Practice in Simpson,s Forensic Medicine. Twelfth Edition. 2003.page 1-8

2. Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 39-49

3. Sanbar, S.S. et al. Legal Medicine and Health Law Education in : Legal Medicine. Sanbar, S.S. (Ed). 1998.Page 3-10

4. Piorkowski, J.D.Medical testimony and the expert witness in : Legal Medicine. Sanbar, S.S. et al (Ed.). 1998. Page 132-144

5. Wiradharma, D. Penuntun Kuliah Hukum Kedokteran. Page 25-35 6. Ohoiwutum, T. Bunga Rampai Hukum Kedokteran.page 1-13

Legal Aspect of Medical Practice

dr. Dudut Rustyadi, Sp.F, SH

In general, the understanding of criminal law is the law which legislate and control a human’s forbidden act and when this is disobeyed, the respected person will be charged according to law. A doctor is said to have done a criminal act when he/she breaks the rules stated in Indonesian Criminal Law (KUHP), and other laws, for an example, Law of Health.

A patient or his/her family’s dissatisfaction towards a medical care received from a doctor or a hospital can evoke a legal action. The legal action occurred perhaps not because of the mistake done by a doctor or the hospital, but because of the breach in medical ethics, medical disciplines, or even the criminal act and the medical malpractice itself. Occurrence of medical malpracticeis solely because of the doctor’s negligence which causes loss for the patient and his/her family. To prove a malpractice has occurred, there are two proving procedures or mechanism, the first is direct proving method using 4D criteria; Duty, Dereliction of duty, Damage and Direct causation. The second proving procedure is via indirect method using doctrine Res Ipsa Loquitor (the thing speaks for itself).

Refferences :

1. Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 15-21

2. Flamm, M.B. Medical Malpractice and the physician defendant in : Legal Medicine Sanbar, S.S. et al. (Ed.) 1998. Page 123-129

Doctor who main profesion for health sevices also has responsibility to make medical documents in form of certificate needed by patient, third party and state in the name of law. These medical documents consist of Health Certificate, Sick Leave Certificate, Certificate of non-infected from any contagious disease and etc. There are trends of upward need to medical certificate for many different purposes according to development of medical technology and science. Nowadays, Certificate of Patternity, Certificate of Gender, Certificate of Virginity and etc are frequently needed.

Basic principal of medical certificate on medicolegal aspect mainly consist of fact and medical opinion. Facts based on medical examination meanwhile medical opinion made according to medical procedure. Therefore, medical certificates are tightly attached to medical confidentiality.

Legal Aspect of Medical Record, Medical Certification and

Visum et Repertum

(

Medico-legal report)

Dr. I.B. Alit, DFM. SpF

Criminal Law and Medical Malpractice

Doctor profession has many responsibilities, one of them is legal duty. This responsibility is an obligation mainly assisting law and trial process. For instance, Visum et repertum is medical certificate made for law enforcement. The division of visum et repertum depends on substance needed by the state. Generally, it is differentiated in to Psychiatric Visum et Repertum and Physical Visum et Repertum. Physical Visum et repertum can be divided in to death victim Visum et repertum and live victim Visum et repertum. Meanwhile live victim visum et repertum can be made for physical violence and toxin VeR and sexual harassment VeR.

Medical record in other hand is a note for all medical information collected from patient examination and analysis including medical procedure performed. Medical record is compulsory to all practicing doctor which has function for administration, legal, financial, research data and education. Its legal function needed as a source for medical certificate and VeR aside used as written evidence on medical dispute.

Refferences :

1. Hirsh, H.L. Medical Record in : Legal Medicine. Sanbar, S.S. et al (Ed.).1998. Page 280-296

2. Plueckhahn, V.D. and Cordner, S.M. Ethics, Legal Medicine and Forensic Pathology, Second Edition. 1991. Page 111-122

In medical services, a doctor needs a special document which is known as Medical Record to keep all the information about patient’s health status. Medical Record is used to describe the systematic documentation of patient’s medical history and care across time within one particular health care provider’s jurisdiction. Medical Record is very important as it contains various types of notes entered over time by health care professionals, diagnosis, test results and also recording observation and orders for drugs’ administration and therapies. The purpose of medical report is to ensure documentation of compliance with institutional, professional or governmental regulation. The information contained in the medical record also allow the health care providers to determine the patient’s medical history and provide informed care. Medical Record also serves a purpose as the mean of communication among patient, health care provider and other professionals contributing to patient’s care. Apart from being a medical report itself, Medical Record are legal document which can be used as a basis for hospital development, building statistic also for educational and juridical purpose. In the service of clinical forensic medicine, Medical Record are used especially in the law enforcement.

Medical Record

dr. Kunthi Yulianti Sp.F

Legal basis of medical record in Indonesia are regulation number 29/2004 on Medical Practice and Ministry of Health regulation (Permenkes) number 269/MENKES/PER/III/2008 on Medical Record. In medical record, the diagnosis refer to ICD X. Information relating to Medical Record is confidential which should be kept only by doctors, students, certain health workers, medical records officer and chairman of health care facilities. Contents of Medical Record can be opened through the regulation applicable in Indonesia.

References:

1. Undang-undang Republik Indonesia nomer 29 tahun 2004 tentang Praktek Kedokteran 2. Peraturan Menteri Kesehatan RI nomer 269/MENKES/PER/III/2008

3. WHO. Medical record manual : A guide for developing country. World Health Organization : Western Pacific region; 2006.

4. Health information systems knowledge hub. Dokumentating medical record : A handbook for doctors. University of Queensland; 2013.

5. WHO. ICD X : International statistical classification of disease and related health problem. 2010 ed. World Health Organization; 2011.

LEARNING TASKS

Vignette 1

Mr. A complained that when urinating he had pain. He went to a hospital and was managed by an urologist who said that laser treatment should be performed because it might be due to prostate. So far only USG had been performed. The doctor was threatening to such an extent that the patient sister started crying. The threat was made like this: “If a laser is not performed, you will have to read the holy verses," that is, he would die. This physician proceeded to perform intravenous pyelography. Then the patient was instructed to undergo a laser treatment that same evening by paying an advance of approximately Rp. 15.000.000,-. The patient was bewildered and contacted his brother who was engaged in

Day 1

the health field. He told him to delay it for one day until he would reach there. But the physician got angry and said, If this was not conducted, he would not care any more. It was not until realizing who his brother was that the physician was alerted. He asked what he should do to apologize for what he had done. Finally, the hospital director and one of his staff apologized to his brother. The patients decided to go to another private hospital where ultrasonography (USG) and other specific laboratory examinations showed that it was an inflammation.

Assignments:

1. Identify the moral-ethical issue in this case

2. Identify the professional personal attribute in this doctor-patient relationship

3. What is your view about the doctor’s attitude in this case?

4. Has the doctor tried to demonstrate his/her empathy? Explain!

Vignette 2

Dr. P. an experienced and skilled surgeon, is about to finish night duty at medium-sized community hospital. A young woman is brought to the hospital by her mother, who leaves immediately after telling the intake nurse that she has to look after her other children. The patient is bleeding vaginally and is in great deal of pain. Dr. P examines her and decides that she has had either a miscarriage or self induced abortion. He does a quick dilatation and curettage and tells the nurse to ask the patient whether she can afford to stay in the hospital until it is safe for her to be discharged. Dr. Q comes in to replace Dr. P, who goes home without having spoken to the patient.

Assignments:

1. Identify the moral-ethical issue in this case!

2. Identify the professional personal attribute in this doctor-patient relationship 3. If you were doctor P, what would you do?

4. Has the doctor tried to demonstrate his/her empathy? Explain!

Learning Tasks

Please answer these question by giving ethical arguments!

1. Is health care just a business like any other, or should health care professionals have a higher standard of ethics?

2. Should we invent a pill that enables people to live for hundreds of years? 3. Have parents the right to use science to design the kind of children they want? 4. Does everyone have an equal right to health care, whatever it costs?

5. Is abortion the same as killing babies?

6. Should we create creatures that are partly animal and partly human?

7. Is it OK to sell our body parts, such as one of our kidneys, like we buy and sell our material possessions, our cars or our mobile phones?

8. Should the state force people to adopt healthy life styles? 9. Should mercy killing be made legal?

10. Does it matter if our current use of natural resources is likely to totally destroy the environment in a few years from now?

Day 2

Vignette 1

O is a 27-year-old woman who has struggled with anorexia nervosa since she was 11 years old. She is extremely intelligent, and having gained a first class degree in history at Oxford University, she is now halfway through her PhD. It is at times when her life is most stressful that she struggles with her anorexia. The first time she was admitted to hospital was when she was 13. She was being badly bullied at school and had stopped eating in order to become thin to prevent being teased about being overweight. Being able to lose so much weight gave her the sense that she had some control over at least one aspect of her life. O has spent the past 14 years in and out of hospital. On two occasions she had to be admitted to intensive care as she had lost consciousness. During these admissions she was fed by a nasogastric tube. She also has a history of obsessive-compulsive disorder and has been receiving cognitive behavioral therapy. A year ago she had managed to stabilize her weight at 50 kg – she is 1.7 m tall. With the stress of her PhD and the breakdown of her relationship with her boyfriend, when you initially see O she weighs less than 35 kg. Although you want to feed her by nasogastric tube to prevent her needing a third admission to intensive care, she adamantly refuses to have this. She tells you that she does not want to die, but neither does she want to be force fed. She is extremely frail and needs constant supervision by a healthcare assistant. Due to a shortage of beds on the psychiatric ward, O is currently being nursed on a general ward. The older women in her bay are complaining about the amount of personal attention she is receiving, as when they need assistance to change position or to go to the bathroom there is often a long wait due to staff shortages.

Assignments:

1. What is principlism?

2. How can the four principles be applied to this case scenario to offer guidance to the doctor about whether O should be force fed?

VIgnette 2

You are a doctor called to the ward to see an elderly, confused man. He is wandering around and crying out. The nurses have tried persuading him to stay by his bed or at least in his bay, but he is refusing to listen to them. One female patient has become upset because he keeps going to stand at the end of her bed and stares at her. The nurses are worried that as well as upsetting other patients, he is very unsteady on his feet and they fear he may fall over and injure himself. You read his notes to try to find a cause for his confusion. You learn that M, 76 years old, was an elective admission yesterday for a laparoscopic cholecystectomy. Two weeks earlier he had been admitted to Accident and Emergency with shortness of breath and pleuritic chest pain. He was kept in for 3 days and treated with intravenous antibiotics. There are at least two possible causes for his confusion: a recurrence of his pneumonia (or other sepsis) or a reaction to the general anesthetic. You decide to speak to M and try to take some blood. M refuses to cooperate and actively pushes you away from him, shouting and swearing. He then tries to leave the ward, claiming he is well enough to go home and it is illegal for you to keep him a prisoner. The nurses suggest he should be physically restrained so that you can take blood and assess him, and that it may be a good idea to give him a sedative so that he does not continue to upset the other patients.

Assignments:

1. Should you use restraint in this case?

Day 3

2. Could you please explain your reasoning based on ethical theories?

VIgnette 3

Please read the KODEKI (Kode Etik Kedokteran Indonesia) and then analyze each article based on any ethical theories that you know!

Vignette 1

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm (a weakening in the wall of the aorta which causes it to stretch and bulge). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is a photo model and actress; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence; the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of biomedical ethics which can be implied in this case?

3. What is your view on the application of the principle of informed consent in this case?

4. Try to find the reason, why the doctor decides as he did?

5. If you were doctor in this case, what would you do? (Explain your arguments based on prima facie duties, the principle of informed consent, ethical theory, KODEKI, and legal aspect)

Vignette 2

Joice and Doni have been married for 12 years and have a 6-year-old son. Doni’s father and grandfather died from cancer when they were in their early forties. Because of the strong family history of cancer, Doni wanted to have a genetic test to find out his level of risk. Although no clear diagnosis was possible, tests indicated that he was at risk of hereditary non-polyposis colorectal cancer. Now, Doni is feeling tired and unwell, and has a colonoscopy. The test reveals that he has inoperable bowel cancer. Joice is concerned that their son might also be at risk of colon cancer when he is older. She asked you to do a genetic test for his son to see if he is at risk.

Assignment:

1. What is the ethical issue in this case?

2. What are the principles of biomedical ethics which can be implied in this case?

3. Should parents be allowed to have their children tested for adult-onset genetic conditions? Why?

4. What would you do? (Explain your arguments based on prima facie duties, the principle of informed consent, ethical theory, KODEKI, and legal aspect)

DAY 4

Informed Consent , Confidentiality,

Patient’s right and Autonomy

5.

What are the foreseeable consequences of your decision? Can you justify this decision to accommodate: the patient or the patient’s family value; to your consultant; and to your peers?

Vignette 3

Tony is 35 years old and is married. He has had unprotected sex with prostitutes on 2 occasions. Although he is asymptomatic, he becomes anxious about the possibility of having contracted a venereal disease and consults his physician. After conducting a thorough physical examination and providing appropriate counselling, Tony’s physician orders a number of tests. The only positive result is for the HIV blood test. The physician offers to meet with Tony and his wife to assist with the disclosure of this information, but Tony states that he does not want his wife to know about his condition.

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of biomedical ethics which can be implied in this case?

3. Should the doctor disclosed this information to his wife? (Explain your arguments based on prima facie duties, the principle of confidentiality, ethical theory, KODEKI, and legal aspect)

4.

What are the foreseeable consequences of your decision? Can you justify this decision to accommodate: the patient or the patient’s family value; to your consultant; and to your peers?

5. Does it make any difference if the Tony’s diagnosis is not HIV? Explain!

Vignette 4

A 75-year-old woman shows signs of abuse that appears to be inflicted by her husband. As he is her primary caregiver, she feels dependent on him and pleads with you not to say anything about it.

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of biomedical ethics which can be implied in this case?

3. Should you report this case to the police? (Explain your arguments based on prima facie duties, the principle of confidentiality, ethical theory, KODEKI, and legal aspect)

4. What are the foreseeable consequences of your decision? Can you justify this decision to accommodate: the patient or the patient’s family value; to your consultant; and to your peers?

5. If you are asked to testify and disclose patient information in court, what would you do?

Vignette 1

Jehovah's Witnesses have a belief that it is wrong to accept a blood transfusion.

Therefore, in a life-threatening situation where a blood transfusion is required to

save the life of the patient, the patient must be so informed. The consequences of

Day 5

Awareness to diversity in medical

practices

refusing a blood transfusion must be made clearly to the patient at risk of dying from

blood loss. A desiring to "benefit" the patient, the physician may strongly want to

provide a blood transfusion, believing it to be a clear "medical benefit." When

properly and compassionately informed, the particular patient is then free to choose

whether to accept the blood transfusion in keeping with a strong desire to live, or

whether to refuse the blood transfusion in giving a greater priority to his or her

religious convictions about the wrongness of blood transfusions, even to the point of

accepting death as a predictable outcome. This communication process must be

compassionate and respectful of the patient’s unique values, even if they differ from

the standard goals of biomedicine.

Assignment :

Discuss the problem !

Vignette 2

This case comes from Emergency Medicine. When the patient is incapacitated by the grave nature of accident or illness, we presume that the reasonable person would want to be treated aggressively, and we rush to provide beneficent intervention by stemming the bleeding, mending the broken or suturing the wounded.

Assignment :

Please discuss what the physician can do!

Vignette 3

This case, in the treatment of suicidal patients who are a clear and present danger to themselves. Here, the duty of beneficence requires that the physician intervene on behalf of saving the patient's life or placing the patient in a protective environment, in the belief that the patient is compromised and cannot act in his own best interest at the moment. As always, the facts of the case are extremely important in order to make a judgment that the autonomy of the patient is compromised.

Assignment:

Please discuss your opinion!

Learning tasks:

1. Explain and elaborate the journey of research ethics (including Nuremberg Code, Declaration of Helsinski, Belmont Report, etc.)!

2. Explain about principles of Good Clinical Practice in human subject research! 3. Explain and give examples of fabrication, falsification, plagiarism and false

claim to authorship!

4. Explain 4 different areas of research and give examples of each area!

Day 6

Vignette 1

Ministry of Health of Indonesia have reported several 199 confirmed cases of and

167 death due to Avian Influenza since 2003 to 2015. This infection is fatal and

become global public health concern. Several human cases reported in Indonesia

was coming from Bali Province. Until now, chicken and duck, are considered as

transmiter of and source of infection. Therefore, when there are suddent death of

them, the procedure should be follow is elimination of all the chicken/ducks in

certain related area. However, this outbreak control may not work well for some

reason. In practice, there are many farmers who do not want to eliminate their

chickens. Usually Bali Province fulfilled the need of chickens from outside Bali,

particularly from East Java.

Carefully read several related information provided in the link below

1. http://www.who.int/influenza/human_animal_interface/2016_02_25_tableH5N1.pdf? ua=1

2. http://balipost.com/read/bali/2016/03/21/47304/puluhan-ribu-unggas-mati-mendadak-diduga-terjangkit-flu-burung.html

3. http://bali.tribunnews.com/2016/03/24/bali-resah-dengan-merebaknya-wabah-flu-burung

4. http://balipost.com/read/kesehatan/2016/03/22/47399/warga-banyuwangi-musnahkan-unggas-terjangkit-flu-burung.html

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of PH ethics which can be implied in this case?

3.

If you were doctor who work at the Public Health Office, how you explain the

rationale in term of PH ethics of this situation to the community?

Vignette

2

Based on the report of Ministry of Health of Indonesia, Bali rank the fourth in term of

HIV prevalence in Indonesia. Currently the HIV epidemic was mainly driven sexual

transmission, which is believed to be related with female sex workers (FSW). In

order to control the spread of HIV, at other provinces, many Governors have closed

localisation where FSWs usually do the transaction with their clients.

The followings are information related to the above case:

1. http://lipsus.kompas.com/topikpilihanlist/3064/1/gang.dolly.ditutup

2. https://m.tempo.co/read/news/2014/06/20/058586646/psk-dolly-dilaporkan-pindah-ke-papua

3. http://www.bbc.com/indonesia/berita_indonesia/2016/02/160228_indonesia_kalijodo

Day 7

4. http://www.bbc.com/indonesia/berita_indonesia/2016/02/160225_indonesia_kalijodo _ditutup

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of PH ethics which can be implied in this case?

3.

If you are doctor who open the general doctor private practice in the area,

where you also have many patients from the localisation; how you will

response to the closing of localisation? Explain your answer using the PH

ethic concepts.

Vignette

3

Japanese Encephalitis (JE) has been reported in Bali, where Bali is the province

with the highest cases in Indonesia. Compare to other endemic country such as

China, the Incidence of JE in Bali is still far lower. However, JE can cause severe

neurologic complication in to death. Therefore, there is a need to do more intensive

and effective prevention control through vaccination program. Recently, JE vaccine

is available in certain private clinic and only accessed by foreign tourist and some

Indonesian. Decision on vaccination program is on the Ministry of Health, and

currently is not allowed yet. Vaccine price is expensive (1.5 million in a private

clinic). One study in Bali has noted that mothers are willing to pay at least IDR

50.000,00 for this vaccine.

The followings are information related to the above case:

1. http://www.kalbemed.com/Portals/6/09_193Japanese%20Encephalitis.pdf 2. http://www.klinikvaksinasi.com/mengenali-japanese-encephalitis-lebih-dekat/ 3.

http://kalteng.litbang.pertanian.go.id/ind/pdf/all-pdf/peternakan/fullteks/wartazoa/wazo153-1.pdf 4. http://saripediatri.idai.or.id/pdfile/10-5-5.pdf 5. http://www.klinikraisha.com/daftar-harga-vaksin/

Assignments:

1. What is the ethical issue in this case?

2. What are the principles of PH ethics which can be implied in this case?

3. If you are living in Bali, what will be your opinion in term of vaccination

program being conducted in Bali?

Learning Tasks

Please watch the Movie in class.

Assignments:

1. Please identify at least 3 ethical issues in the movie!

2. Do you agree about how the ethical problems resolved in the movie?

Day 8

3. Could you please explain your reasoning based on ethical theories?

Write an experience, when did you feel empathy and when you feel sympathy. Your feelings descriptions should be clear that includes: how it came, when it came, why it came, and what you're doing when it came.

Example of feeling description :

“ Waktu saya bertemu dengan pemulung tua ibu Ketut Sunie, hati saya tergetar, kok tega-teganya petugas malam itu mengusir dia dari halaman kantor. Dia berjalan sendirian, padahal dia sudah sangat tua dan renta....wah teganya. Hati saya semakin kasihan saat melihat dia menyeret kantong plastiknya dan jika kelelahan dia tidur di emperan toko dengan hanya beralaskan koran. Hati saya semakin trenyuh saat dia menceritakan pengalaman hidupnya yang penuh dengan derita, ingin rasanya saya setiap hari menyediakan makanan dan tempat beristirahat untuk dia,....E aaalah kok yha tega-teganya anggota satpam itu”

Once your feelings descriptionsis is clear, then describe whether these feelings can affect your attitude toward the events on your everyday life. Give your opinion if these feeling are useful for yourself and your profesion as a doctor and if useful how you maintain these feelings.

Write your observation report with a brief on A4 paper with a font 12, 1.5 spaces line as much as 4 pages. The report will be discussed at the Small Group Discussion, and also will be discussed at the Plenary Session.

Assigments :

1. What is the difference between empathy and sympathy and give an examples ! 2. Explain with your own word the definition of empathy!

3. Why empathy is important in medical practice

4. Is empathy can be developed or learned? If the answer is yes, how?

Vignette 1

A mother, 68 years old, who currently staying with her married child, have been experiencing series of minor cerebral hemorrhage for the past 11 years and for the past two years she has been unable to talk and showing signs of diminishing hearing abilities. This has resulted in lack of communication between her and her family. The family later requested a doctor to do euthanasia to her.

Day 10

Legal Aspect of Medical Practice

Day 9

Assignments:

1. In your opinion, what the doctor should do?

2. In your opinion, is the doctor guilty if at all he/she grants the family’s request of euthanasia towards her (mother)? Explain!

3. What is your point of view regarding the ethical aspect in euthanasia?

Vignette 1

A female, aged 14 years old, went with her mother to a hospital with possible pregnancy after forced to do an intercourse with her neighbor. The test results reveals positive pregnancy test aged 6 weeks of gestation. The girl then consulted to psychiatry department, diagnosed with mild post psychic traumatic depression. The mother then requested the medical doctor to do an abortion procedure with an excuse that her daughter not yet ready mentally and physically to conceive the pregnancy and so that she can be back to school again.

Assignments:

1. In your opinion, what the doctor should do regarding the mothers request?

2. When the doctor agrees’s for an abortion, can the doctor be said to have done a criminal act? Explain!

Vignette 2

A young man, aged 21 years old, had a traffic accident. He is diagnosed with right epidural hematoma by a surgeon in the hospital where he receiving treatment. The surgeon suggested a trepanation procedure to be done to evacuate the bleeding occurred. In the operation room, the surgeon has done the trepanation procedure in the left lobe instead of doing in right lobe. After a while, the surgeon realized that he has mistakenly interpreted the CT scan results. The surgeon then has done the trepanation procedure in the right lobe to evacuate the bleeding. After operation done and the patient treated in the same hospital for few days, the patient discharged in improved condition.

Assignments:

1. In your opinion, does the mistake done by the surgeon considered a malpractice? How do you prove it?

2. After arriving home, the patient then realize that there has been a mistake in the operation done (trepanation) and he decided to sue the surgeon to compensate the damage done to him. In your opinion, how the surgeon should do or explain his decisions to defend himself from a possible malpractice charge?

Vignette 3

A 45-year-old man was suffering from intestinal cancer stage IV. The surgeon who handled him post medically decided the patient to be operated though the possibility of success was

Day 11

very little. However, it was preferable as compared with no operation. In consideration of the patient’s weak condition and the anticipated influence of anesthetic, the surgeon undertook the operation in a hurry in the hope that the patient’s condition would not become worse due to the surgery. After the operation and during treatment, the patient complained of a chronic stomachache despite long administration of analgesic. To find out the cause of pain, an X-ray of the abdomen was made and the image showed that a metal instrument was lying inside the patient’s abdomen.

Assignments :

1. Does the doctrine res ipsa loqiutur apply on the above case? 2. Explain the term and condition of res ipsa loquitur!

3. What are the conditions that can serve as a defense on the above case?

Vignette 1

A husband punched his wife till made her fell and hit a table. This violence caused by his suspicion on their 2 years old child not from their married. His wife was brought to hospital and examined by doctor A. Doctor A recorded all findings from examination and treatment given on medical record. On examination found bruises on right forehead and open wound on left temple that required treatment.

His wife brought by police to hospital and asked for wound VeR. The victim want to have Sick Leave Certificate for getting off from duty cause she works in a private company. A few days later, her company asked for Medical Certificate needed to reimburst to health insurance company.

On the other hand, her husband insist for patternity test to their child by DNA examination to ensure the real father. Based on the test result, he want Certificate of Patternity to the corresponding child.

Assignments:

1. Medical certificate has vary form according to patient need but in general it has the same components. Discuss about this components!

2. Medical certificate required by the law must follow medicolegal procedures. Discuss about this medicolegal procedure and how it is connected with profession responsibility in law!

3. Discuss about medical confidentiality aspect on medical certificate making process!

4. If the requirement for medical certificate delayed after examination. Discuss about the solution regarding to this certificate making process!

Vignette 2

A policewoman escorted a 20-year-old girl who was a victim of sexual harassment. A doctor at the emergency department examined her after obtaining the consent from her.

Day 12

Legal Aspect of Medical Record, Medical

Certification and

Visum et Repertum

(Medico-legal

Assignment:

1. What the doctor should do to document the result of the examination?

2. The policewoman requested the doctor to make medico-legal report (visum

et repertum). Explain the role of and procedures to make visum et repertum!

3. According to the legal procedures, the attorney requests the doctor to give expert witness at a trial. Explain the differences between witness and expert witness. What the doctor should do if requested to stand in trial?

Vignette 1

A 49-year-old male was brought to the emergency department with convulsions.

Assignments:

1. What data is needed during registration that will be used in patient records?

2. Is it necessary to ask the socioeconomic status of patients during registration? Explain why!

Vignette 2

A 49-year-old male was brought to the emergency department with an infected wound of the right foot. Because of repeated convulsions, he was admitted to the hospital. The examining doctor made a diagnosis of tetanus. His wife reported that working in the fields two weeks previously, he stepped on a nail. Then the doctors manage the tetanus based on standard procedure.

Assignments:

1. What are the information required to be created by physician in the patient's medical record?

2. When the doctor incorrectly write the data in the medical record, explain how to correct the writing!

Vignette 3

A 49-year-old male was brought to the emergency department with an infected wound of the right foot. Because of repeated convulsions, he was admitted to the hospital. The examining doctor made a diagnosis of tetanus. His wife reported that he was working in the fields two weeks ago while he stepped on a nail. He treated the wound by himself. The patient died because of asphyxia during convulsions one day after admission.

Assignments:

1. Complete the death certificate and make a diagnosis of the cause of death based on ICD X!

Day 13

Medical Record

BASIC CLINICAL SKILL

Date and Place :



Wednesday, 04

th

_{March 2015}



Class Room and Lab. Bersama

Facilitator : Forensic team

LATAR BELAKANG

Day 15

MEDICAL CERTIFICATION AND VISUM ET

REPERTUM WRITTING SKILL TRAINING

SELF ASSESSMENT

Bioethic :

1. What is ethics?

2. List and explain the principles of biomedical ethics! 3. List and explain any ethical theories that you know!

4. Please read the KODEKI (Kode Etik Kedokteran Indonesia) and then analyze each article based on the principles of biomedical ethics!

Informed Consent

1. Describe the principles of informed consent!

2. Explain under what circumstances a physician should or should not respect the patient's right to informed consent!

3. How to provide informed consent to the patient?

4. Describe the patient's right to informed consent in emergency circumstances! 5. Is a families’ informed consent justified? Under what circumstances?

6. Is there any relationship between informed consent and law? Explain! 7. Is there any relationship between informed consent and autonomy? Explain!

Confidentiality

1. Describe the principles of confidentiality!

2. When does disclosure not constitute a breach of the confidentiality? 3. What are the consequences if the physician breaches confidentiality?

Professional Personal Attribute

1. What are the principles underlying the doctor-patient relationship? 2. What personal attribute constitutes a good doctor?

3. Why doctor should be competent?

4. What is honesty, and its role in doctor-patients relationship? 5. What is compassion, and its role in doctor-patients relationship? 6. What is truthfulness, and its role in doctor-patients relationship? 7. What is empathy?

8. What are differences between empathy and sympathy and antipathy? 9. What is the role of empathy on doctor-patients relationship?

10. How the doctor should apply empathy?

Patient’s right and Autonomy

1. Describe the principles of patient’s autonomy

2. Is there any relationship between patient’s right and autonomy? Explain!

3. Explain under what circumstances a physician should or should not respect the patient's right to autonomy

4. Describe the possible conflict that may arise between patient autonomy and the interests of the family

5. Explain under what circumstances the patient lost his/her autonomy!

2. What are differences between empathy and sympathy and antipathy? 3. What is the role of empathy on doctor-patients relationship?

4. How the doctor should apply empathy?

Awarness Diversity in Medical Practice

1. Explain about the perception of health and illness in the community. 2. Culture is one of determinant factors of human health and illness. 3. Explain with your own language and argue it.

4. Give an example, why we have to understand diversity and multiculturalism.

5. Describe, why you have to develop the strategies of cross-cultural perspective in health care program.

Legal Aspect of Medical Practice

1. What is the purpose of accomplishment in good medical practice?

2. What else do you know about the incumbency of a doctor pursuant to rules and regulation that pertinent on execution of medical practice?

Criminal Law and Medical Malpractice

1. What is the intentional of Medical Malpractice?

2. Explain and mention the term and conditions of Medical Malpractice! 3. What is the intentional of medical adverse event?

4. Explain about the doctrine res ipsa loquitur

Legal Aspect Medical Record, Medical Certification and Visum et Repertum

1. Interpret and mention the sustention of medical record!

2. Explain about civil and criminal problems that can arise from the use of medical record! 3. What are the similarities and dissimilarities between visum et repertum and medical

certificate?

4. What a doctor should do if he had been called to court and how should he behave in court?

Public Health Ethics

1. “X” Island is located at the remote and difficult to reach area in Indonesia. Due to geographic situation, vaccination program cannot be done properly. This situation reflected the existence of imbalance of:

a. Social justice b. Distributive justice c. Equal justice d. Equality justice

e. Social and distributive justice

2. Due to in adequate vaccination program in the above island, a private pharmacy take advantage by providing immunization for under-five children living in that island.

The cost of vaccines are varied, but still considered as expensive for most people living in the island. This situation reflected the existence of imbalance of:

a. Social justice b. Distributive justice c. Equal justice d. Equality justice

e. Social and distributive justice

3. Due to in adequate vaccination program at the above island, the under-five children are mostly susceptible to certain diseases. Finally an outbreak of “Y” disease occurs, that made Government had to compulsory isolate many children and their family at their houses. This situation may results an issue of:

a. Social justice b. Distributive justice c. Equal justice d. Equality justice

e. Social and distributive justice

4. The head office at District “A” introduces screening of cervical cancer using “X” method to mothers living in the district. Eventhough the test is highly accurate, the cost of package for screening test is very expensive and the government is not be able to pay all the cost of the test. Because the head wants to test all mothers, the cost of test is shared with the mothers What ethical issue may rise for this situation?

a. Social justice b. Distributive justice c. Test accuracy d. Equal justice e. Equality justice

5. Life expectancy of people in Bali province is higher than in Nusa Tenggara Barat province. Therefore there are a lot of ageing persons living in Bali. A national health survey showed that expenditure for maintain health for elderly in Bali is far higher than in NTB. In addition, numbers of chronic diseases such as hypertension and diabetes in Bali also higher in Bali than in NTB. This phenomen is called:

a. Social justice b. Distributive justice c. Test accuracy

d. Paradox of health care e. Equality justice

6. Terminology to describe the condition of poor persons who have a complex disease and multi problem is called:

a. Social justice b. Distributive justice c. Test accuracy

d. Paradox of health care e. Heartsink patients’

7. A study in Indonesia showed that graduates MD from Faculty of Medicine in Indonesia tend to work in the big cities, in busy and productive island, than work in remote areas. This phenomenon is reflected PH ethics issue at the level of:

a. Macro b. Meso

d. Meso and micro e. Macro and meso

8. Patient “A” need to get kidney transplation soon; however he is very poor; so he cannot afford the service. Currently he still living, but with bad quality of live. Patient “B” also need to have kidneytransplation, but his condition is much better than patient “A”. Patient B is also rich man, so he can do transplation whenever he wants. This phenomenon is reflected PH ethics issue at level of:

a. Macro b. Meso c. Micro

d. Meso and micro e. Macro and meso

9. Principles to be used to allocate health resources fairly is the belows, unless: f. To each equal share

g. To each according to individual choice h. To each to potential for future life years i. To each person based on what he want j. To each according to their needs

10. Based on John Rawl theory, two fundamental principles are: k. Social and distributive principles

l. Macro and micro principles m. Equal and equitable principles n. Liberty and difference principles o. None of the above

~ REFERENCES ~

1. Tony Hope et al. Medical ethics and Law the core curriculum. Churchill Livingstone. Edinburgh. 2003 page : 51-57

2. Beauchamp T.L. and Childress J.F. principles of Biomedical Ethics. 4th _ed.

Oxford University Press. NY. 1994 3. CMA. Professionalism in Medicine.2001

4. Bendapudi,N.M. et al. Patient’s Perspectives on Ideal Phsician Behaviours.

Mayo Clin Proc.2006.81(3):338-344

5. Batmanabane, V.Empathy: A vital attribute for doctors. Indian Journal of Medical Ethics. 2008. 5(3) :128-129

6. Hardee, J.T. An Overview of Empathy. The Permanente Journal.2003.7 (4):51-54

7. Ross J.Taylor. et al. Health and Illness in the community. Oxford University Press. 2003

8. Shepherd, R. The Ethics of Medical Practice in Simpson,s Forensic Medicine. Twelfth Edition.2003. page 8-14

9. Sanbar, S.S. et al. Legal Medicine and Health Law Education in : Legal Medicine. Sanbar, S.S. (Ed). 1998.Page 3-10

10. Piorkowski, J.D.Medical testimony and the expert witness in : Legal Medicine. Sanbar, S.S. et al (Ed.). 1998. Page 132-144

11. Wiradharma, D. Penuntun Kuliah Hukum Kedokteran. Page 25-35 12. Ohoiwutum, T. Bunga Rampai Hukum Kedokteran.page 1-13

13. Flamm, M.B. Medical Malpractice and the physician defendant in : Legal Medicine Sanbar, S.S. et al. (Ed.) 1998. Page 123-129

14. Hirsh, H.L. Medical Record in : Legal Medicine. Sanbar, S.S. et al (Ed.).1998. Page 280-296

15. Plueckhahn, V.D. and Cordner, S.M. Ethics, Legal Medicine and Forensic Pathology, Second Edition. 1991. Page 111-122

16. Kushe H. and Singer P. Bioethics An Anthology. Blackwell Pub. Ltd. Oxford. 1999