ppt Bio ethics 2014
- 1. The Phylosophy of Bioethics and Medical Ethics Sept 9, 2014 Teguh Wahju Sardjono Faculty of Medicine University Brawijaya
- 2. Learning Objectives At the end of this study, the students should be able to: • explain what Bioethics and Medical Ethics is • explain the basic principle of Bioethics and Medical Ethics • understand about the essential of Hyppocrates oath • explain the role of bioethics in medical profession • explain the value of good-bad, wright-wrong in community • identify bioethical problems in medical practice and give the alternative to solve the problems
- 3. History • Van Rensselaer Potter (biological/oncological researcher professor in Wisconsin University), wrote books: Bioethics, the Science of Survival (1970) Bioethics: Bridge to the Future (1971) The aim of writing books: “not only to enrich individual lives but to prolong the survival of the human species in an acceptable form of society".
- 4. ETHICS • the branch of philosophy that deals with distinctions between right and wrong – with the moral consequences of human action” (Coughlin & Beauchamp, 1996) • Effort to create the positive reflection on activities or intuition and moral choice which decided by someone • Medical ethics moral responsibility that influencing any activities in medical practice
- 5. “ETHICS” Consists of three meanings : 1. Moral values or norms that used to be a guidance for individuals or groups in their activities 2. A moral philosophy that deals with distinctions between right and wrong 3. Collection of moral rules ethical codes (K. Bertens, 2004)
- 6. Two meanings of ETHICS in community Bioethics ≈ ethics of life? Moral norms or values which are accepted as guidance in our life/community Example: -“it is not ethical" -“that activity is not suitable with the right ethics", - “we should not only thinking about the benefit, as it is still ethics there". Ethics = moral or morality
- 7. • Ethics as science: a study about morality or about ethics in first meaning – Learning about life (right or wrong) in moral term – Trying to decide what, and why it should be or not to be done • Ethics in philosophy ethical philosophy or moral philosophy . • Long history, ± 25 centuries. • Greece. Socrates, Plato, and Aristoteles (384-322 BC) Bioethics ≈ ethics of life?
- 8. What is bioethics and why do we need it? • Bioethics: how scientists and health professionals ought to behave in the biomedical sciences • the attempt to understand and justify the link between values (fundamental principles) and actions • Many (or all?) people feel the need to justify their behaviour to explain why their behaviour is (un)acceptable
- 9. Ethics in Medical Science (Medical Ethics) “Patients are entitled to good standards of practice and care from their doctors. Essential elements of this are professional competence, good relationships with patients and colleagues and observance of professional ethical obligations.” (From Good Medical Practice, GMC) Ethics in Medical Science is one of the “Seven basic competences of Indonesian doctors” (SKDI, 2012)
- 10. Why Ethics Become Important? • Nowadays, conflicts of interests between the government and medical institutions, between medical institutions and medical personnel, between physicians and patients are getting more and more serious and complex. • High technologies not only brought us hopes of cure but have also created a heavy economic burden. • The ethical dilemmas of high technology medicine-brain death, organ transplantation, and concerns about quality of life-have become increasingly prominent
- 11. Why Ethics Become Important? • A new and more specific code of ethics must be developed to meet the demands of social development and medical service. • This new code integrates the traditional medical ethics with modern principles and values.
- 12. There are 4 (four) principles • Autonomy – Right of self-determination • Related to ‘informed consent’ • In order to give consent: autonomy/competency/capacity must be possessed. • Beneficence – to do well, to promote well-being • Non-maleficence – to do no harm, to avoid doing harm • Justice – treat like alike (Beauchamp and Childress, 2001.)
- 13. Ethics in Medical Profession • Hippocrates (460-370 BC) : the father of medicine “The Oath of Hippocrates". • Ethics in medical science is as old as the medical profession itself The connection between medical ethics and medical profession everlasting. • "Hippocratic Oath“ still exist in medical profession and give great contribution for the existence of medical profession as a respected and noble profession in community.
- 14. Prominent ethical codes • Oath of Hippocrates (4th c BC) • Nuremberg Code (1947): issue of human experimentation • Declaration of Helsinki (1964) (WMA): issue of human experimentation – First serious attempt of medical community to regulate itself • Declaration of Geneva (1948) – Issued as a development on the Oath of Hippocrates • CIOMS Guidelines (1993) – ‘International Ethical Guidelines for Biomedical Research Involving Human Subjects’ (CIOMS: the Council for International Organizations of Medical Sciences) (UNESCO, 2005)
- 15. Importance of Medical Ethics 1) Increase in technology 2) Better informed society 3) Doctors in Management 4) Public scrutiny 5). Increasing profileRecent press headlines: – Dr Cox (euthanasia) – Alder hay Enquiry – Jodie and Mary – Destroying frozen embryos – Refusal to fund marrow transplantsnew drugs
- 16. Scope of ethics in Medical Practice 1. Historical background • Hippocratic oath • Geneva(1947) • Sydney(1968) • Tokyo(1975) • Lisbon(1981) 2. Multidisciplinary nature
- 17. The source and legal definition of medical ethics Medical ethical issues arise out of specific fields of health care such as: matters related to infertility or any reproductive health related issues, experimentation with genes, dealing with terminal illness, organ transpants etc. “Medical ethics is a discipline/methodology for considering the implications of medical technology/treatment and what ought to be”
- 18. Graduation Day
- 19. Graduation Day • On the day of graduation/before start the medical profession, every new medical doctors should swear the “Hippocratic Oath” • Year 1948 : a New version of " Hippocratic Oath ". Declaration of Geneva • The original " Hippocratic Oath“ is still used • Traditional Medical Ethics especially focused on: – the relation of doctors-patients – the responsibility of doctors to their patients • During the 20th century developments of biomedical sciences and technology caused a lot of new ethical problems which never predicted before and untouched by Traditional Medical Ethics
- 20. "Hippocratic Oath". • The Hippocratic Oath (ancient and modern versions) is one of the oldest binding documents in history. Written in antiquity, its principles are held sacred by doctors to this day: (treat the sick to the best of one's ability, preserve patient privacy, teach the secrets of medicine to the next generation, and so on). • "The Oath of Hippocrates," held by the American Medical Association's Code of Medical Ethics (1996), "has remained in Western civilization as an expression of ideal conduct for the physician."
- 21. THE OATH OF HIPPOCRATES (From "Harvard Classics, Volume 38" Copyright 1910 by P.F. Collier and Son) • I SWEAR by Apollo the physician and Æsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, • I will keep this Oath and this stipulation — to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction,
- 22. THE OATH OF HIPPOCRATES (cont) • I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. • I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. • I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.
- 23. THE OATH OF HIPPOCRATES (cont) • I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, • I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.
- 24. " Hippocratic Oath". (1) I swear to fulfill, to the best of my ability and judgment, this covenant: • I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. • I will apply, for the benefit of the sick, all measures whish are required, avoiding those twin traps of over-treatment and therapeutic nihilism. • I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
- 25. " Hippocratic Oath". (2) • I will not be ashamed to say “ I know not”, nor will I fail to call in my colleagues when the skills of another are needed for patient’s recovery. • I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play of God.
- 26. " Hippocratic Oath". (3) • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. • I will prevent disease whenever I can, for prevention is preferable to cure. • I will remember that I remain a member of society, with special obligations to all my fellow human being, those sound of mind and body as well as the infirm.
- 27. " Hippocratic Oath". (4) • If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. (Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today)
- 28. The Oath of Indonesian Doctors • Is an Oath which is sworn by someone which is graduated to be an Indonesian medical doctor, before being and doing a formal doctor (licensed) • The Oath of Indonesian Doctor is based on Declaration of Geneva (1948) Revision of The Oath of Hippocrates • Text of the Oath of Indonesian Doctor firstly used in 1959 and stated as rule (law) according to Peraturan Pemerintah No.69 Year 1960. • The Oath was revised in 1983 dan 1993.
- 29. The Indonesian Physician’s OATH content • Duties to the patients. • Duties to the colleagues. • Duties to the teacher. • Against abortion. • Against Euthanasia. • Duties to keep secret what has been confided.
- 30. The Oath of Indonesian Doctor Demi Allah, saya bersumpah, bahwa: Saya akan membaktikan hidup saya guna kepentingan perikemanusiaan Saya akan menjalankan tugas saya dengan cara yang terhormat dan bersusila, sesuai dengan martabat dan tradisi luhur jabatan kedokteran Saya akan merahasiakan segala sesuatu yang saya ketahui karena pekerjaan dan kelimuan saya sebagai dokter Saya akan mengutamakan kesehatan dan keselamatan penderita Saya akan berikhtiar dengan sungguh-sungguh supaya saya tidak terpengaruh oleh pertimbangan keagamaan, kebangsaan, kesukuan, politik kepartaian atau kedudukan sosial dalam menunaikan kewajiban terhadap penderita
- 31. The Oath of Indonesian Doctor Saya akan memberikan kepada guru-guru saya penghormatan dan pernyataan terimakasih yang selayaknya Saya akan memperlakukan teman sejawat saya (seperti saudara kandung) sebagaimana saya ingin diperlakukan Saya akan menghormati setiap hidup insani mulai dari (saat pembuahan) awal kehidupan (sekalipun diancam) Saya tidak akan mempergunakan pengetahuan kedokteran saya untuk sesuatu yang bertentangan dengan hukum kemanusiaan, sekalipun diancam Saya ikrarkan sumpah ini dengan sungguh-sungguh dan dengan mempertaruhkan kehormatan diri saya
- 32. The Indonesian Physician Oath By the name of God (Allah) I swear or promise that • I will seek to do the art of medicine as well as I can at the service of my fellow human being. • I will care for the sick, enhance health, and alleviate suffering. • I will put the interest of the patient first and respect his ideas and attitudes. • I will not harm the patient. I will listen and inform him adequately. • I will keep secret what has been confided to me.
- 33. The Indonesian Physician Oath • I will enhance my medical knowledge and that of others. • I recognized the limits of may possibilities. • I will take an open assessable stance, and I know my responsibility to society. • I will encourage the availability and accessibility of health care. • I will not abuse of my medical knowledge, not even under pressure. • I will honour the profession of the physician
- 34. Taking the Physician Oath • is a very important moment for any new physician, • on this occasion he vowed that in the practice of his profession, he will always seek to do the art of medicine as well as he can • Therefore swearing-in ceremony should be conducted in a solemn and sacred atmosphere • It can be realized when the swearing-in ceremony held in particular, preceded the physician inauguration.
- 35. Who shall take the oath? • All Indonesian doctors, graduate education in the country and abroad • Foreign students studying in Indonesia Medical Colleges. • Foreign Doctors should not sworn in as guests, becomes the responsibility of the agency that hired her/him. • Foreign doctors who provide services directly to the people of Indonesia, should be subject to KODEKI. (Kode Etik Kedokteran Indonesia/ Ethical Code of Indonesian Physician) .
- 36. Ironics!!!! • Oath-taking (Hippocratic/Doctor’s Oaths) or others: something that should be meaningful and sacred • All of Government Officials, member of “MPR/DPR” swore the Official Oath • Yet paradoxically, some people see oath-taking as little more than a pro-formal ritual with little value beyond that of upholding tradition. • The Hippocratic Oath Today Seemed to be Meaningless Relic or Invaluable Moral Guide? (Kartono Mohamad, Ex. Head of Indonesian Doctor Association) INDIVIDUALS!!!
- 39. Four Misconceptions 1. Clear distinction :clinical and ethical analysis 2. Clear distinction: profess. and everyday ethics 3. Enshrined in lead 4. Medical ethics=matter of opinion Sometimes a doctor in certain conditions which makes him difficult to decide of doing something • Limited time, equipments, or other condition If you can not do everything, please do something, but do not do nothing
- 40. Principles 1. Beneficence 2. Non-Maleficence 3. Autonomy 4. Truth telling 5. Confidentiality 6. Preservation of Life 7. Justice
- 41. Principle of Beneficence • Based on Salus aegroti suprema lex maxim • usually advocated by the churches in reference to reproduction of human related problems or infertility. eg, IVF (in vitro fertilization) the church is highly against. What happens in IVF is the ova and sperm, which when fused initiates the process of fetus formation and eventually the baby, are fused in an unnatural way and outside the woman's body. So this principle says that medical purposes are to be used only to help cure an ailment and nothing else that is artificial or involves experimenting.
- 42. Beneficence and Non-Maleficence Questions: 1) Is the patient your only concern? (possible conflict with utility) 2) Do we always know what is good for the patient? (patient’s view may differ from ours)
- 43. 3 constraints on Beneficence 1. Need to respect autonomy-patient and doctor may differ 2. Need to ensure health is not bought at too high a price 3. Need to consider rights of others
- 44. Principle of Autonomy • This principle works on the maxim of Voluntas aegroti suprema lex, means that the patient is at liberty to make his own decision • to what treatment he wants to undergo and under whom but this does not mean that the doctors are relieved off the responsibility of the health of the patient. • The onus totally lies on the doctor to inform the patient about the disease he has and the available treatment options which need not necessarily be available with him. He has to help the patient to make an informed decision.
- 45. Autonomy 1. Capacity to think, decide, take action 2. Mental incompetence = no autonomy 3. Autonomy vs Paternalism When patient not autonomous –no clash. When patient autonomous-questionable procedure
- 46. Principle of Non-Maleficence • his particular term non-maleficence is common in laws of many countries. It literally means non harmful, in Latin. • The maxim primum non nocere says that whatever a doctor does for treating a patient, with the best interests in heart, he cannot harm the patient. In the legal terms, it should be deciphered as 'should not.' Elaborating on this idea further, a doctor is supposed to 'not do any harm' to his patients more than 'treating' and curing him for his suffering. • Just like the law says, hundred culprits may be let to go but not a single innocent is to be hanged. The current medical ethical issues can be categorically listed as follows which can be largely categorized into societal nonacceptance and professional misconduct.
- 47. Truth telling In much wisdom is much grief If you override it you endanger doctor/patient relationship(based on trust) You offend against the principle of autonomy At times there are good reasons for overriding the truth telling principle
- 48. Confidentiality • Act against this principle and you destroy patient’s trust • Clash –when keeping confidentiality would harm others eg child abuse • Should patients have access to their notes?
- 49. Against • Layman unable to cope with data • Opinions not facts cause anxiety • Third party information • Defensive medicine For • Data belongs to patient • Accuracy improved by sharing
- 50. Exceptions to Medical Confidentiality • Pt gives written and valid consent • To other participating professionals • Where undesirable to seek patients consent info can be given to a close relative • Statutory requirements • Ordered by Court • Public interest • Approved Research
- 51. Justice How to allocate scarce healthcare resources? 1. Medical need 2. Medical Benefits 3. Social worth-discriminates against underprivileged 4. Merits/contribution to society-very contentious 5. Desert 6. Market Forces 7. A lottery
- 52. More Problems in Medical Ethics • Doctors – social values • Doctors – formal regulations • Bio – revolutions • Bioethics & Modern Biotechnology
- 53. Eugenics • An effort to breed better human beings • Encourage “good genes” • Discourage “bad genes” • Fear of history – Sterilization of the mentally ill in early America Nazi concentration camps
- 54. Reproductive Cloning • Creating a genetically identical organism • Many animals have been successfully cloned
- 55. Human Cloning • Clonaid claims that they have the ability to clone humans
- 57. Therapeutic Cloning • Cloning Individual Human Cells • Involves Stem cells – precursor cells that give rise to specialized cells/multiple tissue types • Allows for the generation of human tissue and organs • Enhances our understanding of human development and serious medical conditions (cancer, birth defects, etc) • Embryonic vs Adult Stem Cells
- 58. Pre-Implantation Genetic Diagnosis (PGD) • Diagnosing inherited genetic disorders “in vitro” • Choosing which embryos will be transferred to the uterus based upon desired traits • Gender decisions • “Designer Babies?”
- 59. Genetic Testing • Individual risk assessment based upon a person’s DNA profile • DNA chip identifies genetic predispositions • Potential for genetic discrimination • DNA profiling? DNA banks?
- 60. Transgenic Plants • Engineered plants that contain novel genes from other species • Results in new characteristics that make plants more desirable and useful to humans • Are they safe to eat? • How do they affect the ecosystem?
- 61. Transgenic Animals • Engineered animals that contain novel genes from other species • Results in animals that are more desirable and useful to humans • Are they safe to eat? • Where do we draw the line?
- 62. Xenotransplantation • Harvesting organs from animals for organ transplantation into humans • Severe Organ donor shortage • Pigs – Perfect match! • Do we have the right? PETA • Dangers of Creating New Human Viruses
- 63. Finding a Balance • Focusing on whether or not “we could” • Instead of whether or not “we should” Weighing the Pros versus the Cons Acknowledging the tremendous responsibilities that must be faced with the information that we have acquired.
- 64. Summary Be a good doctor • Ethics – morallity : Good – bad, Wright – wrong, etc • Bioethics/medical ethics vs Modern Biotechnology • needs balancing religion Religion without science is lame, science without religion is blind Java: blaèn = dangerous