VALUE BASED ETHICS

Agus Purwadianto

Biomedik

Indikasi
medik
Keputusan
Medis

Pilar Keputusan Klinis/PH sehari2

VALUE

Keputusan
etis

BIOKULTURAL

Infomedik

Mindset non medis

Struktur PsikoSosio-budaya

pilihan pasien
kualitas hidup
fitur kontekstual

HIGHER EDUCATION AS KNOWLEDGE

AND CULTURE GENERATORS
HIGHER EDUCATION
UNIVERSITY ?
PROCESS
TO PRODUCE
SCIENCE OR
NEW
INVENTION

TRUTH
SCIENTIST
SCHOLAR

NEW MANAGEMENT
NEW PARADIGM
NEW SYSTEM
???

EDUCATION/
TYPHICAL
LEARNING
PROCESS
CIVILIZED & PROFESSIONAL
HUMAN RESOURCES

GLOBAL ECONOMY

INTI EVIDENCE BASED MEDICINE modifikasi Sudigdo S

Saintifikasi Jamu

Physicians competence
IDI
KOLEGIUM nakestrad

BALITBANGKES
Kolegium peneliti

INTI RIs
JAMUOLOGY

LEADING TO
BIOCULTURAL MED

Valid evidence
Patients values
FROM STUDIES

inter-subyektivitas
(bukan obyektivitas)

PATIENTS PREFERENCE
JAMU DIPAKAI & BERMANFAAT
(Riskesdas 2010)
Akuntabilitas publik : papan nama + RM

EBM
THE

CARE OF INDIVIDUAL PATIENTS SHOULD

INVOLVE : the conscientious, explicit and judicious
use of current best evidence
Cochrane collaboration as officially pooler of
published SCIENTIFIC research
Improve

clinicians knowledge & reading habit & computer

literacy
Provides framework of teaching
Democratization : juniors as best partners, >>
communication Dr-Pat, >>> use of resources

EBM : EMBEDDED PATIENTS VALUE

IDENTIFY : The best evaluated methods of health care > useless >
harmful methods
Enables Dr Pat make better informed CHOICE & CONSENT decision

HOW FAR VBM PENETRATE

HEALTH CARE SERVICES W/
EBM ?

The objectives & trilogy of

CLINICAL MANAGEMENT
To relieve his or her symptoms,
2. To make him or her comfortable again.
3. To restore his or her sense of well-being.
1.

a.
b.
c.

d.

diagnosis (to identify the cause of symptom and

to decide on the natural of the illness );
treatment; and
prognosis (estimate of how long the patient will
be ill due to present condition with or without
treatment).
(Curran, W, J., 1982)

Physician act as (only) AMPLIFIER (IN VITRO APPROACH) of

THE CARTEL industry producing of EBM SCIENTISTS +
LEGALLY POSITIVISTIC MODERN REGULATORS ?

WHAT ABOUT DRS

SOUVEREIGNTY (TOTAL
INTEGRITY), AS THE
PATIENTS HERO?

VALUE ..
DECENCY

ALTRUISM

KINDNESS

SACRIFICE

SYMPATHY

LOVE

EMPATHY
CARING
DEVOTION
SERVICE
GENEROSITY

.other

GOODNESS

COMPONENT OF MEDICAL
DECISION MAKING
(ian Kerridge, 1998)

SCIENTIFIC

EVIDENCE (ebm)
PERSONAL EXPERIENCE
PERSONAL BIASES & VALUES
ECONOMIC & POLITICAL
CONSIDERATIONS
PHILOSOPHICAL PRINCIPLES
bioethical principles

THE ROOT of MEDICAL SCIENCES

UU DIKDOK no 20 th 2013
Healthy
Community
& publics
prepathogene
sis

Patients individual/ Human suffering

(bedside)
Diagnosis

Treatment

Prognosis

2. Clinical
Sciences

3. Public Health

4. Medical
Humanities

1. Biomedical
Sciences
PHARMACEUTICALS/DEVICES as
PRODUCTS HEGEMONY, bench

HOLISTIC MEDICINE #
Science & arts # T&CM

Key characteristics of
good services delivery
WHO Health System
Strengthening

COMPREHENSIVENESS
ACCESSIBILITY
COVERAGE
CONTINUITY
QUALITY

PERSON-

CENTEREDNESS
CONTINUATION

ACCOUNTABILITY

& EFFICIENCY

Phenomenology of Medicine
Patients perception
Finitude & dying
Imagination
Human personhood
Hope
Embodiement
Illness
Emotive structure of
abstract knowledge

Drs details of life-world

Emphaty (of idiographic
events)
Uniqueness
Interpretation
hermeneutics
Emotive structure of
abstract knowledge
Freely profess ability to
heal

HEALTH & HUMAN RIGHTS

WHO

Constitution: "the enjoyment of

the highest attainable standard of health
is one of the fundamental rights of
every human being..."
"The world needs a global health
guardian, a custodian of values, a
protector and defender of health,
including the right to health." Dr
Margaret Chan, Director-General, WHO.
SETIAP ORANG BERHAK ATAS KESEHATAN ps 4 UU Kes No. 36/2009

MEDICAL EDUCATION
EBM
FORMAL CURRICULUM

SKILLS
TRAINING
(TRANSMISSION OF
SPECIFIC SKILLS FOR
THE PREDICTABLE
SOLUTION, ABILITY TO
DOMINATE FACTS)
MEDICINE AS SCIENCE

VBM
ESPECIALLY HIDDEN
CURRICULUM
ORIENTATION
EDUCATION (INQUIRY,
ADAPTABILITY,
FLEXIBILITY, BE
COMPASSIONATE &
CARING DR)

MEDICINE AS ART

VBM consideration
Tony Hope, J.Med.Ethics, 1995

Health

care purchasing

EBM

as a tool to cut funding only highly relevant valid

evidence = reason to purchase

Critic

to systematic bias into purchasing

Amount
Drug

Ease

as OBJECTIVE WEAPON after being FUNDED

quantification of desired outcome

Acute

Public

of effort of previous research

relieves : > dramatic than chronic disease

health perspective >< individual Patient s choice

best

buy logic > most effective treatment

VBM > EBM

EBM

: > Drs centered bias

Hierarchical

Consumers

evidence : RCT, DB, MA

section of Cochrane Collab

Objectivity

& rationality behind the medical data ..

Who determined the research question ?
Fact

: Value driven question behind the research

question !!!
Why

some hospital units had a high infection rate ? >

than : Do all women who undergo SC should be given an
antibiotic prophylaxis ?

Patients Involvements
Clinical

Practice Guidelines (CPG) as the

Drs monopoly ?
No !!! Patient & Public Involvement
Program
Patients,

consumers & public

Involvement : communication, consultation,
participation
>>> in Scandinavian countries

VBM on patients side :

BALLANCING the benefit harm
Patients

decision aids presenting options

Individualised risk assesment
Probabilities of benefits & downsides
supporting choices of preference
sensitive decisions (of mass screening)

Patients rationality
3

MUs : mujarab, mudah, murah

Accountability : Effective & Quality
Accessible
Affordable

WHICH VALUES INFLUENCING HEALTH PROFESSION :

EXISTENCY, CLINICAL SETTING, RELIGION, CULTURE,
HUMAN DIGNITY

HUMAN VALUES

Existency of Values :
7 THREATS TO ETHICS

The

Death of God
Relativism
Egoism
Evolutionary Theory
Determinism & Futility
Unreasonable demands
False consciousness

Simon Blackburn, 2001

Clinical Setting Advantages

More

humane

Full

of phenomenology Merleau Ponty

Responsibility precedes the freedom - Levinas
Emancipating power Juergen Habermas
Plenty

of contextualities point of hermeneutics

Elective

vs emergency, social vs individual, East vs

West, EBM vs VBM, biosafety vs biosecurity

Melting

pot of theories/perspectives/paradigm

Biomedic

vs infomedic Foss & Rothenberg

Ethicolegal system - AP
Agent

of change & iatrogenicity par excellence

Agus Purwadianto, 2009

3 Ihsans components
Ikhlasun

niyat : melakukan pekerjaan dg motif yg

bersih, murni krn Allah = profesi luhur = tak ada
sengaja misconduct/WCC .
Itqanul amal : rapi dalam bekerja patut, teliti,
hati2, sesuai indikasi medik & standar, spy mujarab
Jaudatul ada : melakukan dan menyelesaikan
pekerjaan hingga tuntas : komprehensif : D/ Th/ s/d
Prognosis, mujarab, murah, mudah.

Abdallah S. Daar and A. Khitamy CMAJ January 9, 2001; 164 (1)

VALUEs origin :
SECULAR vs Islamic Ethics
Western

bioethics = rights-based, with a

strong emphasis on individual rights,
Islamic bioethics is based on duties and
obligations (e.g., to preserve life, seek
treatment), although rights (of God, the
community and the individual) do feature
in bioethics, as does a call to virtue
(Ihsan).

Values source : Human dignity

Intrinsic

value of every human being, equal

for all humans
Because

of the sole fact that he/she is human

Ricoer

1988, De Koninck, 1995

Respect

for the inherent value of every

human being and of humanity
respect for autonomy + spiritual
dimension of human existence
Lenoir

Human

& Mathieu 1998

: > biological & genetic level

2 aspect of human dignity

Individual
Foundation

of all rights & freedom

Promoting self-determination & protect
against any inhuman/degrading treatment
Collective

wholistic incl future

generations
Society

have a solidarity rights : society have

an intrinsic value as well (in a derivative way
from individual perspective)

Value - Norm

Value
Not

concrete (no empirical-observational facts)

subjective
(basic/motivation

of will, idea, hope and internal

judgment/mind of human behavior/action explicitly or
tacitly

Norms
Concrete
Value

objectivation

Values
Pre-moral
Not

refered to specific concrete norm of

human action

Moral
Imperative

of human to conduct or to refer

specific action of concrete norm;

Value
Triad

: Choosing, Prizing, Acting

Cant

be taught, but can be experienced

As basic cause of conflict
Category
Value

in itself (intrinsic value)

Pleasure
Happiness

Instrumental
Good/right

value (extrinsic value)

if the goal have been achieved

NORMS (:modernity)
Ethics

(narrow interpretation)

Goals of the goodness of personal life or clearness/purity of

conscience (intra-personal principles).

Law

Goals of peaceful social life (inter-personal principles) after

socializing & enforcing determined-norms

Etiquette

Goals of harmony of social life, esp. physical aspect (inter-personal

principles)

Religion/beliefs

Goals of akhlak/good behavior purification & celestial (world +

heaven) (intra-personal principles)

Ethical justification
Claims

of rights (goal oriented)

Claims of conscience (process oriented)
Distinguishing morality & ethics

Rights
=

justified claims that a person can

make on others or on society
often controversy : individual vs
society, individual vs individual;
society vs society

Conscience
=

self-reflection + judgment about

whether an action is right or wrong
= build a sense of wholeness or
integrity & responsibility, not to feel
ashamed & guilty

Meaningful Life - theory

Love

incorporated to God (Plato, sufi-ism

Islam, Kejawen)
Pleasure-based (eudamonia)
Virtue Ethics (Aristotle)
Pain-hindrances feeling (Epikurus)
Individual voluntariness incorporating with
Natural Law as Gods Law/sunatullah
(Stoa)

Meaningful Life theory (2)

Love

of God (Agustinus)
Follow the natural law (Love to God + virtue)
Not having, but being (Erich Fromm)
Freedom/autonomy of subject as moral
resources (Kant)
World view/lebenswelt (Habermas)

etc

NILAI dlm Kode Etik Dokter RI

Kemurnian niat = sikap moral tanpa

pamrih, rela berkorban/menolong

Kesungguhan kerja = ketuntasan
tindakan baik & adil, teliti hati2
Kerendahan hati = santun
Integritas ilmiah & sosial
kesesuaian kata-perbuatan/pikiran-sikaptindak-perilaku = martabat profesi luhur
(hormat diri sendiri & adil)

VBE FRAMING THE AGENTS

ETHICAL THEORY
AGENT :

MEANINGFUL LIFE
FIDUCIARY RELATION

VIRTUE

ACTS

: DEONTOLOGI

ENDS

: TELEOLOGICAL

CONSEQUENCES

(UTILITARIAN)

Golden rule
Kantian
Plural
Goal-based

: CONSEQUENTIALIST

RELEVANCY OF VBM
CATCHING DRS IDENTITY & CHARACTER
COGNITIVE ETHICS
GOOD DOCTORS
ETHICAL DR

ISOLATED ETHICS
(INDEPENDENT OF ITS
PRACTITIONERS &
EXTERNAL TO THE
PROBLEM AT HAND)
GOOD APPLICANT DR

CULTURAL ETHICS
DRS WHO DO GOOD
DRS WHO ACT
ETHICALLY
INTEGRATED ETHICS
(FUNCTION AS
INTEGRAL PART OF
DRs IDENTITY)
GOOD = SENSITIVE/CARING DR
BAD = INSENSITIVE DR

SOCIALIZATION

MERTON, READER, KENDALL, 1957

PROCESS

BY WHICH PEOPLE ACQUIRE

THE VALUES & ATTITUDES, THE
INTERESTS, SKILLS & KNOWLEDGE
=

THE CULTURE, IN THE GROUPS OF WHICH

THEY ARE, OR SEEK TO BECOME, A MEMBER

VBM

= AS AN VALUE APPLICATION to the

STUDENT during SOCIALIZATION
About

rightness/wrongness within overall culture

of medicine

Self reflection
Are

you a virtuous student ?

Do you understand the ambiguity of
medicines culture ?
Are you preparing to act rightly while
maintaining your natural good character ?

Self-reflections vigilance
Are you preparing to act rightly while maintaining
your natural good character ?
after internalize the hidden value which you got at
the place between the :
blackboard

pen (not at the formal curriculum) ?

ward A ward B (at corridors of the clinical ward, not
bedside)?
Lab C lab D (at locker s room, not bench)
Health centre A posyandu B (at market, not health
care facilities)

Good doctors
combine individual
clinical expertise
and best available
external
evidence; they are
thoughtful,
evidence based
practitioners

Good doctors

"intangible personal
resources" in the care of
their patients; . attaches
to vocationalism in
medicine and to the
personal qualities

use

required of its practitioners,

including truthfulness

reflective turn of mind

open to audit
and to learning from
mistakes ....
personal qualities more
prominently than
proficiency in
knowledge and
technical skills.

Good

doctors

CONCLUSION
Value

based ethics (VBE) is a tool to balance & to

criticized EBM by raising the whats behind
question
Drs VALUE as the subjective core of meaningful
life basis should be balance with Patients & Public
Involvements forming the virtuous
association/institution
VBE as a source of norms, are incorporated &
embedded in every article Code of Medical Ethics
& Other health professionals

Agus Purwadianto