The Norm of Medical Practice

Dr H Tatang Kartawan
TA 2008/2009
The Norm of Medical Practice is
Ethics and Law

Dr H Tatang Kartawan
TA 2008/2009
1. Consequently, ethics refers to :
a. moral values and norms that are to be guide for a people or a society in
regulating their conduct. In brief, it refers to value system.
b. a set of moral principles or values; in term it is ethic code.
c. the science of badness and goodness

2. MORAL
The term “moral” etimologically has the similar meaning to “ethic”, though they
derived from different languages, thus it refers to values or norms to be the
guideline for someone or a group in regulating their conduct. Amoral means
violating the current ethic values or norms that are valid in a certain society.
MORAL AND RELIGION
Inevitably religion has close relationship to moral.
• In daily life, religion brings about the most important and strongest motive for moral behaviour.
• In spontaneous reply to the question whether the conduct is permissible or impermissible (forbidden?), it is based
on favourability/prohibition in religion.
• There would appear : I am a religist and my religion forbides me to do it.
• Any religion contains moral study to be a guide as the way of life for every believer.
• Different religions may have slight different moral doctrines; however, in general, they are non-significant.
• The truth of faith is not necessarily proved (rationally), but believed. The truth comes from The God/Allah
(absolute truth).
• The relationship between religion and ethic bring about motivation and inspiration in order that all followers
obey the accepted faith-based values and norms.
MORAL AND LAW
As in the close relationship between moral and religion, there has been similar relationship
between moral and law.
• Law requires moral.
• In Roman Empire, there was a phrase saying that “Quid leges sine moribus” meaning
“what is a constitution if it is not with morality”
• Law may be less meaningful when it is not inspired by morality; without morality, law
is nonsense.
• On the other side, moral also requires law. Moral will be only a daydream when it is not
described definitely and institutionalized in society as the same way to law.
• In consequence, law can enhance morality and social impact. Appreciating other
people’s properties,for example, is one of the most important moral principles that led to
the elicitation of intelectual property rights.
At least there are 4 differences between law and moral
1. Law has been more codified than moral did; it has been systematically written and
arranged within legislation book; yuridical norms are much more certain, in contrast,
moral norms are subjective and more intruded regardingto ethical or non-ethical. In
law, there are a few uncertainty, but in moral , it is found much more.
2. Both law and moral regulate human conduct; however, law requires legality and
limits itself to the physical behaviour, whereas moral involves attitude.
3. Sanctions in law is different from those in morality. Law is underlined by social
desire, then by the state’s desire; for example, a traditional law to be considered as a
valid law, it should be acknowledged/legislated by the state.
4. In contrary to law, morality is based on norms. Hence, a society may alter a law, but
not a moral norm.
The International and National
(Indonesian) Medical Ethics

Dr H Tatang Kartawan
TA 2008/2009
 A. Indonesian Medical Ethics

1. Introduction
2. The Problems of Medical Ethics in Indonesia
3. Indonesian Medical Ethic Code
4. The Challenge in Indonesian Medical Ethic Code
1. INTRODUCTION
The discussion scope was both national and international, especially
and emphatically on the curriculum of Bioethics and Humaniora
for Faculty of Medicine, Padjadjaran University.
One of the constraints that has been disclosed here is about Human
Resources Development, the experts are still very scarce.
Nevertheless, the seminarists have successfully construct the
network of bioethics and humaniora in Indonesia.
In this chance, Indonesian Medical Ethics will be discussed here.
 KODE ETIK KEDOKTERAN
LATAR BELAKANG (1)

• Abad XXV sM Kode Eik pertama di Babylonia

• Abad V sM Sumpah Hippopcrates
• Abad XI M kembali ke Sumpah Hippocrates
• Nuremberg Code 1948
• International Code of Medical Ethics :
-> WMA 3rd London (England) Oct 1949

-> WMA 22nd Sydney Aug 1968

• KODEKI SK Menkes No 434/1983 Okt 1983
• KODEKI dan Pedoman Pelaksanaannya MKEK IDI
tahun 2001
 KODE ETIK KEDOKTERAN
LATAR BELAKANG (2)
Beberapa Deklarasi untuk menyempurnakan permasalahan Etik :
1. Deklarasi Helsinki (1964) tentang Penelitian dengan Subyek
Manusia.
2. Deklarasi Sydney (1968) dan Venice (1983) tentang Kriteria Mati
dan Penyakit Terminal dikaitkan dengan Transplantasi Organ.
3. Deklarasi Oslo (1970) tentang Pengguguran Kandungan.
4. Deklarasi Munich (1973) tentang Penerapan Teknologi
Administrasi.
5. Deklarasi Tokyo (1975) tentang Penggunaan Obat Terlarang.
6. Deklarasi Brussel (1985) tentang Bayi Tabung.
7. Deklarasi Madrid (1989) tentang Euthanasia dan Rekayasa
Genetik.
 KODE ETIK KEDOKTERAN
PERUBAHAN DARI WAKTU KE WAKTU

Terjadi karena :
• Perubahan sosio-kultural masyarakat.
• Kemajuan Ilmu dan Teknologi
Kedokteran.
• Perubahan Hubungan Dokter-Pasien (ada
pihak ketiga).
• Kompleksitas masalah kesehatan.
• Kompleksitas masalah Moral.
 ASAS ETIK KEDOKTERAN
(UNIVERSAL)

• Asas menghormati otonomi pasien (Principle of

Respect of the Autonomy).
• Asas kejujuran (Principle of Veracity).
• Asas perilaku beramal dan berbudi luhur (Principle
of Beneficence).
• Asas Keadilan (Principle of Justice).
• Asas tidak menyakiti atau merugikan
(Principle of Non-maleficence, Primum non Nocere).
• Asas kerahasiaan(Principle of Confidentiality)
 KODE ETIK KEDOKTERAN INDONESIA
FUNGSI KODEKI

1. Sebagai kode etik “umum”  Memuat Kaidah

Dasar Bio-Etika.
2. Sebagai kode etik “Spesialis”  Karena
spesialistik keilmuannya membawa kadar
etika tanggung-jawab lebih besar.
3. Memuat etiket sopan santun (antar sejawat).
4. Merupakan acuan untuk disiplin kedokteran
(setelah verifikasi keterangan saksi ahli) 
Pedoman memberikan sanksi kepada sesama
anggota profesi.
KODE ETIK KEDOKTERAN INDONESIA
CIRI-CIRI TINGGINYA MORALITAS KODEKI

• Berani berbuat sesuai tuntutan profesi

(Etika Epikurian).
• Sadar akan kewajibannya (Etika
Kantian).
• Memiliki idealisme tinggi (Etika
Aristotelian)
 Secara eksplisit tidak
tercantum dalam KODEKI.
2. THE PROBLEMS OF MEDICAL ETHICS IN
INDONESIA
Terminology
The origin of ethics is from two Latin words : Ethos and Mores
Here they involve mores of community and ethos of people,
respectively.
The problem that develops in ethic is ethic deviation, that is,
the evaluation is based on which one is right and which one
is wrong. Consequently, this perception is very difficult and
complex; because the perception is overviewed from each
individual points of view.
2. THE PROBLEMS OF MEDICAL ETHICS IN
INDONESIA
Terminology
Referring to “Tantangan Etika Kedokteran di Indonesia” (The
Challenges of Medical Ethics in Indonesia) (Samil,2001),
there are some points to take attention :
• What are to be the goodness and to be the badness
• What are to be wisdom and to be crime
• What are to desire and to reject
Further, three causes leading to the development of
medical ethics : Research, The evelopment of
medical science and technology, and moral
fundamental crisis; considered to be dilemma in
making decision.
The problems to ethics actually do not stand solely,
some of them are : the relationship among doctors,
patients, producers (manufacturers) of medical
equipments, Laws of Health or regulation are so
strict that some doctors hesitate to act, etc.
Saving life is a good ethical action, however, which
quality of life should be saved (?).
Qualified life, of couse, spends high cost; then, what next?
This consideration will lead the doctors to their own
conflicts. The problems that are not less important are as
follows :
• The pluralism of Indonesian nation with its characters and
cultures
• The uneven distribution of health services
• Tendency to ethic deviation
• The deviation in informed consent
• The deviation in medical recordings
• The deviation in medical researches
There are 2 aspects of ethic in medicine should be noticed :
1. Medical ethics (Etik Jabatan Kedokteran)
2. Ethics of medical care (Etik Asuhan Kedokteran)

1. Medical ethics
• Involving the problem concerning the doctor’s attitude against
colleagues, assistants, and people.
• Every profession possesses each ethics, such as : journalist ethics,
justice ethics, etc.

2. Ethics of the medical care

• Tends to ethos, however, the two words are related each other.
 INDONESIAN MEDICAL ETHICS CODE
HISTORY
The earliest ethic code in medical practice was published by
Mesopothamian tribe (Babylonian) about 2500 BC.
Hammurabi’s Ethic code was a code of conduct, i.e. a regulation for
attitude urged by doctor profession. Hippocratic oath itself ,
declaring the doctor conduct, is appreciated by doctors.
This oath was accepted in the glory of Greek about in the fifth
century BC.
Hippocratic oath protects the rights of patient and give rise a deep
and holy feeling of doctors without sanction or punishment for
doctor.
The most profound contribution to the history of medical ethic after
Hippocrates was a British philosophist Thomas Percival who
published Code of Medical Ethics in 1803.
The first Indonesian Medical Ethic Code was arranged during
Musyawarah Kerja Susila Kedokteran in Jakarta in1969. The
References were from The International Medical Ethic Code.
It had been completed in 1968 on The 22th Congress of The
World Association of Doctors.
The Indonesian Medical Ethic Code also underwent modification
in “Musyawarah Kerja Nasional Etik Kedokteran Ke-2” in
Jakarta. In 1983 , it was acknowledged that The Ministry
Decree No.434/Menkes/SK/ conscience /1983 dated October
20th, 1983 based on its commitment to be 20 articles.
In general, it can be differ into five parts :
1. General duty of doctor(9 articles)
2. The doctor’s duty on patents (5 articles)
3. The doctor’s duty on colleagues (2 articles)
4. The doctor’s duty on him/herself (2 articles)
5. Closure
KODE ETIK KEDOKTERAN INDONESIA
MKEK IDI 2001

MUKADIMAH

• Sejarah Kedokteran
• Falfafah
• Prinsip-prinsip
• Komitmen profesi
KODE ETIK KEDOKTERAN INDONESIA
KEWAJIBAN UMUM (1)

• Tentang Sumpah Dokter

• Tentang Profesi Dokter
• Perbuatan yang bersifat memuji diri
• Perbuatan yang melemahkan daya tahan
pasien
• Tentang penemuan baru
• Tentang kebenaran keterangan/pendapat
KODE ETIK KEDOKTERAN INDONESIA
KEWAJIBAN UMUM (2)

• Tentang pelayanan medis

• Bersikap jujur
• Tentang hak-hak
• Kewajiban melindungi hidup insani
• Kepentingan masyarakat
• Kerjasama dengan pihak lain
 KODE ETIK KEDOKTERAN
INDONESIA

KEWAJIBAN DOKTER TERHADAP PASIEN

• Bersikap tulus ikhlas

• Kesempatan pasien untuk berhubungan
dengan keluarga/penasihatnya
• Kerahasiaan pasien
• Tentang Pertolongan darurat.
 KODE ETIK KEDOKTERAN
INDONESIA

KEWAJIBAN DOKTER
TERHADAP TEMAN SEJAWAT

• Tentang perlakuan
• Tidak boleh mengambil alih pasien
dari teman sejawat
 KODE ETIK KEDOKTERAN
INDONESIA

KEWAJIBAN DOKTER TERHADAP DIRI SENDIRI

• Tentang memelihara kesehatan diri

• Mengikuti perkembangan Ilmu
Pengetahuan dan Teknologi
Kedokteran/Kesehatan
 THE CHALLENGES OF
INDONESIAN MEDICAL ETHICS
• The human thinking pattern is always continously changing
from year to year.
• The advances in medical science and technology to enhance
the quality of living influences the development of medical
science and profession.
• It induces the development of various problems including high
cost of medical care.
• The changes in social value system from common in the past
time to be uncommon at present.
• The society is becoming more critisizing and urging doctors
and medical centers to deliver their services better; and part of
the fact that a doctor can be accused in court.
• In anticipating the unexpected issue, medical profession requires the
guidelines of attitude and behaviour for doctors. The guidelines is so-
called Medical Code of Ethic.
• To implement the medical ethic, a doctor requires education in
religion including moral and good characters in human interaction.
• The most important is the necessity to comprehend fully and entend
the the code of ethic.
• By guidance of ethic code, expectedly a doctor can perform his
profession well, in consequence, the professional dignity can be kept
maintained.
 B. INTERNATIONAL MEDICAL ETHICS
International ethic code is used as main reference for every country.
International ethic code has several times undergone completion; the
last was in The 22th Congress of World Medical Association in
Sydney, Australia in 1968.
In order to add and complete consistent to the advances in medical
science and technology,Worl medical Association has made
declarations as follows :
a. Helsinki Declaration (1964): The study on Human Subjects
b. Sydney Declaration (1968) and Declaration of Venice (1983) :
Criteria of death and Terminal Diseases related to Organ
Transplantation.
 INTERNATIONAL MEDICAL ETHICS
c. Oslo Declaration (1970): Abortus
d. Munich Declaration (1973) : The adoption of
Technology in Administration
e. Tokyo Declaration (1975) : The Drug Abuse
f. Brussel Declaration (1985) : Bayi tabung
g. Madrid Declaration (1987) : Euthanasia and Genetic
Engineering
The medical ethic code and other documents on ethics and medical laws had ever been
published internationally, mostly by Word Medical Association. Some of the important
are :
1. Hippocratic Oath (century 4 BC)
Eventhough, the Greek Hippocrates is considered as The Father of Medicine, the
Hippocratic oath was thought not composed by Hippocrates himself; but based on
history, it was possibly by the surrounders of Hippocrates. This oath is known to be the
oldest on medica ethics and suprisingly long-standing great influence the professional
ethos of medicine along its history.
(Free-)Citation : “I swear in the name of Apollo and Asklepios and Hygycia and
Panaceia and all Gods and Godess, with their witness, that I will meet my swear and
decree in accordance to my capability and consideration.”
 2. The Constitution of World Health
Organization (WHO) 1946.

In The International Health Conference in New

York, 61 representatives of each country signed the
preambule of The constitution of WHO established in
1948, then, to be controversial.
Definition of Healthy : a state of complete physical, mental
and social well-being and not merely the absence of
disease or infirmity; and the acknowledgement of being
healthy as one of basic human rights.
 3. Nurenberg Code (1947)
After Second World War (1945), eventually it was known that
the doctors in Germany undertook violence in their medical
researches on prisoners (mostly Jewish ethnic).
The World condemned these experiments and the related doctors
were taken into allied court in Nurenberg. The judiciary elicited The
Nurnberg Code (1947) describing about ethics of biomedical
research.
In the 10-item document, a number of basic principles must be kept.
The longest description is the first article containing voluntary
agreement of the human subjects involved in biomedical studies; this
principle, in fact, is frequently violated in practice.
 4. The Geneva Code (World Medical
Association, 1948).
It was revised in 1968 and 1983.
It has humanitarian target of medical profession as the
reaction to criminal of German medical doctors.
The Geneva Declaration can be viewed as modern version.
 5. International Code of Medical
Ethics 1949
It was revised in 1968 and 1983.
This code of ethic was based on The Geneva
Declaration and codes of ethic from various modern
countries trying to formulate the principles of medical
ethic code that have been most common. In fact, the
national ethic code refers to it.
 6. The Helsinki Declaration (WMA 1964).
It was revised in 1975, 1983, 1989,
and 1996. There are many principles of
ethic for biomedical experiments with
human subjects presented in it.
 7. The Sidney Declaration (World Medical
Association, 1968)
The understanding of life aid in ICU results in the traditional
understanding about death must be reviewed. In fact, a patient can
rebreath and the blood circulation may still be running on in his body
on the assistance of very sophysticated technology. Consequently,
there a novel term so-called brain dead.
It is very important to determine the timing of death appropriately,
especially in a patient as an organ donor.
Since the time of the first heart transplantation happenedin 1967, The
22th General Congress of WMA in Sydney has been facing the new
situation; leading to establishing electroencephalography as the
important method for detemining the brain death.
 8. The Oslo Declaration (about
therapeutical abortion, WMA, 1970).

In the end of 1960s, some countries has begun to legislate

abortus provocatus, such as Britain with The Abortion Act
(1967), USA did it someyears later (1973).
In anticipating this new situation of medical profession, WMA
with its Statement on Therapeutic Abortion, without clear
suggested definition, permitted medical doctors to perform
therapeutical abortion with regarding to local medical
association commitment.
 9. The Tokyo Declaration (1975)
This declaration was accepted by The 29th Congress of
WMA in Tokyo. The objective was to present some guidelines
for medical doctors concerning non-humanitarian tortures and
other actions that are unhumanistic and humiliating through
arrest and imprisonment.
This guideline is required because many doctors were involved
in such practices.
 10. The Belmont Report (1978)
The principles and guidelines of ethic for protecting human subjects
participating in studies (The National Commission for Protecting Human
Subjects from biomedical and behavioral experiments).
It was one of the documents yielded by The National Commission for Protecting
Human Subjects from biomedical and behavioral research established by USA in
1974.
During its 5-year existence, the reports contained the guidelines of researches
involving fetus, child, prisoner, mental-disabled people, etc.
The final report formulated the principles of general ethic in reseach involving
human subjects.
Beside the concised introduction, this report also consisted of 3 parts :
1. Boundaries between practice and research.
2. Basic ethical principles
3. Applications
 11. The Lisbon Declaration on Patient’s
Rights (WMA,1981)
This right is related to the state of ill patients who
require health services. USA is the first country which
possesses it, called “A Patient’s Bill of Rights” (1973).
The Lisbon Declaration indeedly provided International Code
of Medical Ethics (1949) that merely talked of the doctor
obligations. This declaration said about the doctor obligation to
patient but on the orher side patients also have their own rights.
 12. The Declaration on Medical Doctor
Independence and The Profession
Freedom (WMA, 1986)
This declaration had been approved by The Congress of
WMA in California, USA.
It described and detailed point (b) of The Lisbon Declaration
(1981). Unlike The Lisbon Declaration was about the patient’s
rights, the declaration here highlightened the independence of
medical profession and medical profession freedom, in order
that doctor will side with patientconcern.
The regulation of health service costs.