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ETHICS AND LAW IN CLINICAL PRACTICE: PRINCIPALS OF HOW

TO UNDERSTAND AN ETHICAL DILEMMA

Yohanes Firmansyah

, St. Laksanto Utomo

health services. Services include what the health care profession does, how to do it, the

equipment used, and no less important is the results achieved from the service. The medical

profession is required to do the best in providing health services (Afandi, 2017; Suryadi &

Bioetika, 2009).

In the current global era, the medical profession is one of the professions that gets the

spotlight. The spotlight on the medical profession is a sign that currently some people are not

satisfied with health services and the service of the medical profession in the community.

Patient dissatisfaction occurs because of unbalanced communication between doctors and

patients, there is no relationship of trust between doctors and patients in the relationship that

occurs. According to Suryawati (2006) the cause of patient dissatisfaction is the delay of

Ethics and Law in Clinical Practice: Principals of How to Understand an Ethical Dilemma

466 Interdisciplinary Social Studies, 1(4), Jan 2022

Medical ethics is ethics for the medical profession that deals with moral issues that arise

in the practice of medicine. Ethics has been an important part of medical practice since at least

the time of Hippocrates, a Greek physician who is considered a pioneer of medical ethics in

the 5th century BC. Medical ethics is now considered a key fundamental component of the

essential knowledge and skills required for clinical practice. Medical ethics in Indonesia is

regulated by the Medical Ethics Honorary Council in the form of the Indonesian Medical Ethics

Code. The Indonesian Medical Code of Ethics is a reference and ethical standard for doctors

oath, the Indonesian Medical Code of Ethics, and professional standards can minimize or even

eliminate problems between doctors and patients, as well as with their families (Darwin, 2015;

Mappaware, 2016; Pelafu, 2015; Suryadi & Bioetika, 2009).

Based on the above background, the purpose of this study is to discuss clinical ethics,

health law and their implementation in clinical practice.

METHOD

This research is a multidisciplinary research, which elaborates on the health sector with

the main focus of discussion in the field of law. The type of research that was be used in this

journal research is normative legal research. Normative legal research examines law from an

legal force. The data used in this study is secondary data with legal materials used in this study

consisting of primary legal materials covering all regulations and regulations in Indonesia,

secondary legal materials in the form of books and journals, and tertiary legal materials in the

form of dictionaries and encyclopedias. The technique of collecting data from all literature is

in the form of library research, carried out by reviewing library materials in the form of

statutory books and other written sources, which are related or related to this research. Overall

data obtained from this study, secondary data processed and analyzed qualitatively for further

description in order to provide understanding by describing, describing and explaining the

results of this study. The method of thinking used in analyzing the collected data is to use the

deductive method, which is a way of thinking that starts from general things and then draws

Ethics and Law in Clinical Practice: Principals of How to Understand an Ethical Dilemma

467 Interdisciplinary Social Studies, 1(4), Jan 2022

RESULTS AND DISCUSSION

Bioethics in Clinical Practice (Definition, Types and Principles)

In the 20th century, bioethics has developed as a new academic and applied discipline due

to technological advances in the biomedical field. Bioethics began to develop when Van

Rensselaer Potter wrote a book Bioethics: Bridge to the Future in 1971. In the same year, The

Kennedy Institute of Bioethics was founded at Georgetown University, Washington DC. It is

here that the principles of biomedical ethics, popular in medicine, were formulated by

While the four derived rules consist of 1) Veracity (honest, providing accurate, timely,

reliable, and comprehensive information) (2) Privacy (respect for a person's right to control

access to himself) (3) Confidentiality (maintaining confidentiality) (4) Fidelity (faithful, keep

promises / contracts, and put the patient's interests first) (Henky, 2018).

In simple terms, ethics is the study of morality – a systematic and careful reflection on

morals and the analysis of past, present or future moral decisions and behavior. Morality is the

value dimension of human decisions and actions. The language of morality includes words

such as 'rights', 'responsibility', and 'good' and traits such as 'good' and 'bad' (or 'evil'), 'right'

and 'wrong', 'appropriate' and ' it is not in accordance with'. According to this dimension, ethics

is primarily how to know (Knowing), while morality is how to do it (Doing). The relationship

Two years later, in their second meeting, they formed the Indonesian Health Bioethics and

Humanities Network (JBHKI). In 2007, a non-degree program in Bioethics, Medical Law, and

Human Rights was held for clinical educators to educate medical students to meet the 2006

Indonesian Doctor Competency Standards, particularly in the field of Bioethics. This program

is organized by the Directorate General of Higher Education in collaboration with the Faculty

of Medicine, University of Indonesia, Jakarta (Henky, 2018).

Ethics is a branch of philosophy. In simple terms it can be said that ethics is a discipline

that studies the good and bad attitudes of human actions. Ethics is a philosophical part that is

closely related to human values in appreciating an action, whether it is right or wrong, and

whether the solution is good or not.

Ethics and Law in Clinical Practice: Principals of How to Understand an Ethical Dilemma

468 Interdisciplinary Social Studies, 1(4), Jan 2022

concepts that guide living things in thinking and acting and emphasizes their values (Soesetijo,

2015).

Ethics is concerned with humans personally with their "humanity", namely humans who

have been and are able to realize themselves in thinking, acting, speaking, behaving towards

other humans and (in) society, towards God the Creator and towards the environment in which

they live and all of their contents. Ethics, like philosophical methods, contains deliberation and

explicit arguments to justify certain actions (practical ethics). It also discusses the principles

on ethics and there is greater social pressure, sometimes even backed by law, to act on certain

terms. In such societies, culture and religion often play a dominant role in determining ethical

behavior (Williams, 2005).

As a branch of philosophy that deals with human behavior, ethics provides a standard or

assessment of that behavior. Therefore, ethics is divided into four classifications, namely

(Army, 2013) descriptive ethics (Only explain what is without giving an assessment of the

object being observed), normative ethics (Ethics that put forward an assessment of what is good

and bad, and what people should do), individual ethics (Ethics whose object is humans as

individualists. Relating to the meaning and purpose of human life), social ethics (Ethics that

discusses human behavior as social beings and their interactions with other humans). Both in

hesitation sometimes ask for an explanation of the recommendations given by doctors because

they are different from advice obtained from other health practitioners or from the internet.

Some procedures that were once only performed by doctors can now be performed by

technicians, nurses, or paramedics. Despite these changes affecting the status of physicians,

medicine remains a profession that is highly valued by sick people who need services.

Medicine also continues to attract a large number of talented, hardworking, and dedicated

students. To meet the expectations of patients and students, it is important for doctors to meet

the expectations of patients and students, it is important for doctors to know and provide

examples of the core values of medicine knowing and exemplifying the core values of

medicine, especially compassion, competence, and autonomy (Williams, 2005).

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469 Interdisciplinary Social Studies, 1(4), Jan 2022

a branch of practice that provides a structured approach to identifying, analyzing and solving

ethical issues in clinical practice (Afandi, 2017).

Doctors are often faced with situations of uncertainty in making decisions, including in

making a diagnosis, determining treatment options or management to resolve clinical problems

faced by patients. Decision making on ethico-medicolegal sensitive clinical issues is also faced

with the same problem, namely uncertainty. Doctors must be skilled in making clinical

decisions as well as ethically-medicolegal that can be accounted for without ultimately feeling

do it. A few dentists who commit such violations will reduce public confidence in dentists, thus

leveling this view towards all dentists. It seems that even though dentists have tried to carry

out their professional duties in accordance with professional standards and the guidelines for

their implementation are in accordance with the dental code of ethics, there are still some

doctors who are in the public spotlight with various accusations (Soesetijo, 2015).

The application of medical science and technology cannot be separated from social and

ethical aspects. Doctors who lack a deep understanding of ethics need systematic tools to be

able to make medically correct and ethically correct clinical decisions (Romadhon, 2013).

The main purpose of the practice of the medical profession is to overcome suffering and

restore the health of the sick. There are sick people (Patients, sufferers) and even in a simple

Patients as those who need help believe that doctors can cure their illness. Meanwhile, the

doctor also believes that the patient has given the correct information about his illness and he

will obey all the doctor's instructions (Suryadi & Bioetika, 2009).

Good medical services are those that can meet the needs of the community, are of high

quality and affordable. To be able to provide quality complete medical services (Preventive,

promotive, curative and rehabilitative) is not only determined by knowledge and skills, but also

by behavior (professional behaviour), ethics (bioethics), morals and law (Suryadi & Bioetika,

2009).

In the treatment of patients in the clinic, after medical indications, management is also

determined by "art" based on the basic principles of bioethics. The prima facie principle implies

Ethics and Law in Clinical Practice: Principals of How to Understand an Ethical Dilemma

470 Interdisciplinary Social Studies, 1(4), Jan 2022

Respect for human dignity (Respect for person/autonomy)

First, every individual (Patient) must be treated as a human being who has autonomy (The

right to self-determination), and second, every human being whose autonomy is reduced or lost

needs to be protected. In the context of autonomy, prima facie here appears (Changed into or

in a state) in the patient's figure who is mature and has a mature personality to determine his

own destiny. In addition, autonomy principles are the principle of autonomy is the basis of the

doctrine of informed consent and medical action against a patient must obtain consent

patient is a normal condition and applies to many other patients, so that the doctor will do what

is best for the benefit of the patient. Doctors have calculated that the good that will be

experienced by the patient will outweigh the harm. The prima facie principle is that something

changes into or is in a general state (Soempiet, 2013).

Beneficence principles are: 1) Positive principle beneficence (Prevent evil or harm,

remove evil or harm, do or promote good); and 2) Balancing Principle of utility/proportionality

(Balancing of benefit and harm).

Do not do harm (non-maleficence)

Medical practitioners must choose the treatment with the least risk and the greatest benefit.

evil or harm, remove evil or harm, do or promote good); and 4) Double effect principle

(Harmful actions are not always considered bad actions).

Justice and Equality

Differences in social position, economic level, political views, religion and beliefs,

nationality and citizenship, marital status, and gender differences should not and cannot change

the attitude of doctors towards their patients. There are no considerations other than the health

of the patient that are the primary concern of the doctor. Prima facienya in (change into or in a

state of) the context of discussing the rights of others other than the patient himself. The rights

of other people, especially those who are the same or equal in experiencing health problems

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471 Interdisciplinary Social Studies, 1(4), Jan 2022

medical ethics. The discussion in medical ethics is more focused on the moral foundation that

governs the doctor-patient relationship. The concept of this relationship will further sharpen

clinical decisions that will be made by doctors in various situations, so that standards of

professional behavior will be set.

Quality of Health Services and Ethical Decision Making

Slowther et al. defines clinical ethics services as providing advice and support to ethical

consultation. These functions support the main objective of clinical ethics services, namely

improving the quality of health services (Singer, Pellegrino, & Siegler, 2001; Anne Slowther,

Johnston, Goodall, & Hope, 2004).

Clinical ethics services can improve the quality of patient care. Singer, et al suggested that

the main goal of clinical ethics services is to improve the quality of care and patient recovery.

It is important to note that patient-oriented health care is an obligation that must be fulfilled by

health care providers in modern times. Most of the ethical problems generally arise directly

during patient care, for example not respecting and respecting patient dignity, not

communicating patient information properly, not having compassion, and so on. The non-

application of "microethics" will certainly provide a bad experience for patients, thereby

will guide clinicians to behave professionally when dealing with patients. This support is

expected to encourage doctors to practice microethics in their daily health care activities. Thus,

there is a strong relationship between ethics and service quality, namely the quality of health

services is built on ethical standards and principles, while ethical clinical practice improves the

quality of health services. The two things cannot be separated (Nelson & Gardent, 2008; Singer

et al., 2001).

Clinical ethics services can improve the quality of ethical clinical decision making. This is

in line with one of the main functions of the clinical ethics committee, which is to provide case

consultation. Siegler and Singer emphasize that the primary role of an ethics consultant is to

assist in sound clinical decision making. Ethics consultants play a very important role in dealing

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472 Interdisciplinary Social Studies, 1(4), Jan 2022

consulting services by seeking experienced ethics consultants who understand local wisdom.

Of course, clinical ethics consultation is very useful to facilitate discussion and help both

parties to identify, understand, and manage ethical issues towards mutual agreement (Kerridge

et al., 2001; Nilson, Acres, Tamerin, & Fins, 2008; Singer et al., 2001).

Legal Aspects of Clinical Ethics Services

The most important benefit of clinical ethics services is to prevent lawsuits against medical

addition, the results of the clinical ethics committee discussion regarding some difficult cases

can be considered as a representation of moral values in society because the decisions taken

come from various perspectives, namely doctors, philosophers, ethicists, nurses, patients,

families, sociologists, lawyers, anthropologists. , and even religious scholars. In the event of a

legal dispute in health care, as found in the Quinlan case, the court may consider the

recommendation of the clinical ethics committee as a formal procedure or expert testimony as

part of the judicial process (Bacchetta & Fins, 1997; Anne Marie Slowther & Hope, 2000).

Some experts have mistakenly assumed that decisions made by clinical ethics committees

were paternalistic in nature. The reason is that the meetings held by these experts were secret

and closed, without transparent procedures, so that no one knew how the process of justification

anticipate. Legal responsibility may be attached to clinical ethics committees and they may be

deemed negligent if they make inappropriate recommendations. When clinical ethics

committees provide advice regarding the care of a patient, they should also share responsibility

for that patient. However, medical negligence is only proven if the following four things are

found: (1) there is an obligation, (2) a violation of the fulfillment of these obligations, (3) losses

that occur as a direct consequence of the violation of these obligations, and (4) there is no

evidence of negligence from opposite party (Cheluvappa & Selvendran, 2020; Larcher, 2009).

The clinical ethics committee has no obligation to the patient, but to the physician seeking

advice. Although ethics consultants can be considered part of the healthcare team and therefore

have an obligation to care for patients, it must be proven that there has been a breach of that

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473 Interdisciplinary Social Studies, 1(4), Jan 2022

a previously anticipated adverse event persists, there may be a causal relationship between the

incident and the clinical ethics committee's instructions. However, this condition only occurs

in authoritative clinical ethics services. If the recommendations of the clinical ethics committee

are not binding, in other words doctors have the choice to follow or not follow the

recommendations of the clinical ethics committee, of course doctors are fully responsible for

events that result from their own choices. In addition, in the United States, where clinical ethics

consulting services have been established since 1971, there is no evidence that clinical ethics

about their illness, the right to accept/reject treatment plans). It is also a concrete act of respect

for the health community for individual rights. considering the need and importance of limiting

the authorization of health workers to patients is also something that can be released (Widjaja

& Firmansyah, 2021).

Provide legal protection for the implementers of medical actions from unreasonable

demands from the patient, as well as the consequences of unexpected and negative medical

actions, for example against "risk of treatment" which is unavoidable even though the doctor

has acted carefully and thoroughly and in accordance with with the standards of the medical

profession. As long as this happens within certain limits, it cannot be blamed, except if you

make a big mistake due to negligence or ignorance which would not actually be done that way

this obligation only burdens health workers, while the risks faced in certain medical services

are quite high. In this case, informed consent is defined as the embodiment of the principle of

prioritizing the interests of the patient, but the interests of the health worker are neglected. In

addition, there are also those who interpret that written informed consent from the patient can

be used as evidence of the existence of errors in medical actions carried out by health workers.

Based on the principle of no harm, the stipulation of the requirements for informed consent is

precisely aimed at ensuring that health workers can avoid the slightest risk for the benefit of

their patients.

In order to avoid the demands of patients against health workers, written informed consent

is stated in the condition that health workers are not prosecuted in the future. The intended