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ETHICS AND LAW IN CLINICAL PRACTICE: PUBLIC HEALTH

Hanna Wijaya

, Yohanes Firmansyah

, Yana Sylvana

, Michelle Angelika S

, St.

Laksanto Utomo

University of National Development Veteran Jakarta, Indonesia

hannwijaya@yahoo.com

yohanesfirmansyah28@gmail.com

sylvanayana@gmail.com

michelleangelika111@gmail.com

laksanto@gmail.com

PAPER INFO ABSTRACT

Received:

November 2021

Revised: January

2022

Approved:

January 2022

Background: Public health is the study of disease prevention to enhance

individuals' quality of life. Since the 14

century, public health research has

grown in Indonesia.

Aim: This research aimed to discuss issues on the health sector, with the

primary area of debate being law.

Method: This research employs a systematic review of the literature, which

belongs to qualitative approach, that is organized by subject and then

thoroughly assessed.

Findings: Public health services are designed to help people improve their

health and reduce the risks of exercising their right to health. A multicultural

society is today's public-health concern.

KEYWORDS

Health, Public, Ethics

INTRODUCTION

Public health science is a synthesis of science and art aimed at preventing disease,

extending life expectancy, and optimizing health quality through varied initiatives to

coordinate diverse groups of people. Numerous attempts have been made to improve physical

and mental health, including improving environmental sanitation, eradicating infectious

diseases, and providing health education. Numerous efforts, such as infection control in the

community, individual education about personal hygiene, and the organization of medical and

care services for early diagnosis, disease prevention, and social development, will assist

everyone in the community in maintaining a healthy standard of living. Since the 14th century,

public health has developed in Indonesia.

The problems encountered in public health require multi-causal and multi-disciplinary

solutions, whereas public health as an art encompasses a range of activities that directly or

indirectly prevent disease (Preventive), improve health (Promotive), or provide therapy

(Physical, mental, or social therapy.) Public health as an art is a collaborative effort, for

example, environmental cleaning, providing safe drinking water, and food supervision. Public

health's primary objective is to improve the health of people, families, and specific groups, both

healthy and ill.

Public health services are supposed to contribute to both public health improvement and

risk reduction associated with exercising one's right to health. Today's public health problem

is a diverse society that embraces a pluralistic philosophy, which means that conflicts that may

occur as a result of such variables cannot be avoided (Karkee, 2014).

Based on the explanation above, the researchers were interested in studying the prevailing

ethics and law in the practice of public health since as implied before, public health is supposed

to contribute much to the general improvements.

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

METHOD

This is a multidisciplinary research that focuses on the health sector, with the primary area

of debate being law. This research will employ normative legal research methods. Normative

legal research explores law from within, with a focus on legal norms. The descriptive-

analytical-explanatory technique is employed, together with a juridical-normative legal

research method and a Statute Approach, to examine the fitness and compatibility of one law

with another, or between laws and the basic law, or between regulations and laws and

regulations. Then there is the Case Approach, which is based on an examination of cases

involving the issues at hand that has resulted in court rulings with lasting legal authority. The

data in this study are secondary, with primary legal materials including all Indonesian

legislation, secondary legal materials in the form of books and periodicals, and tertiary legal

materials in the form of dictionaries and encyclopedias. The technique used to collect data from

all available literature is library research, which is accomplished by reviewing library materials

in the form of statutory books and other written sources that are relevant to or related to this

research. The study's overall data were processed and examined qualitatively for further

description to create comprehension by describing, characterizing, and explaining the study's

outcomes. The deductive technique was employed to analyze the acquired data, which is a form

of thinking that begins with broad concepts and progresses to specific conclusions (Soekanto

& Mamudji, 2006).

RESULTS AND DISCUSSION

Ethics in Clinical Practice

According to Beauchamp and Childress (2008), to arrive at an ethical decision, a moral

foundation is required. The four fundamental moral rules are as follows.

The principle of autonomy

A moral principle that requires respect for the patient's rights, particularly the patient's

right to autonomy, which is defined as the right to choose the best course of action for himself

with full awareness and without coercion from any party. This moral premise eventually

resulted in the formation of an agreement known as informed consent. The idea of autonomy

is founded on the belief that each human can reason logically enough to create, choose, and

have decisions for themselves that are consistent with their thoughts. The idea of autonomy is

also a way of showing someone you appreciate them by allowing them to act logically and

without pressure. Several examples of the autonomy principle include the following:

1) Tell the truth or the true story

2) Be considerate of others' privacy

3) Confidentiality of information

4) Obtain consent to intervene on behalf of patients

5) Assist others in making critical decisions

The principle of beneficence

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

A moral principle that places a premium on the patient's welfare, both in terms of behavior,

treatment considerations, and all activities performed on the patient. Not only is beneficence

an act for the greater good, but it is also a premise that an action's benefits outweigh its

drawbacks. Not only is it necessary to accomplish something good, but also to take precautions

against the risk of wrongdoing or committing a crime. Occasionally, in the context of health

care, there is a clash between this ideal and autonomy. As an illustration, consider the

following:

1) Protect and defend the rights of others.

2) Avoid causing harm to others.

3) Eliminate hazardous circumstances that could endanger others.

4) Assisting individuals with a variety of disabilities.

5) Assist those in peril.

The principle of non-maleficence

A moral principle that specifically prohibits all behaviors or actions that have the potential

to deteriorate the patient's health worse than it was previously, also entails avoiding intentional

or unintentional damage to the patient's head. This principle is known as "primum non nocere"

or "above all, do no harm," which suggests that whatever we do, we must avoid causing harm

to the patient's head, whether physical or psychological. For instance, if a doctor's view about

delivering health care is unacceptable to the patient and his family, and if forced to do so, the

patient may suffer a loss.

The principle of justice

A moral principle that ensures that existing resources are distributed equitably following

one's share. By respecting moral ideals, he can achieve equality and legal justice with those

around him. Additionally, humanity. Examples include the following:

1) Each person receives an equal share;

2) Each person receives a share based on his need;

3) Each person receives a share based on his effort; and

4) Each person receives a share based on his contribution

5) For each individual following the benefits or uses

6) On a free-market exchange, for each individual

Public Health

The definition of public health is inextricably linked to the concept of health, which was

defined by the World Health Organization in 1947 as a state in which a person is in perfect

condition in three dimensions, namely physically, mentally, and socially, but not limited to

being free of certain diseases and weaknesses. According to Law Number 23 of 1992 on health,

health is a state in which a person is prosperous in terms of physical health, mental health, and

social health, enabling that person to live a productive social and economic life. (4) Mentally

healthy or mentally sound is a state of being in which an individual can achieve his or her full

Ethics and Law in Clinical Practice: Public Health

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

physical, intellectual, and emotional potential while also contributing to the growth of those

around him.

Socially, a person is said to be healthy if he or she possesses adequate ability to preserve

and improve his or her own and family's health in order to perform work that is balanced with

rest and vacation time. Based on these two definitions of health, it is possible to conclude that

health has four dimensions, which are physical (Body), mental (Soul), social, and economy.

These four characteristics demonstrate an interest and impact in the gift of achieving a high

standard of health, both individually and in groups, as well as in a community group. Thus,

health is a broad concept that encompasses a variety of aspects. Physically as well as

emotionally. If a person is unable to manage his or her emotions whether sad or pleased,

expressing them through loud shouting, crying, or out loud laughter, making it difficult to

return to normal conditions, that person is not healthy. This can also be seen physically; if they

are unable to improve their standard of living through education, employment, and interaction

with the surrounding community, they are classified as unhealthy.

According to the American Medical Association, AMA; Professor Winslow, public health

is the science and art of preventing disease, extending life, promoting physical and mental

health, and maximizing efficiency through coordinated community efforts to improve

environmental sanitation, infection control in the community, individual education about

personal hygiene, and organizing medical and nursing services for early diagnosis, disease

prevention, and social development.

Public health, as defined by the American Medical Association in 1948, is the science and

art of preserving, protecting, and enhancing public health via community organizing initiatives.

Public health is described as the coordinated application and action of sanitation and treatment

to prevent disease in the community or society. Public health is a synthesis of theory (Science)

and practice (Art) the prevent disease, extending life, and enhancing the population's health

(Community). Public health is the application of the integration of medical science, sanitation

science, and social science to the prevention of communicable diseases in communities (Tyler,

1995).

Public Health Target

Individuals, families, and special groups, both well and ill, are public health targets. Each

of these categories is defined as follows.

Individual

Individuals are considered family members if they suffer from health difficulties as a result

of their inability to care for themselves and if their condition has the potential to harm other

family members physically, mentally, or socially.

Relatives

The family is the smallest unit of society, consisting of the family head and other family

members who gather and live in a household due to blood ties and marriage or adoption ties,

reliant on and interacting with one another. If one or more families suffer from health problems,

it will affect other family members and families.

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

Special interest groups

A special group is a group of people who share the same gender, age, difficulties, and

structured activities and are therefore particularly sensitive to health problems. Examples

include the following (Spike, 2018):

1) Special populations with unique health needs due to growth and development, include

pregnant women, newborns, children under the age of five, school-aged children, and

the elderly.

2) Groups with unique health needs, such as those with infectious and non-communicable

diseases, who require supervision, advice, and care.

3) Categories at risk of diseases, such as prostitutes, drug and alcohol abusers, and certain

groups of employees.

4) Social institutions, including nursing homes, orphanages, rehabilitation centers, and

child care.

Implementation of Ethics in Public Health

Assisting health professionals and policymakers in considering moral dilemmas while

making public health policies or decisions. From 1960 to 1970, ethics has been largely

disregarded, resulting in frequent disagreements about how to allocate a matter. Moral

dilemmas are becoming more prevalent when new technologies are developed without proper

research on humans and their needs. People frequently disagree, as in the example of the first

artificial kidney gift, where there is disagreement over whether it should be given to Karen Ann

Quinlan for her to survive artificially despite her lack of cognitive value (Wild & Dawson,

2018).

In 1969, the Institute for Social, Ethics, and Life (now known as Senter Hastings)

established a foundation of ethics and key elements to aid in the analysis of moral challenges

in the health industry. In 1974, in response to various US reports, the American government-

funded academics to investigate human rights and moral norms for public health. One of the

successful studies conducted at the time was a report from Belmont, which included the

following ethical principles for doing research involving human subjects (Rajczi, 2016): Have

no malice, respect an individual's rights, and uphold the values of truth and justice.

The investigations with human subjects that followed the Belmont report concluded that

the three Belmont principles have aided researchers in resolving moral difficulties in their

study, particularly in public health research. At the moment, there is agreement that there is no

moral superiority between individuals. As a result, an ethical and moral dilemma arises

regarding the requirement for ethical and moral consent from study subjects, and the patient

has the right to decline treatment or research, which was previously assumed to occur

automatically without the need for agreement or consent. Informed consent agreements have

become a foundation for both the application of bioethics and its accountability to clinical

practice. This is also done with the fundamental idea of not doing anything bad or against the

patient's wishes (Wild & Dawson, 2018).

Medical ethics or research ethics have established the principle that everyone has the right

to choose what is best for themselves. Because public health practices have limited standards

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

for execution, they require a code of ethics and established points to assist them through moral

issues they encounter when carrying out their public health responsibilities. At times, a

violation of the code of ethics regarding patient confidentiality occurs when a report to the

government is required regarding the presence of a disease in the community. However, this

action is granted an exception and is not considered a violation of the medical code of ethics

because it is necessary to prevent the threat from spreading (Fika, Afandi, & Masdar, 2017).

Essentially, it enables public health practitioners to make the best judgments possible in

the numerous situations in which they find themselves, even if they are deemed to violate the

code of ethics. However, due to the difficulties associated with public health, human resources

involved in public health are frequently viewed as a branch of health services capable of

violating the code of ethics, due to the existence of exceptions for the greater good. As a result

of public health services' extensive responsibilities, it is vital to have a code of ethics and also

rules that are specially designed to serve as a reference for public health practitioners. The code

of ethics can serve as a reference as well as guidance for how public health practitioners should

conduct themselves in order to avoid violating the prior code of ethics and to reduce bad public

perceptions.

All codes of ethics are intended to promote public health as well as to regulate health

practitioners. The code of ethics is not limited to existing human resources, but also to goods

resources that are intended to improve the quality of existing public health. The ethics of public

health seeks to achieve understanding and clarity within existing boundaries so that the

dilemmas of public health practice can be addressed with sound reasoning and under societal

ethical rules (Spike, 2018).

The code of ethics that governs public health services must be written in such a way that

it is consistent with previously established human rights. These public health services are

expected to contribute to both public health improvement and risk reduction associated with

exercising one's right to health. Additionally, the public health services' code of ethics respects

the community's ideals of truth and justice. While there has been a standard operating procedure

for medical resources, there has been no such system for public health practitioners.

We currently live in a diverse society and embrace a pluralistic philosophy, which means

that conflicts that may develop as a result of this diversity cannot be entirely avoided. This is a

challenge in current public health practice, since it requires human resources to work

professionally, makes moral choices from a variety of moral dilemmas, and be under their

society's diversity (Kasuma, Sastra, & Tegnan, 2018).

The Facility and Infrastructure Shortage Dilemma

The condition of adequacy of the need for various health facilities/infrastructure to every

part of the community, and which can be provided without charge, is the ideal goal of public

health; however, due to the limited availability of these facilities/infrastructure, a distribution

is required that takes both the availability of goods and funding into account. Thus,

consideration must be given to a person's entitlement to medical assistance, whether using the

QALYs theory or the management allocation theory based on the individual's lifestyle.

According to the QALY theory, a person's life expectancy is calculated along with the

need for financial support for a medical operation. However, there are disadvantages to this

QALY strategy, including the fact that elderly persons have a lower likelihood of receiving an

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

intervention than young people. There are also limits to this QALY, as it does not take into

account a person's different comorbidities when assigning existing facilities/infrastructure. As

a result, it is sometimes referred to as a lifestyle allocation hypothesis. This approach

emphasizes an individual's responsibility for the quality of his or her own health. This

distinguishes those who are believed to have a lifestyle that contributed to the onset of their

current sickness from those who have the same ailment but are the result of a variety of

variables beyond their control. Thus, according to this view, it is more concerned with

individuals who cannot be held accountable for the onset of the ailment they are currently

suffering from. As a result, varied existing circumstances, based on requirements, benefits, and

fairness, will produce significantly diverse end outcomes and must be taken into account to the

maximum extent possible. QALY is a frequently utilized method, as it takes into account the

cost-effectiveness of life expectancy, and patients are more encouraged to take responsibility

for their health, according to lifestyle theory.

In practice, the priority assessment of patient treatment in Indonesia is left to the discretion

of each physician. Numerous regulations indirectly provide guidelines for allocating the best

facilities and infrastructure, such as the Minister of Health Regulation number 47 of 2018

concerning Emergency Services, which states that treatment is provided by health workers who

consider the patient's vital signs and general condition, medical needs, chances of survival,

available assistance, and prioritizing definitive treatment. According to Law 44 of 2009 on

Hospitals, if a hospital lacks suitable facilities and infrastructure, a referral system is used to

connect it to other hospitals that do, both horizontally and vertically, depending on the nature

of the problem. According to article 42 paragraph 2 of the Hospital Law, every hospital is

required to refer patients who require services that are not provided by the hospital.

National Health Insurance

A doctor's position as the spearhead of health services includes determining how existing

facilities/infrastructure should be allocated. This occurs as a result of many problems around

the fulfillment of one's right to health, as a result of people waiting too long to receive particular

treatment for their sickness, with NICE serving as a benchmark for providing health services.

So that the health services supplied can be carried out ethically, even more so when the costs

of implementation are low.

Because there is a notion that medical care is expensive if it is only given to one person, it

is unethical, even more so if the funds incurred for one person can be allocated to other persons

in need of less expensive treatment, thereby reaching a larger population. As a result, not all

treatments are possible, even when clinical research has demonstrated that certain treatments

can be employed to provide the optimal intervention for a disease. This is because there are

only a limited number of resources accessible to carry out these processes. Treatment and

existing medical interventions must strike a balance between efficacy and cost.

According to the Law of the Republic of Indonesia No. 24 of 2011 on the Social Security

Managing Body, national health insurance is a legal organization founded to administer a social

security program that provides social protection for all Indonesian citizens to meet their

fundamental needs. National health insurance is funded through social security contributions,

including contribution assistance, the growth of social security funds, the transfer of assets

from the social security program, and many other legal sources as permitted by applicable laws

Ethics and Law in Clinical Practice: Public Health

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

and regulations. As such, national health insurance is required to conduct and/or accept

participant registration, collect and manage contributions from participants and employers,

receive contribution assistance from the government, manage Social Security Funds for the

benefit of participants, and collect and manage data on insurance program participants. social

security, pay benefits and/or finance health care services following the social security

program's regulations, and notify participants and the general public about the social security

program's execution.

Appointment of Healthy Tissue as an Effort at Prevention

Considerations of the removal of healthy tissue from a person's body, notwithstanding the

danger of contracting a disease from the tissue. This is because preventive mastectomy is not

a novel operation, but patient demand for this procedure to prevent future disease is increasing.

The treatment of preventative mastectomy surgery is a critical medical concern for the

physicians who perform the procedure. Because breasts represent not just a lady, but also a

mother and a nurturing person. Psychological consequences may follow individuals who

commit it. The ethical concept of health care, which states that no harm should be done to the

patient, becomes a serious consideration while performing this preventative operation, and it

is also extremely difficult to defend.

Thus, if prophylactic mastectomy becomes commonplace in society, it is believed that

more extreme prophylactic operations would develop in the future as a result of an individual's

fear of contracting a disease from the healthy tissue he possesses. While this prophylactic

mastectomy may be justified to avert a more deadly condition in the future, it also respects the

patient's freedom to choose the most appropriate option, surgical or non-surgical, for himself.

Mastectomy has been regulated by the Minister of Health of the Republic of Indonesia's

Regulation No. 34 of 2015 on the Management of Breast and Cervical Cancer, which states

that breast cancer can be treated with mastectomy only if it has been proven by mammography.

However, there is no regulation stating whether it is legal or not to remove tissue that is

currently in good health despite genetic risk factors for future breast cancer.

Vaccination Rejection

If a mother refuses to immunize her child in the context of attempting to control and

eradicate numerous current diseases, then immunizing children is an attempt to achieve herd

immunity. However, immunization can cause a variety of side effects, including fever, redness,

local pain, and in some rare situations, febrile convulsions. As a result, some parents opt out of

this immunization campaign in favor of existing herd immunity.

As a result, it cannot be compelled to immunize a kid whose parents refuse. However, as

a result of this refusal of vaccination, the incidence of measles has increased in the United

Kingdom. This creates a demand for children to be immunized, albeit this cannot be compelled,

and the best decision for a child is again a personal choice for each parent. However, Article

33 of the Minister of Health's Regulation No. 12 of 2017 states that if an individual or group

of individuals takes intentional steps to obstruct the implementation of immunization, including

routine immunization, they may face sanctions under current legislation.

CONCLUSION

Ethics and Law in Clinical Practice: Public Health

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

Public health is the science and art of preventing disease, extending life, promoting

physical and mental health, and maximizing efficiency through organized community efforts

to improve environmental sanitation, infection control in the community, individual hygiene

education, the organization of medical services and treatments, for early diagnosis and disease

prevention, and the development of social aspects that will support everyone in the community

to have a sane life.

Public health problems are multi-causal, the solutions are multi-disciplinary, and public

health as an art encompasses a spectrum of actions aimed at preventing, promoting, and treating

disease. Individuals, families, and specific groups, both well and ill, who have health concerns

are considered public health targets.

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