VALUE BASED ETHICSVALUE BASED ETHICS

Agus PurwadiantoAgus Purwadianto

-

KeputusanMedis

Keputusan etis

Pilar Keputusan Klinis/PH sehari2Biomedik

Info-medik

Indikasimedik

pilihan pasienkualitas hidup

fitur kontekstual

“Mindset non medis”Struktur Psiko-Sosio-budaya

BIOKULTURAL

VALUE

NEW MANAGEMENTNEW PARADIGM

NEW SYSTEM???

HIGHER EDUCATIONUNIVERSITY ?

PROCESSTO PRODUCESCIENCE OR

NEW INVENTION

EDUCATION/TYPHICAL LEARNING PROCESSTRUTH

SCIENTISTSCHOLAR

CIVILIZED & PROFESSIONALHUMAN RESOURCES

GLOBAL ECONOMY

HIGHER EDUCATION AS KNOWLEDGE AND CULTURE GENERATORS

Physician’s competence

Valid evidencePatient’s valuesPATIENT’S PREFERENCE

FROM STUDIES

JAMU DIPAKAI & BERMANFAAT(Riskesdas 2010)

INTI EVIDENCE BASED MEDICINE – modifikasi Sudigdo S

INTI RI’sJAMUOLOGY

“inter-subyektivitas”(bukan obyektivitas)

Saintifikasi Jamu

LEADING TOBIOCULTURAL MED

IDI KOLEGIUM nakestrad

BALITBANGKESKolegium peneliti

Akuntabilitas publik : papan nama + RM

EBMEBM THE CARE OF INDIVIDUAL PATIENTS SHOULD THE CARE OF INDIVIDUAL PATIENTS SHOULD

INVOLVE : the conscientious, explicit and judicious INVOLVE : the conscientious, explicit and judicious use of current best evidenceuse of current best evidence

Cochrane collaboration as Cochrane collaboration as ““officiallyofficially”” pooler of pooler of published SCIENTIFIC research published SCIENTIFIC research Improve cliniciansImprove clinicians”” knowledge & reading habit & computer knowledge & reading habit & computer

literacyliteracyProvides framework of teachingProvides framework of teachingDemocratization : juniors as best partners, >> Democratization : juniors as best partners, >>

communication Dr-Pat, >>> use of resourcescommunication Dr-Pat, >>> use of resources

HOW FAR VBM PENETRATE HOW FAR VBM PENETRATE HEALTH CARE SERVICES W/ HEALTH CARE SERVICES W/ EBM ?EBM ?

EBM : EMBEDDED PATIENTEBM : EMBEDDED PATIENT’’S VALUE S VALUE IDENTIFY : The best evaluated methods of health care > useless > harmful IDENTIFY : The best evaluated methods of health care > useless > harmful methods methods Enables Dr – Pat make better informed CHOICE & CONSENT decisionEnables Dr – Pat make better informed CHOICE & CONSENT decision

The objectives & trilogy of The objectives & trilogy of CLINICAL MANAGEMENTCLINICAL MANAGEMENT

1.1. To relieve his or her symptoms,To relieve his or her symptoms,2.2. To make him or her comfortable again.To make him or her comfortable again.3. To restore his or her sense of well-being.3. To restore his or her sense of well-being.a.a. ddiagnosisiagnosis ((to identify the cause of symptom and to identify the cause of symptom and

to decide on the natural of the illnessto decide on the natural of the illness);); b.b. ttreatmentreatment;; and and c.c. pprognosisrognosis (estimate (estimate of of how how longlong the the patient will patient will

be be ill ill duedue to to present present conditioncondition withwith or without or without treatmenttreatment).).

d.d. (Curran, W, J., 1982)(Curran, W, J., 1982)

WHAT ABOUT DRWHAT ABOUT DR’’S S SOUVEREIGNTY (TOTAL SOUVEREIGNTY (TOTAL INTEGRITY), AS THE INTEGRITY), AS THE PATIENTSPATIENTS’’ HERO? HERO?

Physician act as (only) AMPLIFIER (IN VITRO APPROACH) of Physician act as (only) AMPLIFIER (IN VITRO APPROACH) of THE THE ““CARTELCARTEL”” industry producing of EBM SCIENTISTS + industry producing of EBM SCIENTISTS + LEGALLY POSITIVISTIC MODERN REGULATORS ? LEGALLY POSITIVISTIC MODERN REGULATORS ?

VALUE …..VALUE ….. DECENCYDECENCY KINDNESSKINDNESS SYMPATHYSYMPATHY EMPATHYEMPATHY CARINGCARING DEVOTIONDEVOTION SERVICESERVICE GENEROSITYGENEROSITY

ALTRUISMALTRUISM SACRIFICESACRIFICE LOVELOVE

…….other GOODNESS.other GOODNESS

COMPONENT OF MEDICAL COMPONENT OF MEDICAL DECISION MAKINGDECISION MAKING

(ian Kerridge, 1998)(ian Kerridge, 1998)

SCIENTIFIC EVIDENCE (ebm)SCIENTIFIC EVIDENCE (ebm)PERSONAL EXPERIENCEPERSONAL EXPERIENCEPERSONAL BIASES & PERSONAL BIASES & VALUESVALUESECONOMIC & POLITICAL ECONOMIC & POLITICAL

CONSIDERATIONSCONSIDERATIONSPHILOSOPHICAL PRINCIPLES PHILOSOPHICAL PRINCIPLES

bioethical principlesbioethical principles

               

 

Healthy Community

& public’s prepathogene

sis

Patient’s individual/ Human suffering (bedside)

 

  Diagnosis Treatment Prognosis

 

  

 

3. Public Health 2. Clinical Sciences

4. Medical Humanities

 

 

 

  1. Biomedical Sciences

 

  

  

               

THE ROOT of MEDICAL SCIENCES UU DIKDOK no 20 th 2013

PHARMACEUTICALS/DEVICES as PRODUCTS HEGEMONY, “bench”

HOLISTIC MEDICINE # Science & arts # T&CM

Key characteristics of Key characteristics of good services delivery – good services delivery – WHO Health System WHO Health System StrengtheningStrengthening

COMPREHENSIVENESSCOMPREHENSIVENESS ACCESSIBILITYACCESSIBILITY COVERAGECOVERAGE CONTINUITYCONTINUITY QUALITYQUALITY

PERSON-PERSON-CENTEREDNESSCENTEREDNESS

CONTINUATIONCONTINUATIONACCOUNTABILITYACCOUNTABILITY

& EFFICIENCY& EFFICIENCY

Phenomenology Phenomenology of Medicineof Medicine

Patient’s perceptionPatient’s perception Finitude & dyingFinitude & dying ImaginationImagination Human personhoodHuman personhood HopeHope EmbodiementEmbodiement Illness Illness Emotive structure of Emotive structure of

abstract knowledgeabstract knowledge

Dr’s details of life-worldDr’s details of life-world Emphaty (of idiographic Emphaty (of idiographic

events) events) UniquenessUniqueness Interpretation Interpretation

hermeneuticshermeneutics Emotive structure of Emotive structure of

abstract knowledgeabstract knowledge Freely profess ability to Freely profess ability to

healheal

HEALTH & HUMAN RIGHTSHEALTH & HUMAN RIGHTS WHO Constitution: WHO Constitution: "the enjoyment of "the enjoyment of

the highest attainable standard of health the highest attainable standard of health is one of the fundamental rights of every is one of the fundamental rights of every human being..." human being..."

"The world needs a global health "The world needs a global health guardianguardian, a custodian of , a custodian of valuesvalues, a , a protector and defender of health, protector and defender of health, including the right to health." including the right to health." Dr Dr Margaret Chan, Director-General, WHO. Margaret Chan, Director-General, WHO. SETIAP ORANG BERHAK ATAS KESEHATAN – ps 4 UU Kes No. 36/2009

MEDICAL EDUCATIONMEDICAL EDUCATION

EBMEBM FORMAL CURRICULUMFORMAL CURRICULUM

SKILLSSKILLS TRAINING TRAINING

(TRANSMISSION OF (TRANSMISSION OF SPECIFIC SKILLS FOR SPECIFIC SKILLS FOR THE PREDICTABLE THE PREDICTABLE SOLUTION, ABILITY TO SOLUTION, ABILITY TO DOMINATE FACTS)DOMINATE FACTS)

MEDICINE AS SCIENCEMEDICINE AS SCIENCE

VBMVBM ESPECIALLY ESPECIALLY ““HIDDEN HIDDEN

CURRICULUMCURRICULUM”” ORIENTATIONORIENTATION EDUCATION (INQUIRY, EDUCATION (INQUIRY,

ADAPTABILITY, ADAPTABILITY, FLEXIBILITY, BE FLEXIBILITY, BE COMPASSIONATE & COMPASSIONATE & CARING DR)CARING DR)

MEDICINE AS ARTMEDICINE AS ART

VBM considerationVBM considerationTony Hope, J.Med.Ethics, 1995Tony Hope, J.Med.Ethics, 1995

Health care purchasingHealth care purchasingEBM as a tool to cut funding EBM as a tool to cut funding only highly relevant valid only highly relevant valid

evidence = reason to purchaseevidence = reason to purchase Critic to systematic bias into purchasingCritic to systematic bias into purchasing

Amount of effort of previous research Amount of effort of previous research Drug as Drug as ““OBJECTIVE WEAPONOBJECTIVE WEAPON”” after being FUNDED after being FUNDED

Ease quantification of desired outcomeEase quantification of desired outcomeAcute relieves : > dramatic than chronic disease Acute relieves : > dramatic than chronic disease

Public health perspective >< individual PatientPublic health perspective >< individual Patient’’s choices choice““best buybest buy”” logic > most effective treatment logic > most effective treatment

VBM > EBMVBM > EBM EBM : > DrEBM : > Dr’’s centered biass centered bias

Hierarchical evidence : RCT, DB, MA Hierarchical evidence : RCT, DB, MA ConsumerConsumer’’s section of Cochrane Collabs section of Cochrane Collab

Objectivity & rationality behind the medical data …..Objectivity & rationality behind the medical data …..Who determined the research question Who determined the research question ? ?

Fact : Value driven question behind the research Fact : Value driven question behind the research question !!! question !!! ““Why some hospital units had a high infection rate ?Why some hospital units had a high infection rate ?”” > than : > than :

““Do all women who undergo SC should be given an antibiotic Do all women who undergo SC should be given an antibiotic prophylaxis ?prophylaxis ?””

PatientsPatients’’ Involvements InvolvementsClinical Practice Guidelines (CPG) as the Clinical Practice Guidelines (CPG) as the

DrDr’’s monopoly ?s monopoly ?No !!! No !!! Patient & Public Involvement Patient & Public Involvement

Program Program Patients, consumers & public Patients, consumers & public Involvement : communication, consultation, Involvement : communication, consultation,

participationparticipation>>> in Scandinavian countries>>> in Scandinavian countries

VBM on patientVBM on patient’’s side : s side : BALLANCING the benefit – harmBALLANCING the benefit – harmPatientPatient’’s decision aids presenting optionss decision aids presenting options Individualised risk assesmentIndividualised risk assesmentProbabilities of benefits & downsides Probabilities of benefits & downsides

supporting choices of supporting choices of ““preference preference sensitive decisionssensitive decisions”” (of mass screening) (of mass screening)

PatientPatient’’s rationalitys rationality3 MU3 MU’’s : mujarab, mudah, murahs : mujarab, mudah, murahAccountability : Effective & QualityAccountability : Effective & QualityAccessibleAccessibleAffordable Affordable

HUMAN VALUESHUMAN VALUES

WHICH VALUES INFLUENCING HEALTH PROFESSION : WHICH VALUES INFLUENCING HEALTH PROFESSION : EXISTENCY, CLINICAL SETTING, RELIGION, CULTURE, EXISTENCY, CLINICAL SETTING, RELIGION, CULTURE, HUMAN DIGNITYHUMAN DIGNITY

Existency of Values : Existency of Values : 7 7 THREATS TO ETHICSTHREATS TO ETHICS

The Death of GodThe Death of GodRelativismRelativismEgoismEgoismEvolutionary TheoryEvolutionary TheoryDeterminism & FutilityDeterminism & FutilityUnreasonable demandsUnreasonable demandsFalse consciousnessFalse consciousness

Simon Blackburn, 2001

Clinical Setting AdvantagesClinical Setting Advantages More humaneMore humane

Full of phenomenology – Merleau PontyFull of phenomenology – Merleau Ponty Responsibility precedes the freedom - Levinas Responsibility precedes the freedom - Levinas Emancipating power – Juergen Habermas Emancipating power – Juergen Habermas

Plenty of contextualities – point of hermeneuticsPlenty of contextualities – point of hermeneutics Elective vs emergency, social vs individual, East vs Elective vs emergency, social vs individual, East vs

West, EBM vs VBM, biosafety vs biosecurityWest, EBM vs VBM, biosafety vs biosecurity Melting pot of theories/perspectives/paradigm Melting pot of theories/perspectives/paradigm

Biomedic vs infomedic – Foss & RothenbergBiomedic vs infomedic – Foss & Rothenberg Ethicolegal system - APEthicolegal system - AP

Agent of change & iatrogenicity ‘par excellence’ Agent of change & iatrogenicity ‘par excellence’

Agus Purwadianto, 2009

3 3 IhsanIhsan’’s componentss components Ikhlasun niyat Ikhlasun niyat : : melakukan pekerjaan dmelakukan pekerjaan dgg motif motif yygg

bersibersihh, murni k, murni krn rn AllahAllah = profesi luhur = tak ada = profesi luhur = tak ada sengaja misconduct/WCC sengaja misconduct/WCC . .

Itqanul amalItqanul amal : : rapi dalam bekerja rapi dalam bekerja patut, teliti, patut, teliti, hati2, sesuai indikasi medik & standar, spy mujarabhati2, sesuai indikasi medik & standar, spy mujarab

Jaudatul ada’Jaudatul ada’ : : melakukan dan menyelesaikan melakukan dan menyelesaikan pekerjaan hingga tuntaspekerjaan hingga tuntas : komprehensif : D/ Th/ s/d : komprehensif : D/ Th/ s/d Prognosis, mujarab, murah, mudah. Prognosis, mujarab, murah, mudah.

VALUEVALUE’’s origin : s origin : SECULAR vs Islamic EthicsSECULAR vs Islamic Ethics

Western Western bioethicsbioethics = rights-based, = rights-based, with a with a strong emphasis on individual rights, strong emphasis on individual rights,

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

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

ValueValue’’s source : s source : Human dignityHuman dignity Intrinsic value of every human being, equal Intrinsic value of every human being, equal

for all humansfor all humansBecause of the sole fact that he/she is human Because of the sole fact that he/she is human

Ricoer 1988, De Koninck, 1995Ricoer 1988, De Koninck, 1995

Respect for the inherent value of every Respect for the inherent value of every human being and of humanityhuman being and of humanity

““respect for autonomy” + spiritual respect for autonomy” + spiritual dimension of human existencedimension of human existence

Lenoir & Mathieu 1998Lenoir & Mathieu 1998Human : > biological & genetic levelHuman : > biological & genetic level

2 aspect of human dignity2 aspect of human dignity IndividualIndividual

Foundation of all rights & freedom Foundation of all rights & freedom Promoting self-determination & protect Promoting self-determination & protect

against any inhuman/degrading treatmentagainst any inhuman/degrading treatmentCollective Collective wholistic incl future wholistic incl future

generationsgenerationsSociety have a solidarity rights : society have Society have a solidarity rights : society have

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

Value - NormValue - NormValueValue Not concrete (no empirical-observational facts) Not concrete (no empirical-observational facts) subjective subjective

(basic/motivation of will, idea, hope and internal (basic/motivation of will, idea, hope and internal judgment/mind of human behavior/action explicitly or judgment/mind of human behavior/action explicitly or tacitly tacitly

NormsNorms ConcreteConcrete Value objectivation Value objectivation

Values Values Pre-moralPre-moral

Not refered to specific concrete norm of Not refered to specific concrete norm of human actionhuman action

MoralMoral Imperative of human to conduct or to refer Imperative of human to conduct or to refer

specific action of concrete norm; specific action of concrete norm;

Value Value Triad : Choosing, Prizing, ActingTriad : Choosing, Prizing, Acting

CanCan’’t be taught, but can be experienced t be taught, but can be experienced As basic cause of conflictAs basic cause of conflict

Category :Category :Value in itself (intrinsic value)Value in itself (intrinsic value)

PleasurePleasureHappinessHappiness

Instrumental value (extrinsic value)Instrumental value (extrinsic value)Good/right if the goal have been achievedGood/right if the goal have been achieved

NORMS (:modernity)NORMS (:modernity) Ethics (narrow interpretation) Ethics (narrow interpretation)

Goals of the goodness of personal life or clearness/purity of Goals of the goodness of personal life or clearness/purity of conscience (intra-personal principles). conscience (intra-personal principles).

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

socializing & enforcing determined-normssocializing & enforcing determined-norms Etiquette Etiquette

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

Religion/beliefsReligion/beliefs Goals of Goals of ““akhlakakhlak””/good behavior purification & celestial (world + /good behavior purification & celestial (world +

heaven) (intra-personal principles)heaven) (intra-personal principles)

Ethical justificationEthical justification

Claims of rights (goal oriented)Claims of rights (goal oriented)Claims of conscience (process oriented)Claims of conscience (process oriented)Distinguishing morality & ethicsDistinguishing morality & ethics

RightsRights= justified claims that a person can = justified claims that a person can

make on others or on societymake on others or on societyoften controversy : individual vs often controversy : individual vs

society, individual vs individual; society, individual vs individual; society vs societysociety vs society

ConscienceConscience= self-reflection + judgment about = self-reflection + judgment about

whether an action is right or wrongwhether an action is right or wrong= build a sense of wholeness or = build a sense of wholeness or

integrity & responsibility, not to feel integrity & responsibility, not to feel ashamed & guilty ashamed & guilty

Meaningful Life - theoryMeaningful Life - theoryLove incorporated to God (Plato, sufi-ism Love incorporated to God (Plato, sufi-ism

Islam, Kejawen)Islam, Kejawen)Pleasure-based (eudamonia)Pleasure-based (eudamonia)Virtue Ethics (Aristotle)Virtue Ethics (Aristotle)Pain-hindrancePain-hindrance’’s feeling (Epikurus)s feeling (Epikurus) Individual voluntariness incorporating with Individual voluntariness incorporating with

Natural Law as GodNatural Law as God’’s Law/sunatullah s Law/sunatullah (Stoa) (Stoa)

Meaningful Life – theory (2)Meaningful Life – theory (2) Love of God (Agustinus)Love of God (Agustinus) Follow the natural law (Love to God + virtue)Follow the natural law (Love to God + virtue) Not having, but being (Erich Fromm)Not having, but being (Erich Fromm) Freedom/autonomy of subject as moral Freedom/autonomy of subject as moral

resources (Kant)resources (Kant) World view/lebenswelt (Habermas)World view/lebenswelt (Habermas) etcetc

  

NILAI dlm Kode NILAI dlm Kode Etik Dokter RIEtik Dokter RI

    Kemurnian niat = sikap moral tanpa Kemurnian niat = sikap moral tanpa pamrih, rela berkorban/menolong pamrih, rela berkorban/menolong

    Kesungguhan kerja = Kesungguhan kerja = ketuntasan ketuntasan tindakan baik & adil, teliti hati2 tindakan baik & adil, teliti hati2

    Kerendahan hati = santunKerendahan hati = santun    Integritas ilmiah & sosialIntegritas ilmiah & sosial

kesesuaian kata-perbuatan/pikiran-kesesuaian kata-perbuatan/pikiran-sikap-tindak-perilaku = martabat sikap-tindak-perilaku = martabat profesi luhur (hormat diri sendiri & profesi luhur (hormat diri sendiri & adil) adil)   

VBE VBE FRAMING THE AGENT FRAMING THE AGENT’’S S ETHICAL THEORY ETHICAL THEORY

AGENTAGENT : : VIRTUEVIRTUE

ACTSACTS : DEONTOLOGI: DEONTOLOGI

ENDSENDS : TELEOLOGICAL: TELEOLOGICAL

CONSEQUENCESCONSEQUENCES : CONSEQUENTIALIST: CONSEQUENTIALIST (UTILITARIAN)(UTILITARIAN)

MEANINGFUL LIFE FIDUCIARY RELATION

Golden ruleKantianPlural

Goal-based

RELEVANCY OF VBM – RELEVANCY OF VBM – CATCHING DRCATCHING DR’’S IDENTITY & CHARACTERS IDENTITY & CHARACTER

COGNITIVE ETHICSCOGNITIVE ETHICS GOOD DOCTORSGOOD DOCTORS ETHICAL DRETHICAL DR

““ISOLATEDISOLATED”” ETHICS ETHICS (INDEPENDENT OF ITS (INDEPENDENT OF ITS PRACTITIONERS & PRACTITIONERS & EXTERNAL TO THE EXTERNAL TO THE PROBLEM AT HAND)PROBLEM AT HAND)

CULTURAL ETHICSCULTURAL ETHICS DRDR’’S WHO S WHO ““DO GOODDO GOOD”” DRDR’’S WHO ACT S WHO ACT

ETHICALLYETHICALLY ““INTEGRATEDINTEGRATED”” ETHICS ETHICS

(FUNCTION AS (FUNCTION AS INTEGRAL PART OF DRINTEGRAL PART OF DR’’s IDENTITY)s IDENTITY)

“GOOD “APPLICANT DR“GOOD” = SENSITIVE/CARING DR“BAD” = INSENSITIVE DR

SOCIALIZATIONSOCIALIZATIONMERTON, READER, KENDALL, 1957MERTON, READER, KENDALL, 1957

PROCESS BY WHICH PEOPLE ACQUIRE PROCESS BY WHICH PEOPLE ACQUIRE THE VALUES & ATTITUDES, THE THE VALUES & ATTITUDES, THE INTERESTS, SKILLS & KNOWLEDGE INTERESTS, SKILLS & KNOWLEDGE = THE CULTURE, IN THE GROUPS OF WHICH = THE CULTURE, IN THE GROUPS OF WHICH

THEY ARE, OR SEEK TO BECOME, A MEMBERTHEY ARE, OR SEEK TO BECOME, A MEMBER VBM = AS AN VALUE APPLICATION to the VBM = AS AN VALUE APPLICATION to the

STUDENT during SOCIALIZATION STUDENT during SOCIALIZATION About rightness/wrongness within overall culture About rightness/wrongness within overall culture

of medicineof medicine

Self reflectionSelf reflectionAre you a virtuous student ? Are you a virtuous student ? Do you understand the Do you understand the ““ambiguityambiguity”” of of

medicinemedicine’’s culture ? s culture ? Are you preparing to Are you preparing to ““act rightlyact rightly”” while while

maintaining maintaining ““your natural good characteryour natural good character”” ? ?

Self-reflectionSelf-reflection’’s vigilances vigilance

Are you preparing to Are you preparing to ““act rightlyact rightly”” while maintaining while maintaining ““your natural good characteryour natural good character”” ? ?

after internalize the after internalize the ““hidden valuehidden value”” which you got at which you got at the place between the : the place between the : blackboard – pen (not at the formal curriculum) ? blackboard – pen (not at the formal curriculum) ? ward A – ward B (at ward A – ward B (at ““corridorscorridors”” of the clinical ward, not of the clinical ward, not

““bedsidebedside””)?)?Lab C– lab D (at locker Lab C– lab D (at locker ‘‘s room, not s room, not ““benchbench””))Health centre A – posyandu B (at market, not health Health centre A – posyandu B (at market, not health

care facilities)care facilities)

Good doctorsGood doctors““combine combine

individualindividual clinical clinical expertise expertise andand best best available external available external evidence; evidence; theythey areare thoughtful, thoughtful, evidence based evidence based practitionerspractitioners

Good doctorsGood doctorsuseuse "intangible "intangible personal personal

resources" resources" in the care of in the care of their patients;their patients; …. …. attaches attaches toto vocationalism in vocationalism in medicine medicine and to theand to the personalpersonal qualities qualities required of its practitioners, required of its practitioners, includingincluding truthfulness truthfulness

Good Good doctorsdoctorsreflective turn of mind reflective turn of mind

open to audit open to audit and to and to learning fromlearning from

mistakesmistakes .... .... personal qualities more personal qualities more

prominently than prominently than proficiency in proficiency in knowledge and knowledge and technical skillstechnical skills..””

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

criticized EBM by raising the criticized EBM by raising the ““whatwhat’’s behinds behind”” questionquestion

DrDr’’s VALUE as the s VALUE as the ““subjectivesubjective”” core of meaningful core of meaningful life basis should be balance with Patientlife basis should be balance with Patient’’s & Public s & Public Involvements forming the virtuous Involvements forming the virtuous association/institution association/institution

VBE as a source of norms, are incorporated & VBE as a source of norms, are incorporated & embedded in every article Code of Medical Ethics & embedded in every article Code of Medical Ethics & Other health professionalsOther health professionals

Agus Purwadianto