ETIKA AKADEMIKAcademic Ethics

The Introduction Lecture at the“Post graduate Program, Faculty of Medicine, Public Health and Nursing”

UGM, 2019

Soenarto SastrowijotoCenter for Bioethics and Medical Humanities

Faculty of Medicine, Public Health and Nursing, UGM

IntroductionI. The Reformation of Higher Education (20th and 21st century)II. The Past – Present – Future BioethicsIII. Bioethics in

a. Educationb. Researchc. Practices/Services

IV. Etika Akademik/Academic EthicsV. Discussion and ConclusionReferences

Introduction

Values and ethics in medical and health education have beendiscussed since ancient times. Such of examples in China (2838 –2698 BCE), in Babylonia (code of Hammurabi, 1780 BCE), in theSanskrit document India (1500 BCE). Ethics also has been in themedical and health curriculum in China (AD 618-906), in Rome(Galen, AD 700), and in Arabia (Al Ruhani and Ibnu Sina in theirbook Canon of Medicine, AD 900 – 1200). After the 17th century,medical education developed continuously and was led byAmerica

(Calman, 2007)

The Reformation of Higher Education (20th an 21st century), development from informative-formative-transformative-new transformative curriculum/learning.The Development of ethics – biomedical ethics – bioethics – and

new sense of bioethics.The History of bioethics will be basically clarified, from past-

present- future bioethics.What is really Academic Ethics? (Etika Akademik?)

(Calman, 2007)

I a. Reformations of Higher (Medical) EducationAbad Generasi Reformasi Proses/Objektif Keluar

20 I Informatif• Kurikulum• Pembelajaran

• Kuliah tatapmuka

• Praktikum; Etika• Ujian

Ahli (expert) Dokter

II Formatif• Kurikulum• Pembelajaran

• Idem I• Nilai/Etika/Bioeti

ka• Inovasi : PBL, SGD

Profesional

21 III Transformatif• Kurikulum• Pembelajaran

• Idem II• Kepemimpinan• Pengelolaan• Bioetika baru

Agen perubahan :Toleransi baru padaperilaku transdisiplin

IV Transformatif Baru• Kurikulum• Pembelajaran

• Idem III• Bioetika

terbarukan

Panutan, Inspirator

Nicolescu B, 1997; Frenk et al, 2010; Sastrowijoto, 2011,2018)

Ib. Higher Education Management Process

Masukkan(Input)• Kualitas

mahasiswa, dosen

Proses (Process)• Kualitas belajar,

pembelajaran

Hasil(Output)• Kualitas

lulusan S1, S2, S3, Spesialis, Konsultan

Kinerja(Outcome)• Kualitas

kinerja yang ditunjukkan

Pengaruh (Impact)• Kualitas kesehatan

perseorangan, komunitas

Kurikulum:• Konvensional• Inovatif

• Informatif• Formatif• Transformatif• Transformatif baru

Sumber daya• Manusia• Fisik• Dana• IT

Sastrowijoto, 20176

The Past

• What is ethical is what God tells us is right

The Present

• What is ethical is rational deliberation of facts, values, and theories to make a decision authentic to the self

The Future

• What is ethical is what algorithm calculate is right

• Bioethicist superfluous• A machine occupies the

prime place in the universe

• The future bioethics shaped by new thinking about human based in biology and computer science might find bioethicist superfluous

II. The Past, Present, & Future of Bioethics

(Klugman C, 2019)

In summary, the future of bioethics will be very important and has avery serious responsibility for the moral development from time totime, among various generations, and is not only the relationshipamong human being, but also among human and animal, humanand plantation, especially human and God.

(Klugman C, 2019. A short future of bioethics)

The Present of Bioethics

1. Potter (1960)2. Potter (1970)3. Potter (1971)4. Callahan (1973)5. Callahan (1999)6. Belmont Report (1979)

7. Beauchamp & Childress (1979)8. Soukhanov et al (1996)9. Khushf (2004)10. Nazim (-)11. Callahan (2004)12. Widdow (2011)13. Sastrowijoto (2014)

III. Bioethics in Education, Research, & Services/Practice

1. Educationa. Systematic review of: 1290 – 1332 – 238 – 175 – 134 articles.

Professionalism in medicine is an extraordinarily complex phenomenon, in a complex social system

Curriculum Design

Student Selection

Teaching Learning Methods

Role Modeling

Assessment Methods

29 9 40 19 37

(Passi et l, 2010)

TeachingLearning

Input Process Output Impact

Graduate’sCompetenciesas MD

ProfessionalQuality of Students, Lecturers, and Admin

Curriculum• Conventional

• Innovative

Resources• Human• Physics• Funding• Information's technology

Quality of Quality of Quality of Quality of

Outcome

- Competitive

- Collaboration

b. The complex process of medical education (higher education)

Sastrowijoto, 2004

Health Status

11

c. Educational Reformation for The 21st Century

Abad Generasi Reformasi Proses/Objektif Keluar

20 I Informatif• Kurikulum• Pembelajaran

• Kuliah tatapmuka

• Praktikum; Etika• Ujian

Ahli (expert) Dokter

II Formatif• Kurikulum• Pembelajaran

• Idem I• Nilai/Etika/Bioeti

ka• Inovasi : PBL, SGD

Profesional

21 III Transformatif• Kurikulum• Pembelajaran

• Idem II• Kepemimpinan• Pengelolaan• Bioetika baru

Agen perubahan :Toleransi baru padaperilaku transdisiplin

IV Transformatif Baru• Kurikulum• Pembelajaran

• Idem III• Bioetika

terbarukan

Panutan, Inspirator

Nicolescu B, 1997; Frenk et al, 2010; Sastrowijoto, 2011,2018) 12

d. Medical Education – Undergraduate, Post Graduate, PhD

Basic ME•Undergraduate (Blocks)•Graduate/ clinical rotation

Postgraduate•Master/ Doctorate•Specialist/ Sub Specialist

CPD

UGM implemented the concept of teaching medical ethics in a continuum process, from undergrad –graduated – post grad CPD (Continuing Professional Development)

A Continuum process of bioethics teaching in medical education (Basic, Postgraduate, Continuing Professional Development)

1. Lecture2. Tutorial3. Lab. Works4. Field work5. Self directed

learning6. Campus

environment

(Sastrowijoto, 2006)

In discussing the ethics in medical education, in this case the ethics could be developed to bioethics and HELPapproach could be implemented.As a physician-educator, Society of Teaching and Learning Higher Education (STHLE) included medicalteacher, developed Nine Principles in University Teaching. These principle consisted of:

1) Content competent2) Pedagogical competent3) Dealing with sensitive topic4) Student development5) Dual relationship6) Confidentiality7) Respect for colleagues8) Valid assessment for students9) Respect for institution

(Murray et al, 1996)

e. Nine Principles in University Teaching

UGM Experiences (2009)On Professionalism

Professionalism Challenges1) Altruism and advocacy2) Respect, responsibility and

accountability3) Honor, honesty and integrity4) Life long learning and limit of

knowledge5) Effective communication6) Leadership and management

1) Abuse of power2) Breach confidentiality3) Arrogance & greedy4) Conflict of interest5) Lying & Freud6) Discrimination7) Etc

(Kansas Univ., 2001; Sastrowijoto el al, 2009)

2. Bioethics in ResearchI. The quality and standards in: medical and health research and its

publication.The three steps: prior, during implementation and after the study.1. Prior step

a. Research proposal and protocol developmentb. Scientific validityc. Ethical approval/ clearance, from internationally recognized body

of IRB (Institutional Review Board)d. Informed consent

The board (DMC, CIC, DSMB) developed by sponsor(s) and researcher(s). DMC: Data Monitoring Board; CIC (Conflict of Interest). DSMB (Data and Safety Monitoring Board); and they main goals are to observe, analysis and report.

2. During Research Implementationa. Sampling, data, organization, analysis and result of study. Quality of data,

competence research assistant, statistics, scientific misconduct (fraud, fabrication, falcification), MTA (Material Transfer Agreement), ABCFG partnership.

b. Discussion of result, conclusion, summary and recommendation.c. Writting reportd. QA (Quality Assurance) of research

3. After studya. Writting, publish, PI, Co-PIb. Intellectual property right, sharing benefit, MTA

II. The Ethics of WrittingA Scientific Manuscript of Publication

3. Practice/carea. General principles of clinical ethics (Forrow et al, 1999) Fundamental principles Shared decision making Rules, medico legal perspective Some cases Keep in mind Some questions on what are the important Ethical disagreement Preventive ethics

b. Four Box Approach/ Methods (Jonsen et al, 2010) (Fig. 4)• MEDICAL INDICATION • PATIENT/ FAM. PREFERENCES

Principles of beneficence & non maleficence1. Medical problems?2. Goal of treatment?3. Circumstances, medical treatment, non

indicated?4. Probability of success of treatment?5. Benefited by medicine and nursing care,

harm can be avoided?

Principles of respect for other/ autonomy1. Good informed consent,

understood?2. Mentally capable, legally

competent?3. Preferences of patients/ family stating

4. Patients expression before5. Appropriate surrogate6. Patient unwilling to medicine,

treatment?

QUALITY OF LIFE CONTEXTUAL FEATURESPrinciples of beneficence, non maleficence & respect autonomy1. Medical treatment – physic, mental,

social, deficit?2. Quality of life, before and after?3. Providers evaluator? Bias?4. Ethical issues & patient quality of life?5. Quality of life assessment – life

treatment?6. Plans & rationale?7. Legal & ethical status of suicide?

Principles of Justice & Fairness1. Conflict of interest?2. Fairness preferences?3. Patient confidentiality?4. Financial factors?5. Allocations of scares?6. Religious issues?7. Legal issues?8. Research & education?9. PH issues?10. Interest of hospital? Effect or

patient welfare?

1.Diagnosis2.Treatment3.Prognosis

1.Before2.During3.After

1.Patient2.Family3.Team

1.Support system2.Cost availability3.Special

circumstance

(Jonsen, et al, 2010)

c. Resolving Ethical Dillemmas (Bernard Lo, 2009) Grew from such perplexing or difficult cases Currently patients can obtain genomic information, cross cultural

medicine on disclosing diagnosis end of life care, surrogatedecision making, etc.

Ethical issues in surgery Several ethical guidelines are particularly silent in surgery: Acting in the patient’s best interest Informed consent – discloser of alternative because

A major bodily invansion Dramatically alter patient’s body image, sense of self, etc Learning procedural skills Individual surgeon – responsible for outcome of surgery

Terminally Ill(< 6 months to life) Patient’s Treatment

STOPFutile

CONTINUEDAggresive

1. Questions• What level of statistical/ experience

evidence to support futility?• Who dicide wether an intervention is

futile, physician or patient?• What process should be used to

disagreement, between patient/surrogate and clinical team?

2. Questions• The success of treatment (1 – 3 – 6)%?

Should be continued?• The contextual features, too high price,

minimal benefit, will be continued?• What level of EBP to support

aggressive treatment

1 2

Input1. Student2. Lectures3. Admin

Process1. Education2. Practices3. Research

Output1. Expert2. Professional3. Agent of change4. Role model

Outcome1. Science & Technologies Rocketing Development

Impact1. We have to be a follower?2. We have to be a leader?

1. Cognitive2. Psychomotor3. Affective (ethic, bioethics)4. Leadership5. Management

HIGHER EDUCATIONManagement Process

22

Bioethics 2020 : an International exchange and challenges

1. Who will be a leader?2. Who will be a follower?3. Positive/good collaboration have to be developed!!

Bioethics 2000 : an International ExchangeFK UGM – Harvard Medical School

IV. Some Others Terminologies of Academic1. Academia the academic community2. Academe

a. The academic environment community or worldb. Academic lifec. A place in which instruction is given to studentd. A scholar especially a pedant

Shoukanov et al., 1996

3. Academica. Relating to, characteristic of a school, especially one of higher learning.b. Relating to studies this liberal or classical rather than technical or

vocational.Relating to scholar performance : a student academic average

c. Relating or belonging to a scholarly organizationd. Scholarly to the point of being unaware of outside worlde. Based on formal educationf. Formalistic or conventionalg. Theoretical or speculative without a practical purpose or intention

(synonim-theoretical)h. Having a practical purpose or use – academic

A person who has an academic view point on a scholarly background.

Shoukanov et al., 1996

4. Academic bioethicsa. Is a theoretical or speculative without a practical purpose or intention

of bioethics.b. Is one who is a member of an institution of higher learning of bioethics,

having a practical purpose or use-academic ; based on formal education

ACADEMIC ETHICS/BIOETHICSSome one who is a member of an institution of higher learning, UGM, ofBioethics, having a practical purpose or use-academic; based on formaleducation

Soukhanov et al., 1996

V. Discussion and Conclusion• How important of academic bioethics/ethics in various higher

educations not only in medicine.• The starting of the past, current, and future ethics/bioethics

discussion at the Faculty of Medicine, Public Health, and Nursing have to be followed by all higher education anywhere worldwidely.

• Positive thinking all of us locally, nationally, regionally, and globally, by all leaders and managers, based on :

• Bioethics 2020 : An international exchange and challenges• Positive or fruitful collaboration, institutionally, nationally, and globally have

to be developed

References• Calman KC, 2007. Ancient medicine: the Beginning of Art in Medical Education, Past, Present and Future. Pp15-39. Elsevier Ltd.

Churchill Livingstone. Printed in China.• Soukhanov HA et al, 1996. The American Heritage Dictionary of English Language- Third Houghton Mifflin Co. Boston, New York • Jonsen AR, Siegler M and Winslade WJ, 2010. Clinical Ethics: A Practical Approach to Ethical Decision in Clinical Medicine VIIth Ed.

Mc. Graw Hill Medical Co. New York, Chicago, Sanfransisco, Lisbon, Madrid, Mexico City, Milan, New Delhi, San Juan, Seaoul,Sinagpore, Sydney, Toronto.

• Nicolescu B, 1999 The Transdisciplinary Evolution of Learning: International Congress What University for Tommorrow? Toward aTransdisciplinary Evalution of the University. Locarno, Switzerland, April 30 – May 2, 1997.

• Passi V, Doug M, Peile E, et al, 2010 Developing Medical Professionalism in Future Doctor: A Systematic Review. International Journal of Medical Education 1:9-29. http://creativecommons.org/licenses/by/3.0

• Forrow L, Zand M, Baden L, 1999 Clinical Ethics for the Medical House Officer : General Principle and Cases. IIIrd. Printing, January. Dept. of Medicine and Ethics Support Service, Beth Israel Deaconess Med. Center Boston. MA.

• Murray et al, 1996 Ethical Principles in University Teaching. STLHE (Society for Teaching and Learning in Higher Education. Canada• Frenk J, Chen L Butta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an

interdependent world. Lancet 2010; published online Nov. 29. • Klugman C (2019) “A short future of bioethics”• Kansas University, 2001• Sastrowijoto S, 2011. The New Sense of Global Bioethics: Local/ National Wisdoms Contribution to the Applied Medical Ethics

Principles The 12th ABC Conference Sept 28-Oct 2, Taipei.• Sastrowijoto, S. (2008) Proposal for Master Degree Program in Bioethics and Medical Humanities. Yogyakarta: School of Medicin,e

UGM.