1. The Phylosophy of
Bioethics and Medical Ethics
Sept 9, 2014
Teguh Wahju Sardjono
Faculty of Medicine
University Brawijaya

2. Learning Objectives
At the end of this study, the students should be able to:
• explain what Bioethics and Medical Ethics is
• explain the basic principle of Bioethics and Medical
Ethics
• understand about the essential of Hyppocrates oath
• explain the role of bioethics in medical profession
• explain the value of good-bad, wright-wrong in
community
• identify bioethical problems in medical practice and
give the alternative to solve the problems

3. History
• Van Rensselaer Potter (biological/oncological
researcher professor in Wisconsin University), wrote
books:
Bioethics, the Science of Survival (1970)
Bioethics: Bridge to the Future (1971)
The aim of writing books:
“not only to enrich individual lives but to prolong the
survival of the human species in an acceptable form
of society".

4. ETHICS
• the branch of philosophy that deals with distinctions
between right and wrong – with the moral
consequences of human action” (Coughlin &
Beauchamp, 1996)
• Effort to create the positive reflection on
activities or intuition and moral choice which
decided by someone
• Medical ethics  moral responsibility that
influencing any activities in medical practice

5. “ETHICS”
Consists of three meanings :
1. Moral values or norms that used to be a
guidance for individuals or groups in their
activities
2. A moral philosophy that deals with distinctions
between right and wrong
3. Collection of moral rules  ethical codes
(K. Bertens, 2004)

6. Two meanings of ETHICS in
community
Bioethics ≈ ethics of life?
Moral norms or values which are accepted as guidance in
our life/community
Example:
-“it is not ethical"
-“that activity is not suitable with the right ethics",
- “we should not only thinking about the benefit, as it is
still ethics there".
Ethics = moral or morality

7. • Ethics as science:
a study about morality or about ethics in first meaning
– Learning about life (right or wrong) in moral term
– Trying to decide what, and why it should be or not
to be done
• Ethics in philosophy  ethical philosophy or moral
philosophy .
• Long history, ± 25 centuries.
• Greece. Socrates, Plato, and Aristoteles (384-322
BC)
Bioethics ≈ ethics of life?

8. What is bioethics and why do we need it?
• Bioethics: how scientists and health professionals
ought to behave in the biomedical sciences
• the attempt to understand and justify the link between
values (fundamental principles) and actions
• Many (or all?) people feel the need to justify their
behaviour
 to explain why their behaviour is (un)acceptable

9. Ethics in Medical Science
(Medical Ethics)
“Patients are entitled to good standards of practice and
care from their doctors.
Essential elements of this are professional competence,
good relationships with patients and colleagues and
observance of professional ethical obligations.”
(From Good Medical Practice, GMC)
 Ethics in Medical Science is one of the “Seven basic
competences of Indonesian doctors” (SKDI, 2012)

10. Why Ethics Become Important?
• Nowadays, conflicts of interests between the
government and medical institutions, between medical
institutions and medical personnel, between physicians
and patients are getting more and more serious and
complex.
• High technologies not only brought us hopes of cure but
have also created a heavy economic burden.
• The ethical dilemmas of high technology medicine-brain
death, organ transplantation, and concerns about quality
of life-have become increasingly prominent

11. Why Ethics Become Important?
• A new and more specific code of ethics must
be developed to meet the demands of social
development and medical service.
• This new code integrates the traditional
medical ethics with modern principles and
values.

12. There are 4 (four) principles
• Autonomy
– Right of self-determination
• Related to ‘informed consent’
• In order to give consent:
autonomy/competency/capacity must be
possessed.
• Beneficence – to do well, to promote well-being
• Non-maleficence – to do no harm, to avoid doing
harm
• Justice – treat like alike
(Beauchamp and Childress, 2001.)

13. Ethics in Medical Profession
• Hippocrates (460-370 BC) : the father of medicine 
“The Oath of Hippocrates".
• Ethics in medical science is as old as the medical
profession itself
The connection between medical ethics and medical
profession  everlasting.
• "Hippocratic Oath“ still exist in medical profession
and give great contribution for the existence of
medical profession as a respected and noble
profession in community.

14. Prominent ethical codes
• Oath of Hippocrates (4th c BC)
• Nuremberg Code (1947): issue of human experimentation
• Declaration of Helsinki (1964) (WMA): issue of human
experimentation
– First serious attempt of medical community to regulate
itself
• Declaration of Geneva (1948)
– Issued as a development on the Oath of Hippocrates
• CIOMS Guidelines (1993)
– ‘International Ethical Guidelines for Biomedical
Research Involving Human Subjects’
(CIOMS: the Council for International Organizations
of Medical Sciences)
(UNESCO, 2005)

15. Importance of Medical Ethics
1) Increase in technology
2) Better informed society
3) Doctors in Management
4) Public scrutiny
5). Increasing profileRecent press headlines:
– Dr Cox (euthanasia)
– Alder hay Enquiry
– Jodie and Mary
– Destroying frozen embryos
– Refusal to fund marrow transplantsnew drugs

16. Scope of ethics in Medical
Practice
1. Historical background
• Hippocratic oath
• Geneva(1947)
• Sydney(1968)
• Tokyo(1975)
• Lisbon(1981)
2. Multidisciplinary nature

17. The source and legal definition of
medical ethics
 Medical ethical issues arise out of specific fields of health
care such as: matters related to infertility or any
reproductive health related issues, experimentation with
genes, dealing with terminal illness, organ transpants etc.
 “Medical ethics is a discipline/methodology for
considering the implications of medical
technology/treatment and what ought to be”

18. Graduation Day

19. Graduation Day
• On the day of graduation/before start the medical
profession, every new medical doctors should swear
the “Hippocratic Oath”
• Year 1948 : a New version of " Hippocratic Oath ".
Declaration of Geneva
• The original " Hippocratic Oath“ is still used
• Traditional Medical Ethics especially focused on:
– the relation of doctors-patients
– the responsibility of doctors to their patients
• During the 20th century developments of biomedical
sciences and technology caused a lot of new ethical
problems which never predicted before and
untouched by Traditional Medical Ethics

20. "Hippocratic Oath".
• The Hippocratic Oath (ancient and modern versions)
is one of the oldest binding documents in history.
Written in antiquity, its principles are held sacred by
doctors to this day: (treat the sick to the best of one's
ability, preserve patient privacy, teach the secrets of
medicine to the next generation, and so on).
• "The Oath of Hippocrates," held by the American
Medical Association's Code of Medical Ethics (1996),
"has remained in Western civilization as an
expression of ideal conduct for the physician."

21. THE OATH OF HIPPOCRATES
(From "Harvard Classics, Volume 38" Copyright 1910
by P.F. Collier and Son)
• I SWEAR by Apollo the physician and Æsculapius, and
Health, and All-heal, and all the gods and goddesses,
that, according to my ability and judgement,
• I will keep this Oath and this stipulation — to reckon
him who taught me this Art equally dear to me as my
parents, to share my substance with him, and relieve
his necessities if required; to look upon his offspring in
the same footing as my own brothers, and to teach
them this art, if they shall wish to learn it, without fee or
stipulation; and that by precept, lecture, and every other
mode of instruction,

22. THE OATH OF HIPPOCRATES (cont)
• I will impart a knowledge of the Art to my own sons,
and those of my teachers, and to disciples bound by a
stipulation and oath according to the law of medicine,
but to none others.
• I will follow that system of regimen which, according to
my ability and judgment, I consider for the benefit of my
patients, and abstain from whatever is deleterious and
mischievous.
• I will give no deadly medicine to any one if asked, nor
suggest any such counsel; and in like manner I will not
give to a woman a pessary to produce abortion. With
purity and with holiness I will pass my life and practice
my Art.

23. THE OATH OF HIPPOCRATES (cont)
• I will not cut persons labouring under the stone, but will
leave this to be done by men who are practitioners of this
work. Into whatever houses I enter, I will go into them for
the benefit of the sick, and will abstain from every
voluntary act of mischief and corruption; and, further, from
the seduction of females or males, of freemen and slaves.
Whatever, in connection with my professional service, or
not in connection with it, I see or hear, in the life of men,
which ought not to be spoken of abroad,
• I will not divulge, as reckoning that all such should be kept
secret. While I continue to keep this Oath unviolated, may
it be granted to me to enjoy life and the practice of the art,
respected by all men, in all times. But should I trespass
and violate this Oath, may the reverse be my lot.

24. " Hippocratic Oath". (1)
I swear to fulfill, to the best of my ability and judgment, this
covenant:
• I will respect the hard-won scientific gains of those
physicians in whose steps I walk, and gladly share such
knowledge as is mine with those who are to follow.
• I will apply, for the benefit of the sick, all measures whish
are required, avoiding those twin traps of over-treatment
and therapeutic nihilism.
• I will remember that there is art to medicine as well as
science, and that warmth, sympathy, and understanding
may outweigh the surgeon’s knife or the chemist’s drug.

25. " Hippocratic Oath". (2)
• I will not be ashamed to say “ I know not”, nor will I fail
to call in my colleagues when the skills of another are
needed for patient’s recovery.
• I will respect the privacy of my patients, for their
problems are not disclosed to me that the world may
know. Most especially must I tread with care in matters
of life and death. If it given to me to save a life, all
thanks. But it may also be within my power to take a
life; this awesome responsibility must be faced with
great humbleness and awareness of my own frailty.
Above all, I must not play of God.

26. " Hippocratic Oath". (3)
• I will remember that I do not treat a fever chart, a
cancerous growth, but a sick human being, whose illness
may affect the person’s family and economic stability. My
responsibility includes these related problems, if I am to
care adequately for the sick.
• I will prevent disease whenever I can, for prevention is
preferable to cure.
• I will remember that I remain a member of society, with
special obligations to all my fellow human being, those
sound of mind and body as well as the infirm.

27. " Hippocratic Oath". (4)
• If I do not violate this oath, may I enjoy life and art,
respected while I live and remembered with affection
thereafter. May I always act so as to preserve the finest
traditions of my calling and may I long experience the joy of
healing those who seek my help.
(Written in 1964 by Louis Lasagna, Academic Dean of the School of
Medicine at Tufts University, and used in many medical schools today)

28. The Oath of Indonesian Doctors
• Is an Oath which is sworn by someone which is
graduated to be an Indonesian medical doctor, before
being and doing a formal doctor (licensed)
• The Oath of Indonesian Doctor is based on
Declaration of Geneva (1948)  Revision of The Oath
of Hippocrates
• Text of the Oath of Indonesian Doctor firstly used in
1959 and stated as rule (law) according to Peraturan
Pemerintah No.69 Year 1960.
• The Oath was revised in 1983 dan 1993.

29. The Indonesian Physician’s OATH
content
• Duties to the patients.
• Duties to the colleagues.
• Duties to the teacher.
• Against abortion.
• Against Euthanasia.
• Duties to keep secret what has been
confided.

30. The Oath of Indonesian Doctor
Demi Allah, saya bersumpah, bahwa:
Saya akan membaktikan hidup saya guna kepentingan
perikemanusiaan
Saya akan menjalankan tugas saya dengan cara yang terhormat
dan bersusila, sesuai dengan martabat dan tradisi luhur
jabatan kedokteran
Saya akan merahasiakan segala sesuatu yang saya ketahui
karena pekerjaan dan kelimuan saya sebagai dokter
Saya akan mengutamakan kesehatan dan keselamatan penderita
Saya akan berikhtiar dengan sungguh-sungguh supaya saya tidak
terpengaruh oleh pertimbangan keagamaan, kebangsaan,
kesukuan, politik kepartaian atau kedudukan sosial dalam
menunaikan kewajiban terhadap penderita

31. The Oath of Indonesian Doctor
Saya akan memberikan kepada guru-guru saya
penghormatan dan pernyataan terimakasih yang
selayaknya
Saya akan memperlakukan teman sejawat saya (seperti
saudara kandung) sebagaimana saya ingin diperlakukan
Saya akan menghormati setiap hidup insani mulai dari
(saat pembuahan) awal kehidupan
(sekalipun diancam) Saya tidak akan mempergunakan
pengetahuan kedokteran saya untuk sesuatu yang
bertentangan dengan hukum kemanusiaan, sekalipun
diancam
Saya ikrarkan sumpah ini dengan sungguh-sungguh dan
dengan mempertaruhkan kehormatan diri saya

32. The Indonesian Physician Oath
By the name of God (Allah) I swear or promise that
• I will seek to do the art of medicine as well as I can at
the service of my fellow human being.
• I will care for the sick, enhance health, and alleviate
suffering.
• I will put the interest of the patient first and respect his
ideas and attitudes.
• I will not harm the patient. I will listen and inform him
adequately.
• I will keep secret what has been confided to me.

33. The Indonesian Physician Oath
• I will enhance my medical knowledge and that of
others.
• I recognized the limits of may possibilities.
• I will take an open assessable stance, and I know my
responsibility to society.
• I will encourage the availability and accessibility of
health care.
• I will not abuse of my medical knowledge, not even
under pressure.
• I will honour the profession of the physician

34. Taking the Physician Oath
• is a very important moment for any new physician,
• on this occasion he vowed that in the practice of his
profession, he will always seek to do the art of
medicine as well as he can
• Therefore swearing-in ceremony should be
conducted in a solemn and sacred atmosphere
• It can be realized when the swearing-in ceremony
held in particular, preceded the physician
inauguration.

35. Who shall take the oath?
• All Indonesian doctors, graduate education in the
country and abroad
• Foreign students studying in Indonesia Medical
Colleges.
• Foreign Doctors should not sworn in as guests, 
becomes the responsibility of the agency that hired
her/him.
• Foreign doctors who provide services directly to the
people of Indonesia, should be subject to KODEKI.
(Kode Etik Kedokteran Indonesia/ Ethical Code of
Indonesian Physician) .

36. Ironics!!!!
• Oath-taking (Hippocratic/Doctor’s Oaths) or others:
something that should be meaningful and sacred
• All of Government Officials, member of “MPR/DPR”
swore the Official Oath
• Yet paradoxically, some people see oath-taking as
little more than a pro-formal ritual with little value
beyond that of upholding tradition.
• The Hippocratic Oath Today  Seemed to be
Meaningless Relic or Invaluable Moral Guide?
(Kartono Mohamad, Ex. Head of Indonesian Doctor Association)
INDIVIDUALS!!!

39. Four Misconceptions
1. Clear distinction :clinical and ethical analysis
2. Clear distinction: profess. and everyday ethics
3. Enshrined in lead
4. Medical ethics=matter of opinion
Sometimes a doctor in certain conditions which makes
him difficult to decide of doing something
• Limited time, equipments, or other condition
 If you can not do everything, please do something,
but do not do nothing

40. Principles
1. Beneficence
2. Non-Maleficence
3. Autonomy
4. Truth telling
5. Confidentiality
6. Preservation of Life
7. Justice

41. Principle of Beneficence
• Based on Salus aegroti suprema lex maxim
• usually advocated by the churches in reference to
reproduction of human related problems or infertility.
eg, IVF (in vitro fertilization)  the church is highly
against. What happens in IVF is the ova and sperm,
which when fused initiates the process of fetus
formation and eventually the baby, are fused in an
unnatural way and outside the woman's body. So this
principle says that medical purposes are to be used
only to help cure an ailment and nothing else that is
artificial or involves experimenting.

42. Beneficence and Non-Maleficence
Questions:
1) Is the patient your only concern?
(possible conflict with utility)
2) Do we always know what is good for the
patient?
(patient’s view may differ from ours)

43. 3 constraints on Beneficence
1. Need to respect autonomy-patient and
doctor may differ
2. Need to ensure health is not bought at
too high a price
3. Need to consider rights of others

44. Principle of Autonomy
• This principle works on the maxim of Voluntas aegroti
suprema lex,  means that the patient is at liberty to
make his own decision
• to what treatment he wants to undergo and under
whom but this does not mean that the doctors are
relieved off the responsibility of the health of the
patient.
• The onus totally lies on the doctor to inform the
patient about the disease he has and the available
treatment options which need not necessarily be
available with him. He has to help the patient to make
an informed decision.

45. Autonomy
1. Capacity to think, decide, take action
2. Mental incompetence = no autonomy
3. Autonomy vs Paternalism
When patient not autonomous –no
clash. When patient autonomous-questionable
procedure

46. Principle of Non-Maleficence
• his particular term non-maleficence is common in laws of
many countries. It literally means non harmful, in Latin.
• The maxim primum non nocere says that whatever a
doctor does for treating a patient, with the best interests in
heart, he cannot harm the patient. In the legal terms, it
should be deciphered as 'should not.' Elaborating on this
idea further, a doctor is supposed to 'not do any harm' to his
patients more than 'treating' and curing him for his suffering.
• Just like the law says, hundred culprits may be let to go but
not a single innocent is to be hanged. The current medical
ethical issues can be categorically listed as follows which
can be largely categorized into societal nonacceptance and
professional misconduct.

47. Truth telling
In much wisdom is much grief
If you override it you endanger doctor/patient
relationship(based on trust)
You offend against the principle of autonomy
At times there are good reasons for overriding the
truth telling principle

48. Confidentiality
• Act against this principle and you
destroy patient’s trust
• Clash –when keeping confidentiality
would harm others eg child abuse
• Should patients have access to their
notes?

49. Against
• Layman unable to cope with data
• Opinions not facts cause anxiety
• Third party information
• Defensive medicine
For
• Data belongs to patient
• Accuracy improved by sharing

50. Exceptions to Medical
Confidentiality
• Pt gives written and valid consent
• To other participating professionals
• Where undesirable to seek patients consent
info can be given to a close relative
• Statutory requirements
• Ordered by Court
• Public interest
• Approved Research

51. Justice
How to allocate scarce healthcare resources?
1. Medical need
2. Medical Benefits
3. Social worth-discriminates against underprivileged
4. Merits/contribution to society-very contentious
5. Desert
6. Market Forces
7. A lottery

52. More Problems in Medical Ethics
• Doctors – social values
• Doctors – formal regulations
• Bio – revolutions
•  Bioethics & Modern Biotechnology

53. Eugenics
• An effort to breed better human beings
• Encourage “good genes”
• Discourage “bad genes”
• Fear of history –
Sterilization of the mentally ill in early America
Nazi concentration camps

54. Reproductive Cloning
• Creating a genetically identical organism
• Many animals have been successfully cloned

55. Human Cloning
• Clonaid claims that they have the ability to
clone humans

57. Therapeutic Cloning
• Cloning Individual Human Cells
• Involves Stem cells – precursor cells that give rise to
specialized cells/multiple tissue types
• Allows for the generation of human tissue and
organs
• Enhances our understanding of human development
and serious medical conditions (cancer, birth
defects, etc)
• Embryonic vs Adult Stem Cells

58. Pre-Implantation Genetic Diagnosis
(PGD)
• Diagnosing inherited genetic disorders “in
vitro”
• Choosing which embryos will be transferred to
the uterus based upon desired traits
• Gender decisions
• “Designer Babies?”

59. Genetic Testing
• Individual risk assessment based upon a
person’s DNA profile
• DNA chip identifies genetic predispositions
• Potential for genetic discrimination
• DNA profiling? DNA banks?

60. Transgenic Plants
• Engineered plants that contain novel genes
from other species
• Results in new characteristics that make
plants more desirable and useful to humans
• Are they safe to eat?
• How do they affect the ecosystem?

61. Transgenic Animals
• Engineered animals that contain novel genes
from other species
• Results in animals that are more desirable
and useful to humans
• Are they safe to eat?
• Where do we draw the line?

62. Xenotransplantation
• Harvesting organs from animals for organ
transplantation into humans
• Severe Organ donor shortage
• Pigs – Perfect match!
• Do we have the right? PETA
• Dangers of Creating New Human Viruses

63. Finding a Balance
• Focusing on whether or not “we could”
• Instead of whether or not “we should”
Weighing the Pros versus the Cons
Acknowledging the tremendous responsibilities
that must be faced with the information that
we have acquired.

64. Summary
Be a good doctor
• Ethics – morallity : Good – bad, Wright – wrong, etc
• Bioethics/medical ethics vs Modern Biotechnology
•  needs balancing  religion
Religion without science is lame,
science without religion is blind
Java: blaèn = dangerous