SCENARIOCase 1: Illegal abortionNy Novi, 34 tahun G4PIIIA0, dengan riwayat ketiga anaknya lahir dengan seksio sesarea (indikasinya karena panggul sempit). Anak ketiga diseksio 4 bulan yang lalu di RSB Harapan dan ditolong oleh Dr Bram, SpOG (salah seorang ahli kebidanan senior di RSB tersebut) waktu itu dr Bram telah memberi informed consent / konseling kepada ny Novi untuk menggunakan kontrasepsi dengan pertimbangan umur dan karena riwayat seksionya yang sudah tiga kali. Saat ini Ny Novi kembali datang kontrol ke dr Bram,SpOG dengan keluhan belum datang haid sejak operasi seksio anak ketiga, ternyanta dari hasil pemeriksaan lengkap yang dilakukan oleh dr Bram ternyata ny Novi hamil dan saat ini usia kehamilannya adalah 10-12 minggu, dari keterangan juga diperoleh informasi bahwa Ny Novi tidak mengikuti saran untuk menggunkan kontrasepsi. Saat itu juga Ny Novi dengan perasaan cemas dan sedih memohon kepada dr Bram agar kehamilannya ini digugurkan saja, dengan berbagai macam alasan yang dikemukakan al : masih trauma dengan operasi seksio yang baru 4 bulan kemarin dijalaninya, masalah anaknya yang masih kecil-kecil, dan juga masalah ekonominya yang juga pas-pasan. Dr Bram dengan tenang dan arif menjelaskan tentang kehamilan ny Novi termasuk tidak adanya kemungkinan atau alasan buat dia untuk melakukan abortus. Ny Novi tetap bersikeras dan bermohon kepada dr Bram agar keinginannya untuk abortus bisa dilakukan, bahkan dengan jelas menyampaikan bahwa bila dr Bram tidak memenuhi keinginannya maka dia akan tetap mencari orang yang dapat menggugurkan kandungannya bagaimanapun caranya dan apapun risikonya akan dia hadapi....

GLOSSARYI. GIVPIIIA0

-Gravid(G)- Pregnancy / kehamilan

- Partus(P)- Giving birth/ melahirkan- Abortion(A)- Keguguran

In this case, GIVPIIIA0 means the patient had four times pregnancy, three of them is already be born and no abortion occurred.II. Cesarean section: Caesarean section, also known as C-section or Caesar, is a surgical procedure in which incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk. In this case, the mother has a narrow opening of the vagina that will cause pain a lot if she deliver normally.III. Contraception: The use of artificial methods or other techniques to prevent pregnancy. Examples Using condom

Birth-control pills

Diaphragm- latex or rubber dome that is placed over the cervix to block sperm transmission Intrauterine device(IUD)- springy plastic device inserted through the cervical canal into the uterus and left in place for 1-4 years. It prevents the implantation of a blastocyst in the uterine wall. Vasectomy- severing of the ductus, (vas) deferens done through a small incision in the back of the scrotum

Etc

IV. Criteria of 10-12 weeks fetus: Though he's barely the size of a kumquat a little over an inch or so long, crown to bottom and weighs less than a quarter of an ounce, the baby has now completed the most critical portion of his development. This is the beginning of the so-called fetal period, a time when the tissues and organs in his body rapidly grow and mature. He's swallowing fluid and kicking up a storm. Vital organs including his kidneys, intestines, brain, and liver are in place and starting to function, though they'll continue to develop throughout your pregnancy. If you could take a peek inside your womb, you'd spot minute details, like tiny nails forming on fingers and toes (no more webbing) and peach-fuzz hair beginning to grow on tender skin. In other development. Your baby's limbs can bend now. His hands are flexed at the wrist and meet over his heart, and his feet may be long enough to meet in front of his body. The outline of his spine is clearly visible through translucent skin, and spinal nerves are beginning to stretch out from his spinal cord. The baby's forehead temporarily bulges with his developing brain and sits very high on his head, which measures half the length of his body. From crown to rump, he's about 1 1/4 inches long. QUESTIONS1) Summarize a few ethical dilemmas in this case.2) From your point of view, how did you see the ethical dilemma in this case, by assuming your position as the doctor and as the family of Ny Novi.3) From the ethical dilemma above, analyze it by using the Basic principle of Bioethics and Jonsen Sieglar Clinical Ethics. ( use the table provided)4) Explain the other relevant issues for this case (Law Issue and Human Right Issue) and from the perspective of religion.ANSWERS1) Summarize a few ethical dilemmas in this case.

Summary of ethical dilemma of this scenario

1. Ny Novi, 34 years old with GIVPIIIA0, with the history of three times undergo cesarean section (because of the narrow opening of the vagina). Third child has been sectioned 4 months ago in RSB Harapan and was helped by dr. Bram, SPOG2. Dr Bram had given counseling to Ny Novi to apply contraception method considering her age and her history of being sectioned three times already.

3. Ny Novi really wants to abort her fourth baby with various kinds of reasons such as facing an economy problems, post-section trauma, difficult situation she had and has higher probability to have harder time if her child is increasing. In this case, as a patient, Ny Novi has her own autonomy toward herself.4. With a calm and professionally, dr Bram explain thoroughly to ny Novi that her pregnancy cannot be the reason for her to do the abortion.5. Ny Novi is tightly standing with her decision and asks dr Bram to do the abortion. Clearly, she said that even if dr Bram wont do the abortion, she will find someone who can do that for her by hook or by crook.

2) From your point of view, how did you see the ethical dilemma in this case, by assuming your position as the doctor and as the family of Ny Novi.As the doctor.

Beneficence

1. In receiving and doing the cheak up on the patient Ny Novi, dr Bram,SpOG has used and imply golden rule principle compatable with Kodeki pasal 2 : Every doctor must always capable to accomplish their profession according to the very high profession standard . dr Bram has done he best for Ny.Novi according to him. 2. Dr.Bram did not fulfill the requirement of the patient to do abortion towads her and he gave his best explanation to her.This as been written in Kodeki pasal 1 : Setiap dokter menjungjung tinggi, mengahayati, dan mengamalkan sumpah dokter (lafal 6 : saya akan menghormati setiap hidup insani mulai dari saat pembuahan), Kodeki pasal 7d :Setiap dokter harus senantiasa mengingat akan kewajiban menlindungi hidup makhluk insani He had gurranted the value of pokok harkatand human dignity.

3. Dr. Bram also looks at the patient as not something that benefits the docter. This can be seen when the doctor tells the truth to the patient and inform to the patient about the her actual physical condition.Moreover he did not be a money minder instead of telling the women that theres no reason for her to do abortion.

4. Doktor also tried the best for her by telling the patient to use contraception in order to avoid her from further harm.Nonmaleficence

1. Dr.Bram did not do abortion so that do not harm her and the baby.

Autonomy

1. From the early state dr.Bram always keep the relationship with the patient by doing the informed consent suitable with the Kodeki pasal 7c :Seorang dokter harus menghormati hak-hak pasien .......... dan harus menjaga kepercayaan pasien.

2. In the other hand the attitude of the docter by refusing the illegal abortion and did not stop the patient to choose other docter sikap dokt. He appreciate the rights of the patient to decide on her ownself.

Justice

Pasal 348 (1) Barang siapa dengan sengaja menggugurkan atau mematikan kandungan seorang wanita dengan persetujuannya, diancam dengan pidana penjara paling lama lima tahun enam bulan.

(2) Jika perbuatan itu mengakibatkan matinya wanita tersebut, diancam dengan pidana penjara paling lama tujuh tahun.

The doctor finally made a decision not to do the abortion which will then trap him by the law.As the patient

Autonomy

1. Dr Bram should help Ny Novi to make her own decision, respect and follow it.

2. Dr Bram is also responsible to listen and evaluate the decision that been taken by Ny Novi.

3. Dr Bram must care about Ny Novis feelings, emotions and her comfortable towards the upcoming treatment.

.

4. Ny Novi wants to proceed for abortion because of the economic problems that she is handling. Most probably she will not be able to support her babys expenditure in future. So, Dr Bram should make sure that the patient gets the life that she deserves.

5. According to Ny Novi, she is still having trauma because of the caesarean that is done 4 month ago and she is having 3 children to be taken care. So Dr Bram should care about the physical, mental and social life of the patient in future.6. Ny Novi took the decision to still find other doctor who can do an abortion for her even how high is the risk. Dr Bram should respect and do not interpret the patients autonomy.3) From the ethical dilemma above, analyze it by using the Basic principle of Bioethics and Jonsen Sieglar Clinical Ethics. ( use the table provided) Autonomy

Autonomy refers to the right of the patient to determine what will be done with his or her own person. The principle of respect for autonomy refers to a patients right to make decisions regarding treatment according to ones own belief system, cultural and personal values and life plans. The right to autonomy applies even when the patients decisions differ from the physicians recommendations. Moreover, disagreement about proposed medical care is not grounds for a paternalistic determination of impaired decision-making capacity. However, autonomy does not extend to the patient a right to insist that any and all treatments be provided, regardless of the likely benefit or costs. In addition, autonomy is not always absolute. It may not impinge on the rights and freedoms of others.

Non-maleficence

The principle of non-maleficence denotes a responsibility to avoid doing harm to patients, either through acts of commission or omission. This is one of the principal precepts physicians are taught in medical school. It reminds a physician that he or she must consider the possible harm that any intervention might do. It is most often mentioned when debating use of an intervention with an obvious chance of harm, but a less certain chance of benefit.

Beneficence

Beneficence is strongly tied to the utilitarian theory of ethics. The principle of beneficence obliges physicians to act always in the best interest of the patient, or more explicitly, to do good for patients. Doing good is considered virtuous conduct. However, fidelity to this principle does not mean preserving life at any cost. It is sometimes held that non-maleficence is a constant duty, that is, one ought never to do harm to another individual, whereas, beneficence is a limited duty. Though a physician has a duty to seek the benefit of any or all of his patients, he has the option of choosing whom to admit into his practice. Justice

The principle of justice implies that physicians have an obligation to treat similar patient situations in a similar fashion. The term distributive justice refers to fair, equitable and appropriate distribution of resources in society determined by justified norms that structure the terms of social cooperation. The good of society must be considered in light of finite resources, which should be equitably allocated to benefit all patients. To quote Aristotle, Giving to each that which is due.The state of Oregon was the first to put forward a plan for systematic rationing of health care funds in the United States. It underscores the need for a comprehensive and coherent health care system for the nation. Physicians must affirm that good stewardship of finite, material resources and financial solvency are ethical goods that on the whole need to be pursued and protected.

BASIC PRINCIPLES OF BIOETHICSNoSituationKDB valueCriteriaAnalysis

1Ny Novi, 34 tahun G4PIIIA0, dengan riwayat ketiga anaknya lahir dengan seksio sesarea (indikasinya karena panggul sempit). Anak ketiga diseksio 4 bulan yang lalu di RSB Harapan dan ditolong oleh Dr Bram, SpOG (salah seorang ahli kebidanan senior di RSB tersebut).B-Mengutamakan alturism (rela berkorban untuk kepentingan orang lain)-Minimalisasi akibat buruk.

Ny Novi has a narrow opening of the vagina. So, dr Bram give birth to her third child by undergo caesarean section. This method will reduce the pain of the labor process.

2.... waktu itu dr Bram telah memberi informed consent / konseling kepada ny NoviA-melaksanakan informed consentdr Bram explain and asks Ny Novi to use contraceptive methods but Ny Novi refused.

2.untuk menggunakan kontrasepsi dengan pertimbangan umur dan karena riwayat seksionya yang sudah tiga kali. NM-Tidak menghina/mencaci-maki /memanfaatkan pasiendr Bram advised Ny Novi to apply the contraceptive method to prevent any pregnancy and avoid her from getting any harm because of her history, undergo three times caesarean section.

3.ternyata dari hasil pemeriksaan lengkap yang dilakukan oleh dr Bram ternyata Ny Novi hamil dan saat ini usia kehamilannya adalah 10-12 minggu,B

4...dari keterangan juga diperoleh informasi bahwa Ny Novi tidak mengikuti saran untuk menggunakan kontrasepsi. Saat itu juga Ny Novi dengan perasaan cemas dan sedih memohon kepada dr Bram agar kehamilannya ini digugurkan saja, dengan berbagai macam alasan yang dikemukakan al : masih trauma dengan operasi seksio yang baru 4 bulan kemarin dijalaninya, masalah anaknya yang masih kecil-kecil, dan juga masalah ekonominya yang juga pas-pasan.A-membiarkan pasien dewasa dan kompeten mengambil keputusan sendiri

2...dr Bram dengan tenang dan arif menjelaskan tentang kehamilan Ny Novi termasuk tidak adanya kemungkinan atau alasan buat dia melakukan abortus. A-Berterus-terang

-Tidak berbohong ke pasien demi kebaikan pasien.Even though Ny Novi really want to abort her fourth baby, dr. Bram still refused to do it and thoroughly and truly explain to her about the exact condition.

4Ny Novi tetap bersikeras dan bermohon kepada dr Bram agar keinginannya untuk abortus bisa dilakukan,bahkan dengan jelas menyampaikan bahawa bila dr Bram tidak memenuhi keinginannya maka dia akan tetap mencari orang yang dapat menggugurkan kandungannya bagaimanapun caranya dan apapun risikonya akan dia hadapi.... J-tidak melakukan penyalahgunaanDr Bram did not misused his power as a doctor to do the abortion although he was forced by Ny Novi.

CASE ANALYSIS BASED ON JONSEN, SIEGLAR AND WISLADE CLINICAL ETHICS

Medical indication NOETHICAL QUESTIONSANALYSIS

1What is the patients medical problem? history? diagnosis? prognosis?Ny. Novi decided to have an abortion. She has the history of three times caesarian section. No diagnosis and prognosis.

2Is the problem acute? chronic? Critical? emergent? reversible?

Chronic because it takes an interval of time for the problem to devastate.

3What are the goals of treatment?Not available.

4What are the probabilities of success?Not available.

5What are the plans in case of therapeutic failure?Not available.

6In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?For the patient, she can be benefited in terms of finance and avoid the risk of further pregnancy.

Quality of life NOETHICAL QUESTIONSANALYSIS

1What are the prospects, with or without treatment, for a return to normal life?The prognosis is that she could be in traumatic condition after the surgery and the suture of the previous section being torned. If she experienced shock, she might die but with recent technology, she could be saved. Her fallopian tubes should be closed afterward.

2What physical, mental, and social deficits is the patient likely to experience if treatment succeeds?The patient would be in a better situation, whether physically or financially, if the abortion is done.

3Are there biases that might prejudice the providers evaluation of the patients quality of life?Not available.

4Is the patients present or future condition such that his or her continued life might be judged undesirable?The current status of Ny. Novis life is that she had a financial problem. Future condition that is predicted is that she might had more difficulties to deal with her financial problem if her family size is getting bigger.

5Is there any plan and rationale to forgo treatment?If Ny. Novi choose to continue her pregnancy, she needs some follow-ups with the doctor. When she has delivered, treatments are needed for both mother and child. However, if she choose to have abortion, she will be dealing with the law.

6Are there plans for comfort and palliative care?Not available.

Patient preferencesNOETHICAL QUESTIONSANALYSIS

1Is the patient mentally capable and legally competent? Is there evidence of incapacity?The patient is mentally competent. No evidence of incapicity.

2If competent, what is the patient stating about preferences for treatment?Patient chose the treatment according to her own opinion and not according to the doctors advice.

3Has the patient been informed of benefits and risks, understood this information, and given consent?Yes. Dr. Bram has explained all the information of his diagnosis and treatment to Ny. Novi.

4If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making?Her nearest family member or the person who paid for the treatment cost.

5Has the patient expressed prior preferences, e.g., Advance Directives?Yes, she insisted for abortion.

6Is the patient unwilling or unable to cooperate with medical treatment? If so, why?Yes, due to traumatic condition, financial and family problem.

7In sum, is the patients right to choose being respected to the extent possible in ethics and law?Religion and the law prohibited abortion. So, Ny Novi has no right for abortion.

Contextual featuresNOETHICAL QUESTIONSANALYSIS

1Are there family issues that might influence treatment decisions?Yes. She stated that her 3 children are still small and thats why she insisted for abortion.

2Are there provider (physicians and nurses) issues that might influence treatment decisions?Not available.

3Are there financial and economic factors?Financial problem has a main role in this case. Ny. Novi has 3 small children and the cost of treatment for further pregnancy may be unaffordable for her.

4Are there religious or cultural factors?Religion doesnt allow abortion.

5Are there limits on confidentiality?Yes

6Are there problems of allocation of resources?Not available

7How does the law affect treatment decisions?The law prohibited any abortion. So, Dr. Bram is not alloed to perform it.

8 Is clinical research or teaching involved?Not available

9Is there any conflict of interest on the part of the providers or the institution?Not available

4) Explain the other relevant issues for this case (Law Issue and Human Right Issue) and from the perspective of religion.LAW ISSUEAccording to Indonesias Law, this case is related to a few articles in law on medical practice and abortion. If Dr. Bram did the abortion by granting Ny. Novis wish without any indication, it would fall under criminal criteria:

Pasal 346 Seorang wanita yang sengaja menggugurkan atau mematikan kandungannya atau menyuruh orang lain untuk itu, diancam dengan pidana penjara paling lama empat tahun. Pasal 347 (1) Barang siapa dengan sengaja menggugurkan atau mematikan kandungan seorang wanita tanpa persetujuannya, diancam dengan pidana penjara paling lama dua belas tahun. (2) Jika perbuatan itu mengakibatkan matinya wanita tersebut diancam dengan pidana penjara paling lama lima belas tahun

Pasal 348 (1) Barang siapa dengan sengaja menggugurkan atau mematikan kandungan seorang wanita dengan persetujuannya, diancam dengan pidana penjara paling lama lima tahun enam bulan. (2) Jika perbuatan itu mengakibatkan matinya wanita tersebut, diancam dengan pidana penjara paling lama tujuh tahun. Pasal 349 Jika seorang dokter, bidan atau juru obat membantu melakukan kejahatan berdasarkan pasal 346, ataupun melakukan atau membantu melakukan salah satu kejahatan yang diterangkan dalam pasal 347 dan 348, maka pidana yang ditentukan dalam pasal itu dapat ditambah dengan sepertiga dan dapat dicabut hak untuk menjalankan pencarian dalam mana kejahatan dilakukanHUMAN RIGHT ISSUEIn this case, there are also issues on human right. According to Universal Declaration of Human Right:

1) Article 3:

Everyone has the right to life, liberty and security of person.

Analysis:

Ny. Novis baby, although was still not born yet, can be considered as a human. So, abortion cant be done arbitrarily because it can kill the baby and violate the babys right.

2) Artikel 25:

Everyone has the right to a standard living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and to the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Analysis:

Ny. Novi gave the reason to do abortion that shes still in traumatic condition because of the section operation that was done just about 4 months ago. In this case, Ny. Novi has the right to be safe from the risk of being pregnant again for the fourth time because it can bring danger to her health. Other than that, Ny. Novi also stated that her children were still small and she had a financial problem. She definitely had a right to do abortion because if she continue her pregnancy and deliver her fourth child, her financial problem will become worse and will make her familys life more difficult.ISLAMIC LAWMost religions do not allowed abortion.For an example, many Muslims in Indonesia and elsewhere raise the question of abortion in Islam. It is therefore useful to shed some light on this issue from an Islamic perspective.

Humans are the most favoured creation of the Creator, Allah (swt):

"And indeed We have honoured the children of Adam, carried them on land and sea, gave them lawful, pure provisions, and greatly preferred them above many of those We have created." (Al-Isra,17:70)

Among these signs of Allahs favour on the children of Adam, is the sacred value Allah (swt) assigns to the life of a human being. When that value was violated with the first unlawful murder of a human being on earth, when one of Adams sons killed his own brother out of malice, Allah (swt) condemned that act and put it on record in the Quran as a reminder, to be recited until the Day of Judgement.Allah (swt) went even further, making unlawful killing of a single individual human being equal to mass murder of the whole of mankind:

"Because of that, We ordained for the children of Israel that if anyone killed a person not in retaliation for murder or for spreading mischief on earth, it would be as if he killed all mankind. And who saved a life, it would be as if he saved all mankind." (Al-Maidah,5:32)

Some Muslims argue that abortion is permissible if the foetus is younger than four months (120 days). They quote a statement from the Prophet (s) that refers to a human being starting as a fertilised ovum in the uterus of the mother for forty days, then it grows into a clot for the same period, then into a morsel of flesh for the same period, then an angel is sent to that foetus to blow the Ruh into it and to write down its age, deeds, sustenance, and whether it is destined to be happy or sad. Assuming the hadith to be authentic, scholars explain that the error comes from understanding that before the Ruh is blown into the foetus at 120 days, the foetus is not a living entity, and therefore aborting it does not amount to killing it. This understanding is wrong, scholars argue, because the foetus is a living entity right from the moment of fertilisation and implantation on the wall of the uterus. Scholars explain that the Ruh mentioned in this hadith of the Prophet (s) is something other than being alive and only Allah (swt) knows what it is, based on the verse in the Quran:

"And they ask you about the Ruh. The Ruh is one of the things the knowledge of which is only with my Lord, and you, mankind, have been given only little knowledge." (Al-Isra,17:85)

It therefore becomes clear that aborting a foetus before 120 days is still killing a living entity, let alone abortion after that presumed period. The only case when aborting a foetus, before or after 120 days, is allowed in Islam, is when a medical situation threatens the life of the mother, leaving only two options, to let either the other or the foetus survive, but not both. Scholars argue that such a case can only be determined by a specialist, trusted and committed Muslim doctor. They argue that the mother can have other children, whereas the child cannot make up for losing the mother. Briefly, once the semen from a man fertilised an ovum from a woman, and went into the womb of the mother, it was indeed a living entity and should not be intentionally aborted. As the foetus progressively develops in the womb, intentional abortion becomes an even worse sin amounting to killing a living entity. In some schools of Islamic thought, causing a foetus to be accidentally aborted, say by beating a pregnant mother, results in payment of the blood money penalty equal to one-tenth of that paid for mistakenly killing a mature human being. This is Islam, in all its mercy, humanity and firmness.