Tutorial Report.docx

TUTORIAL REPORT BIOETHICS, HUMANITIES AND PROFESSIONALISM BLOCK Makassar,December 28th2015

1st MODUL “Medical Humanities, Ethics and Professionalism”

“The Woman Who Was Forced to Offer Her Kidney” MEMBERS OF GROUP 15th INNAL HAMDA

(110 2015 0019)


NISRINA NUR AZISAH

(110 2015 0026)


DIAH RINDAYANI HASBI

(110 2015 0028)


ALVI KAMAL FIKRI

(110 2015 0043)


MAFTUHATUL AFIAH

(110 2015 0061)


DESI TRIUTAMI SALEH

(110 2015 0068)


DONITA RIAN UTAMI

(110 2015 0080)


MUHAMMAD FUAD ALAMSYAH

(110 2015 0113)


A. MUH. FADILAH M. GITA REFINA RAHMADINI

(110 2015 0126)
 (110 2015 0130)

MUHAMMAD FAUZAN

(110 2015 0151)


Tutor

:DR.dr. Sri Vitayani Muchtar,Sp.KK MEDICAL FACULTY

MUSLIM UNIVESITY of INDONESIA 2015

Preface Thanks to the Allah almighty we pray over abundance of grace, bless, and His guidance so this Problem Based Learning (PBL) report from group 15th can be resolved properly. And do not forget we send greetings and blessings to our master the Prophet Muhammad SAW which has brought us from a state of ignorance to a state of intelligence. We also would like to thank to all those who have helped in the creation of this report and who have helped during TUTORIAL especially to DR. dr. Sri Vitayani Muchtar, Sp.KK who have helped during the PBL process. And we also would like to apologize to any part of the PBL process has done wrong either intentionally or unintentionally. Hopefully this report TUTORIAL results can be beneficial to all parties who have read this report and especially for his own drafting team. Expected after reading this report, readers can broaden their knowledge of the Humanities, Ethics and Medical Professionalism. Makassar, December 28th 2015

Group15

A. SCENARIO “The woman who was forced to offer her kidney” Physician: This was a case of a woman of 22 years of age who came to donate a kidney for our patient who was supposedly her brother. She was a good match, but I strongly suspected that she was not related and was either being coerced or being paid to donate the kidney. We have a policy against doing transplants from unrelated donors. We make it very clear that we will consider a transplant only if the donor is related to the recipient and is not doing it for gain. I asked her several times but she said that she was his sister. I still had my suspicions, so I sent her to a psychiatrist for assessment. She was of subnormal intelligence and did not understand the procedure. We could have refused to do the operation here, but they would have gone to some other center and had it done anyway. So, we carried out the operation. Much later, we learned that she was a paid, distantly related person who was possibly forced by her family. We are trying to avoid that this becomes a commercialized process of buying and selling goods in the market. We have pioneered the process of renal transplantation in the country and we have found that our results are comparable to the advanced centers in the West. A very important cornerstone of our policy is that we do not accept unrelated donors. Many hospitals in our country allow unrelated donations. The demand for transplants is far greater than available donors can meet. We do not have a government-approved cadaver organ harvesting policy. So the patients have to rely on willing relatives or buy it in the market. It would cost the recipient a big sum of money and then there is the cost of life-long immunosuppression. Some people can afford this and they create a demand for kidneys from unrelated willing donors. The donors desperately need the money and the doctors tell them they can manage with one kidney. Innocent people, underprivileged, unrelated or distantly related, are coerced or even tricked into giving a kidney. Sometimes they don't even know it. They may not be given any money or less than what was promised. This is not new; we have had quite a few reports already. The implications are very serious as have been seen in

many developing countries. We had another case where the donor was clearly a first cousin of the patient and was apparently willing. We had some vague feeling about her and sent her for psychiatric assessment. They found that she had subnormal intelligence and had no clue about the issue, the procedure and what it meant for her. We refused. The patient and his family, and even the donors' parents were upset with us.

B. DIFFICULT WORDCLARIFICATION and KEYWORD 1. Difficult Word a. Transplant Transplant is grafting tissue from one place to another, such as a plant tissue may be transplanted to another rod. Transplanting tissue from the patient's own body can be in other parts (autologous transplant), as in the case of skin grafts using a patient's own skin, or from one patient to another (allogeneic transplant), as in the case of kidney transplant donors to recipients. Kidneys for transplantation may come from a living donor or from someone who has recently died. Reference: Dorland’s medical dictionary 31st edition

b. Subnormal intelegence

Mental retardation is a large group of disorders of infancy, childhood, or adolescence is characterized by intellectual functioning significantly below average (IQ of 70 or below), which is manifested before the age of 18 with impaired adaptive functioning Reference: Margaret Adams, Howard Lovejoy. 2014. Problem of Employment and Occupation.

c. Immunosuppression Immunosuppression is a weakening of the immune system that causes a decreased ability to fight infection and disease. Reference: Mosby's Medical Dictionary, 9th edition. P.1154 © 2009, Elsevier

d. Psychiatrist

The psychiatrist is a physician who specializes in the prevention, diagnosis, and treatment of mental disorders, emotional, and behavioral. Reference : Ruth Elder, Katie Evans, Debra Nizette. 2008. Developing Skill for Mental health Nursing

e. Policy

Regulation is one form of decisions that must be adhered to and implemented, we must obey all regulations to be organized and people will feel comfortable.Regulation is an act that should be done or not to do Reference: JOKO untoro & TEACHER TEAM INDONESIA f.

Donors Donor is someone who donates blood, tissue, or organ for transplant. In the kidney transplant, the donor may be someone who has just died or someone who is still alive, usually relatives. Reference: Kamus kesehatan.com

g. The operation

Surgery or surgery are all actions that treatment using invasive way to open or display the body part to be addressed Reference: R. Sjamsuhidajat & Wim de Jong, 2005

2. Keywords a. A woman 22 years old who came to donate a kidney for our patient who was supposedly her brother b. She was of subnormal intelligence and did not understand the procedure c. We carried out the operation d. She was paid and distantly related person who was possibly forced by her family e. We have pioneered the process of renal transplantation in the country and we have found that our results are comparable to the advanced centers in the West. f. A very important cornerstone of our policy is that we do not accept unrelated donors g. Difficult to have a willing donors

h. Psychiatrist assessment i. The demand for transplant is big but the donors is less j. The donor’s parents were upset with us.

C. Identification of Problems Questions : 

Analyze the case above based on the principles of: a. Medical Humanity Aspects 
 b. Medical Ethics Aspects 
 c. Medical Professional Aspects 




How do you see the case in the perspective of Islam (all the aspects in the view of Quran and Sunnah)


Answer: 1. Analyzing the case based on the medical humanity, ethics and professional aspects From the scenario under title“The woman who was forced to offer her kidney” we do believe that this scenario is divided in two cases.

First case : This was a case of a woman of 22 years of age who came to donate a kidney for our patient who was supposedly her brother. She was a good match, but I strongly suspected that she was not related and was either being coerced or being paid to donate the kidney. We have a policy against doing transplants from unrelated donors. We make it very clear that we will consider a transplant only if the donor is related to the recipient and is not doing it for gain. I asked her several times but she said that she was his sister. I still had my suspicions, so I sent her to a psychiatrist for assessment. She was of subnormal intelligence and did not understand the procedure. We could have refused to do the operation here, but they would have gone to some other center and had it done anyway. So, we carried out the operation. Much later, we learned that she was a paid, distantly related person who was possibly forced by her family

Second case : We had another case where the donor was clearly a first cousin of the patient and was apparently willing. We had some vague feeling about her and sent her for psychiatric assessment. They found that she had subnormal intelligence and had no clue about the issue, the procedure and what it meant for her. We refused. The patient and his family, and even the donors' parents were upset with us.

From those cases we would like Analyze the case above based on the principles of: Medical Humanity Aspects, Medical Ethics Aspects, Medical Professional Aspects.

Medical Humanities Humanities provide a forum for the birth of the intrinsic meaning of the values of humanism. Humanism itself is aimed at reviving a sense of the flow of humanitarian / aspire to a better association. There is also the opinion of humanism as an attitude / behavior regarding human attention with emphasis on compassion and the dignity of the individual. Reference: Bahan Ajar untuk mahasiswa Fakultas Kedokteran UMI, Makassar Angk.2007

Textual : 

We could have refused to do the operation here, but they would have gone to some other center and had it done anyway.

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She was subnormal intelligence and did not understand the procedure.



it would cost the recipient a big sum of money.



They may not be given any money or less than what was promised.



Innocent people, underprivileged, unrelated or distantly related,



We have pioneered the process of renal transplantation in the country and we have found that our results .



The demand for transplants is far greater than available donors can meet.



The implications are very serious as have been seen in many developing countries.

Contextual Humanism expressed an appreciation to the patient as an individual; show compassion and understand the fear and anxiety within the patient; declare a communication means to the patient as an individual rather than as a disease. Furthermore, he said, humanism in medicine is more of an ethic. More than just refrain from doing things that harm the physical and mental patients due to neglect themselves. More than just written in the Hippocratic oath. Humanism is a positive action, such as compassion is not just feeling sorry for the suffering of others but to help by giving advice or actions that alleviate suffering. However, it was surprising because the definition of 'mercy' is not included in the two major medical dictionary - Dorland and Stedman. However, compassion is as important as scientific knowledge and skills in a humanistic doctor.

And from the scenario we have some analysis about it

First case “Doctor save the patient live but do harm to the donor” According to humanities aspect, the doctor done the kidney transplant surgery that made the patients safe and can return to normal life but on the other side the doctor is wrong by done the surgery.Knowing that the donor suffered from mental illness. Based on ethic law people who has mental illnessis prohibit to donate any part of his body because of the assumption that the person can not take right decision and could not keep himself properly and well.

Second case “Doctor do harm to the patient but save the donor” In humanities aspect the doctor do harm to the patient by not doing the transplantation and made the patient being more suffer because the operation is not be done. But the doctor save the donor, because the donor had subnormal intelligence and she didn’t fully understand about the procedure that she about to done. According to medical law, to doing transplantation, the donors should in health condition. Which mean, not only health in physically, but also the mental condition. Medical Ethics 2. Ethics (Ethics) is derived from the Greek word ethos, which means the morals, customs, character, feeling, attitude, good, decent. According to the Indonesian General Dictionary (Purwadarminta, 1953), ethics is the science of moral principles. Meanwhile, according to Dictionary. Indonesia from the Department of Education and Culture (1988), ethics is: 1. The science of what is good, what is bad and the rights and obligations of moral 2. set or a set of principles or values pertaining to morals 3. The value of right and wrong that adopted a group or society

According to the Dictionary of Medicine (Kamali and Pamuncak, 1987), ethics is the knowledge of the correct behavior in the profession.The terms of ethics and conduct are often interchangeable use and no clear distinction between the two. In this book, the definition of ethics is the study of the principles of morality, while ethics is a set of principles or values pertaining to morals as in the Code. The term is usually used to express ethical attitude or view something that is ethically acceptable (ethically acceptable) or unacceptable (ethically unacceptable, unethical).

Textual 

We have a policy against doing transplants from unrelated donors



She was of subnormal intelligence and did not understand the procedure.



A very important cornerstone of our policy is that we do not accept unrelated donors

Contextual

Paragraph 15
 1. Before the approval of transplantation tools and human tissue or given by living donors, potential donors are concerned beforehand was told by his doctors including the consultant doctor about the surgery, consequences, and the possibilities that can occur. 2. Doctors as referred in verse (1) must be certain, that the prospective donor concerned has been fully aware of the meaning of the notice. 

Based on paragraph 15 government regulationfirst case the doctor guilty because even if he knows that the donator has mental illness and it is not appropriate to doing the transplantation but he still going this on.

Paragraph 16
 Donor or donor family that died is not entitled to any material compensation in return for transplantation. Paragraph 17
 It is forbidden to commercialized any part or tissue of human body. Paragraph 33
 1. In the healing of disease and health recovery can be performed transplantation of organs or body tissues, blood transfusion, and drug implants or medical devices, as well as plastic and reconstructive surgery. 2. Transplantation of organs or tissues and blood transfusions as referred to in verse (1) is done only for humanitarian purposes and not for commercial purposes.



Based on paragraph 16 , 17 and 33 we do believe that the donator, patient and also the donator family is guilty because they are all doing commercialized any part or tissue of human body and have compensation in return for transplantation. and in the other hand doctor also mixed up in this crime because as a good and professional doctor he has to seek for the truth of the donator reason why they do so.

Paragraph 34 Transplantation of organs or tissues may only be performed by health workers who have the expertise and authority to do so and carried out in certain health facilities. Or the removal of organs and tissues from a donor must pay attention to the health of the donor concerned and approval heirs or family. Provisions concerning the terms and procedures for the implementation of transplantation as referred to in verse (1) and (2) shall be determined by government regulation.

3.

Medical Professionalism Poerwopoespito & Utomo (2000: 266), says that professionalism means understanding that puts the profession as a major focal point in one's life. People who embrace the ideology of professionalism always shown a professional attitude in work and in everyday life. Professionalism is an attitude of a professional, and professional means doing something as fundamental work called profession, means that the job is not a pastime or as a mere hobby. If the profession is defined as a job and ism as a way of life, the professional can be interpreted as the views to be always thinking, opinionated, behave and work in earnest, hard work, work full time, discipline, honest, loyal and dedicated to the success of his work. So basically professionalism with regard to caring attitude both to the client or to the profession, As expressed by David H. Magister that professionalism is primarily a matter of attitude, not a set of competencies. A true professional is a technician who cares (Magister, 1998: 23).

Textual 

so I sent her to a psychiatrist for assessment.



We are trying to avoid that this becomes a commercialized process

Contextual As a professional doctor he knows that the procedure to doing this transplantation he know the law well and also all regulation so that is why in first and second case the doctor at the very first time examine the donor by sent her to the psychiatry and the regulation are "Transplants can be done by using kidneys from living people or bodies. But we in Indonesia only a transplant from a living donor, because the donor of the bodies has been no strong legal umbrella, so it can not be done," explained Prof Dr Dr Endang Susalit, SpPD- KGH, in a media seminar 'RSCM Able to Perform Kidney Transplant Technique International Standard in Building RSCM Kencana, Jakarta, Thursday (12/1/2012). For living donors, there are several requirements that are set, among others: 1. Age over 18 years 2. Mental and Physical Health 3. Organize the same blood type 4. Normal blood pressure 5. No diabetes 6. Not Cancer 7. Do not have vascular disease 8. Not too fat 9. No abnormalities of kidney stones

Based on those regulation we do believe that the doctor is a professional.

And also the hospital and the doctor are trying to avoid that this transplantation becomes a commercialized process. what we are seeing here is the hospital and the doctor doing their professionalism because they obey the rule and also all the regulateon on ethic code Paragraph 17
 It is forbidden to commercialized any part or tissue of human body.

2. Analyzing all the aspects in the perspective of Islam (in the view of Quran and Sunnah) The purpose of Organ Transplantation

The purpose of the transplant is "as treatment of disease because Islam itself commands people that every disease is treated, for letting the disease lodged in the body can result in death, while allowing yourself to fall into death (without ikhtiyar) is forbidden ".

As Allah says in the Qur'an Surah An-Nisa 'verse 29, "And do not kill yourselves , verily God is merciful to you". That is if the sick man must strive optimally to treat it according to ability, because every disease has been determined the cure, then in this case the transplant is one form of treatment. 

Requirements Implementation of Transplantation. Donating organs is allowed in Islam as long as it is done based on the limits set by law. Thus, Sheikh Ahmad Kutty (article Islam.ca) said that some of the conditions that allow organ transplantation, namely:



Requirements for people who want to donate organs and are still alive: 1) People who would donate organs is a person who has full ownership of his own so that he was able to make their own decisions. 2) People who would donate an organ should be someone who is mature or age reached twenty years. 3) It should be done on his own without any pressure or coercion from anyone. 4) The organs were donated should not be a vital organ in which health and survival

depends on it. 5) Not allowed grafting genital organs. 

Requirements for those who donate organs if the deceased: 1) Do after making sure that the donor wants to donate his organs after he died. Can be done through a will or sign a donor card or other. 2) If there is a case of the donor organ has not given prior consent of donate their organs when he died, the approval can be delegated to the donor families nearby in a position to make a decision over the contributors. 3) Organ or tissue to be donated organs or tissue to be determined can save or maintain the quality of life of other human beings. 4) The organs to be donated should be moved after it was confirmed by a medical procedure that the donor organ has died. 5) Organs that can be donated as well of traffic accident victims whose identity is not known but it should be done with the permission of the judge.

Transplant Law A. Prohibit Transplantation of organs

1. Transplantation of organs while still alive. 

Opinion 1: The statute is not permitted (Haram) .Although these donations for medical (treatment) even though has arrived in an emergency.



Dalil1: Word of Allah

‫ســ ُك ْمتـَـق ْــتلُ ُوا‬ َ ُ‫َولَ اَنـــْف‬ "And do not kill yourselves, Allah is most merciful to you" (Q.S. An-Nisa ': 4: 29)

The point is that Allah forbids people to kill themselves or do anything that leads to destruction and perdition. Meanwhile, people who donate one of their organs

indirectly have committed acts that led to the destruction and perdition. Though humans are not asked to do so, humans just told to keep it (the organs) under paragraph above. Humans do not have the right to organs entirely, because the owners of human organs is Allah.

2. Organ transplants while in a coma. 

Opinion: Doing transplant donor organ in a state still alive, although in a coma, is haraam



Proposition: Verily deeds take one human organs can bring to kemudlaratan, while the act which brings to an act that is forbidden kemudlaratan according Hadith the prophet Muhammad "There should not be doing the job that brings kemudlaratan and there should be no kemudlaratan"

Humans shall endeavor to cure the illness and sustain life, because life and death are in the hands of Allah. Therefore, people should not take his own life or accelerate other death of people, although reducing or eliminating the suffering of patients.

3. Organ transplants when the state has died. 

Opinion: The statute Haram because of the sanctity of the human body every form of aggression on the human body is prohibited.



Proposition: There are a few commands of the Qur'an and Hadith that forbid. Among the well-known hadith, namely: "Breaking bones corpse someone equally sinful and break bones break with that person when he was still alive"

However Donating organs can be forbidden if:

a. Transplantation of organs taken from people who are still in a state of healthy living, with reason: the Word of God in the Qur'an S. Al-Baqarah verse 195, that the verse reminded, lest hasty and careless in doing something, but must pay attention to the consequences, which the possibility could be fatal for the donor himself, even though it has the objective of humanitarian action is good and noble.

b. Perform transplants in the state in a coma. Although the doctor said that the donor was going to die soon, the transplant remains unlawful because it can speed up his death and precedes the will of God. In the hadith the Prophet said: "There should be making madharat themselves and should not also make madharat on others." (HR, Ibn Majah, No.2331)

c. Organ Sales. So far the practice of selling human organs, scholars agree that such practice is haraam based on the following considerations: o A person may not sell objects that are not his. o A hadith states, "Among those who will be questioned in the Hereafter are those who sells a free man and ate the results." o Thus, if a person sells a free man, then forever the buyer does not have any rights over human beings, because since the beginning of the .legal transaction itself is unlawful. o Sale of human organs can bring irregularities, in the sense that it can lead to merchantability organs poor people in the market like any other commodity.

B. Allowing Transplantation of organs

The human body is a trust, basically does not belong to man but is a mandate from God that must be maintained, because the man does not have the right to donate to others. 

Proposition In fiqiyah rule explains that "When met two things that bring mafsadah (destruction), then maintained that bring the greatest madharat by doing the lightest madharat of two madharat". During the transplant work was no element of damaging the bodies as an insult to him. As for the arguments that can be used as a basis in the law-making organ transplantation , among others:



Al-Qur'an a. Surah Al-Baqarah verse 195, which reads:

It means: "And Do not drop yourself into destruction and do good God loves people -people who do good " The verse explains that Islam does not justify someone let himself in danger, without trying to find a cure medical and non-medical, including efforts to transplant, which gave hope to survive and b. Surat Al-Maidah, verse 32

It means: "And He who saved a life, then as if he saved the life of all human beings. and hath come unto them the Apostles We (brought) descriptions are clear, then many of them thereafter seriously exceed the limits in mischief on earth. "

The verse suggests that humanitarian action (such as transplant) is very much appreciated by the religion of Islam.

c. Al-Maidah verse 2

This means: "And you should help to each other in (doing) goodness and piety, and do mutual assistance in sin and transgression. and ye fear Allah, Allah is severe in punishment . " Commands for helping each other in doing virtue and piety is mandatory for all human beings, which is partially let you help others.

The verses are sent to do good to fellow human beings and help each other in goodness. The body of the deceased to donate organs is an act of helping in the good because it gives benefits to people who really need it. 

Hadith Hadith of the Prophet Muhammad: "all people repent you to Allah, because Allah does not put a disease, but he also laid the cure, other than one disease, namely being old." (Reported by Ahmad, Ibn Hibbaan and al-Hakim of Osama Ibn Shuraih)

The hadith indicates that obligatory medical treatment when ill, and illnesses of any kind, except for an old disease. Therefore, a transplant in an attempt to eliminate disease permissible legal, provided it does not violate the norms of Islamic teachings.

D. From The Scenario We Can Summarize Some Points 

According to the rules of bioethics and humanities Humanities provide a forum for the birth of the intrinsic meaning of the values of humanism. Humanism itself is aimed at reviving a sense of the flow of humanitarian / aspire to a better association. There is also the opinion of humanism as an attitude / behavior regarding human attention with emphasis on compassion and the dignity of the individual. In the organ transplant will be involved physicians, donor families and recipients with their families. There is a procedure that must be understood by everyone involved in organ transplantation. May be made, provided in accordance with the indications, as a last resort, there is agreement, and the religion of Islam requires that organs should not be traded. Suggestions for this discussion is that if he wanted to do organ transplants (kidney), apart from the aspects of bioethics / humanities, legal and religious aspects must also be considered.



According to terms of ethics Transplantation is the last attempt to help a patient with failure of one of the main functions of the organs. These actions must be performed if there are indications, KODEKI based on several articles in which article 15, article 16,article 17 and many more that need to obey by the doctor.



According to terms of professionalism professionalism means understanding that puts the profession as a major focal point in one's life. People who embrace the ideology of professionalism always shown a professional attitude in work and in everyday life. Based on those regulation we do believe

that the doctor is a professional. And also the hospital and the doctor are trying to avoid that this transplantation becomes a commercialized process. what we are seeing here is the hospital and the doctor doing their professionalism because they obey the rule and also all the regulation on ethic code 

According to Qur’an and Sunnah Transplantation is a very tricky thing in taking the appropriate action, as many opinions against and in support of the implementation of the transplant with a variety of different reasons. from the description above discussion, it can be concluded that the law enforcement organ transplantation depends on the reason why it should do so. if the reason does not support the activities of the transplant is strictly prohibited and haram, and illegal.