LEGAL AND ETHICAL ASPECT LEGAL AND ETHICAL ASPECT OF MEDICAL EMERGENCIESOF MEDICAL EMERGENCIES

Dr.Herkutanto, SH, FACLMDr.Herkutanto, SH, FACLM

HHerkutantoerkutantoDepartment of Forensic Medicine & MedicolegalDepartment of Forensic Medicine & Medicolegal

Faculty of Medicine University of IndonesiaFaculty of Medicine University of IndonesiaPh.D in Forensic MedicinePh.D in Forensic MedicineFellow of Australian College of Legal MedicineFellow of Australian College of Legal Medicine

Medical & Medicolegal QualificationsMedical & Medicolegal QualificationsUniversity of Indonesia – Faculty of MedicineUniversity of Indonesia – Faculty of MedicineMonash UniversityMonash University, Australia – , Australia – Faculty of MedicineFaculty of MedicineNetherland School of Public HealthNetherland School of Public Health, The Netherland, The Netherland

Qualifications in Health LawQualifications in Health LawUniversity of Indonesia – Faculty of LawUniversity of Indonesia – Faculty of LawLa Trobe University, Australia - School of LawLa Trobe University, Australia - School of Law

International Assignments – Medicolegal ConsultantInternational Assignments – Medicolegal ConsultantWorld Health Organization – 1989World Health Organization – 1989United Nation Funds for Populations Activities – 1992, 1994United Nation Funds for Populations Activities – 1992, 1994John Hopkins University, 2003John Hopkins University, 2003

OBJECTIVES

1) To understand Ethical and Legal Aspect in a medical emergencies and its circumstances

2) To understand the scope of duties and obligations in medical emergencies

3) To understand consent in medical emergencies

EMERGENCY (definition)

Any conditions that in the opinion of the patient, his family, or whoever assumes the responsibility of bringing the patient to the hospital – requires immediate medical attention. This condition continues until a determination has been made by a healthcare professionals that the patient’s life or wellbeing is not threatened.

American Hospital Association

EMERGENCY PHASE

Pre Hospital HospitalPublic >> Medical Personel

Good Samaritan Doc P-P Relationship

voluntarism (-)

pre-existing (-)

“Public Good” “Private Good”

All Aid in Emergency Phase FINISH

Avoid the loss of chance to survive

ROLE OF MEDICAL FIRST ROLE OF MEDICAL FIRST RESPONDERRESPONDER

• ACCESS TO THE VICTIM AND COMMUNICATION

• SAFETY AND SECURITY• ASSISTING THE VICTIMS• ASSISTING OTHER

MEDICAL EMEREGINCY PERSONNELS

• DATA PROTECTING• TRANSPORTATION

• Access to communication facilities 118; 110; 113

• Access to the victim and environment assessment

• Access to security personnel

• Victim and self Personal protection

• Assists the victim according to the competence

• Reliability & Confidenti- ality medical information

• Vehicle & transportation route

SCOPE OF ASSISTANCE

• Knows the limit of competence

DO NO FURTHER HARM

LEGAL CONCERN LEGAL CONCERN IN MEDICAL EMERGENCIESIN MEDICAL EMERGENCIES

• Is there any legal obligation in medical emergency circumstances?– Who are obliged? every person?– Are there any limitation to act?

• Are there any legal consequences for persons who helps another person in emergencies?– Is there any protection for a person who is in good faith

voluntarily helps other people in medical emergencies?– Are there legal liability to the helpers?

• What about the costs of treatment?– EMTALA (Emergency Medical Treatment and Labor Act) -

USA– COBRA (Consolidated Omnibus Budget Reconciliation Act)

ETHICAL CONCERN ETHICAL CONCERN IN MEDICAL EMERGENCIESIN MEDICAL EMERGENCIES

• Is there any basic moral principle in medical emergency circumstances?– What basic moral principle are?– What ethical conduct for medical emrgencies

• Are there any legal consequences for persons who helps another person in emergencies?– Is there any protection for a person who is in good faith

voluntarily helps other people in medical emergencies?– Are there legal liability to the helpers?

• What about the costs of treatment?– EMTALA (Emergency Medical Treatment and Labor Act) -

USA– COBRA (Consolidated Omnibus Budget Reconciliation Act)

MEDICAL PRACTICE ACT 2004 (Indonesia)

Article 51

(d) Medical practitioners shall have the obligation to provide humanitarian emergency medical assistance, except that they convince that another competent person is available to provide such assistance, …..

GOOD SAMARITAN DOCTRINE

“The principle that a person who is injured while attempting to aid another in imminent danger and who the sues the one whose negligence created the danger, will not be charged with contributory negligence unless the rescue attempt is an unreasonable one or the rescuer acts unreasonably in performing the attempted rescue”

CONFIDENTIALITYMANDATORY-REPORTING

RIGHT TO PRIVACY Duty to medical secrecy

REPORT TO PUBLIC AGENCY Police

CHILD ABUSE No mandatory obligation in

Indonesia

SPECIFIC CIRCUMSTANCES SPECIFIC CIRCUMSTANCES IN MEDICAL EMERGENCIESIN MEDICAL EMERGENCIES

• SHORT OBSERVATION TIME• SUDDEN & UNEXPECTED CLINICAL

MANIFESTATION• HIGH MOBILITY OF HEALTH PERSONNEL• INSUFFICIENT INFORMATION TO ESTABLISH

CLINICAL JUDGEMENT

HIGH RISK!!

LEGAL CONCERN IN EMERGENCY-TRAUMA

CONSENT REFUSAL OF

TREATMENT CONFIDENTIALITY MANDATORY-

REPORTING

INFORMED CONSENT EMERGENCY DOCTRINE GOOD SAMARITAN D. PATIENT’’S

COMPETENCY ASSAULT & BATTERY RIGHT TO PRIVACY REPORT TO PUBLIC

AGENCY CHILD ABUSE CHAIN OF CUSTODY

CONSENT TO TREATMENT

• Every action must be consented by the competent patient or the next of kin (when the patient is incompetent)

• Expressed Consent

• Implied Consent– the patient is unconscious– medical treatment is urgent– no next of kin present

CONSENT IN MEDICAL EMERGENCY & CONSENT IN MEDICAL EMERGENCY & CONSENT COULDNOT BE OBTAINEDCONSENT COULDNOT BE OBTAINED

No Consent No Consent NeededNeeded

Good FaithGood Faith

Patient’s Best Patient’s Best InterestInterest

CONFIDENTIALITYMANDATORY-REPORTING

RIGHT TO PRIVACY Duty to medical secrecy

REPORT TO PUBLIC AGENCY Police

CHILD ABUSE No mandatory obligation in

Indonesia

LEGAL CONCERN IN EMERGENCY-TRAUMA

NEGLIGENCE

DEATH / DNR

PATIENT’S PROPERTY

MEDICAL CERTIFICATION

LIABILITY STANDARD OF CARE ABANDONMENT PATIENT’S TRANSFERS DEFINITION OF DEATH DNR INDICATIONS WITHHOLDING&WITHDRAW

AL TREATMENT UNCLAIMED DEATH BODIES CHAIN OF CUSTODY

NEGLIGENCE

LIABILITY STANDARD OF CARE ABANDONMENT PATIENT’S TRANSFERS

ABANDONMENT

Terminating an on-going emergency assistance regardless the absence of a more competent health personnel

NEGLIGENCENEGLIGENCE

• Recklessness

• Foreseeable

• Preventable

DEATH / Do Not Resuscitate

DEFINITION OF DEATH Clinical Brain Stem Death

DNR INDICATIONS The death has been declared

UNCLAIMED DEATH BODIES Sent to the city morgue

PATIENT’S PROPERTY

CHAIN OF CUSTODY

MEDICAL CERTIFICATEMEDICAL CERTIFICATE

PURPOSE

LEGAL CONSEQUENCES

MEDICOLEGAL ASPECT OF MEDICOLEGAL ASPECT OF EMERGENCIESEMERGENCIES

According to Causes

•TRAUMA•NON-TRAUMA

According to the Number of Victims

•Individual Casualty

•Mass Casualty

Criminal Act?

Medicolegal Certification

IdentificationRights of victims

DISCUSSION

ISSUES TO BE EXPLORED

• Don’t know his/her limitation of competence

• Negligence

• Different opinion amongst the helpers

• Patient’s consent

• Refuse of treatment by the patient

• Etc, etc

DISCUSSION PROCEDURES

1. What kinds of conflicts that possible to be arisen when a MFR helps a victim?

2. Play the role of two parties in conflict

3. Identify potential problems

4. Develop options to solve the problems

5. What is the theoretical background?

POTENTIAL CONFLICT• .

• .

POSSIBLE SOLUTION

POTENTIAL CONFLICT• Pasien tidak mau ditolong, tidak mau di RJP, Keluarganya

minta agar dilakukan tindakan (bertentangan dengan kemauan pasien), & butuh RJP, tidak ditolong, pasien meninggal. Keluarga menuntut.

• .

POSSIBLE SOLUTION

• Sikap dokter (merespon permintaan pasien):analisis kondisi mental pasien (sehat:turuti pasien)

• Sikap dokter (merespon keluarga yg minta RJP):menjelaskan kpd keluarga, menunjukkan surat pernyataan sikap pasien

• DNR adalah advance directive, sejauh alasan dpt diterima, dokter menuruti kehendak pasien

• Dokter punya kewajiban utk menolong sesama

• Dokter tetap melakukan RJP meskipun permintaan pasien menolak RJP. Krn RJP life-saving. Lebih baik dituntut krn melakukan perbuatan yg baik.

• Advance directive:dokter harus memastikan bhw pasien benar-benar memahami keadaan dirinya.

• Dr.amal:tetap mengikuti keinginan pasien krn hak otonomi pasien

• Respon keluarga:marah krn next of kin minta RJP tapi dokter tdk mengabulkan permintaan keluarga.

• pasien hrs dinilai apakah dpt menilai hak2nya sendiri

• Dokter hrs menjelaskan krn pasien belum tentu dpt mengerti kondisinya yg sebenar2nya.

POTENTIAL CONFLICT• Di tengah jalan,dokter bertemu seseorang yg tertembak.

Dokter menelpon ambulans,tetapi datangnya lama. Klinik terdekat fasilitasnya tidak lengkap. Jadi,menunggu ambulans atau menolong di klinik (kemungkinan tertolong kecil)

• .

POSSIBLE SOLUTION

• Dr.anton:ditolong dulu di klinik dan meminta ambulans menjemput di klinik

• Adakah dilema moralnya? • Apa yg terbaik utk korban? (asas

beneficence,non-maleficence)• Mana yg lbh mencelakakan pasien? • Mana yg lbh menolong pasien?• Benefit/Risk ratio?

POTENTIAL CONFLICT• Ditengah jalan bertemu wanita bercadar (tdk boleh kontak

fisik dg lawan jenis) yg saat itu mengalami serangan jantung. Sedangkan dokter penolong laki-laki.

• .

POSSIBLE SOLUTION

• Mencari orang lain (perempuan) utk memeriksa korban

• Sebagai pasien,saya terima penolong apabila juga perempuan

• Dlm agama diijinkan utk menolong meskipun lawan jenis.

POTENTIAL CONFLICT• .

• .

POSSIBLE SOLUTION

POTENTIAL CONFLICT• .

• .

POSSIBLE SOLUTION

KEMUNGKINAN KONFLIK

1. Menolak pengobatan (belakangan ) setelah pengobatan dilakkan dalam keadaan tidak sadar

2. Menolak pengobatan karena masalah kultural3. Menolak pengobatan – meninggal, orang lain

menuduh penolong tidak bersedia melakukan pertolongan

4. Penolong dijadikan saksi dan direpotkan:1. Konflik antara penolong dengan pihak lain yang

berkepentingan untuk menyelesaikan perkara tersebut (keadaan hukum)

5. Multiple korban, tidak semua bisa ditolong sekaligus. Korban merasa ditelantarkan dan dinomorduakan.

KEMUNGKINAN KONFLIK

1. Menolak pengobatan – meninggal, orang lain menuduh penolong tidak bersedia melakukan pertolongan

2. Akses ke korban terhalang, konflik dengan masyarakat ketika akan melakukan akses kepada korban

3. Masalah ekonomi. Pasien tidak punya biaya. Konflik dengan tenaga kesehatan.

KEMUNGKINAN KONFLIK

1. Ada 2 orang korban. Salah satu satu penjahat. Fasilitas saat itu hanya menungkinkan untuk menolong satu orang saja. Siapakah yang harus ditolong?

2. Tenaga medis dalam situasi pertempuran / konflik. Apakah tenaga medis itu dianggap netral, ataukah memang bertugas menolong salah satu pihak saja?

KEMUNGKINAN KONFLIK

1. Korban yang mati secara klinis. Apkaah akan dilakukan resusitasi? Pertimbangan:

1. Bila dilakukan resusitasi, korban akan mengalami sequele (cacat)

2. Bila tidak ditolong, keluarga marah

2. Penolong dituduh lalai melakukan tindakan pertolongan sehingga menyebabkan kematian.

1. Menolong pernafasan buatan terhadap jenis kelamin lain, ada hambatan agama. Bila mencari orang lain, tidak sempat, korban meninggal.

2. Dokter salah diagnosis, dengan akibat salah terapi.

3. Korban massal, petugas terlalu letih, tak mampu menolong lagi

4. Dalam keadaan perang, kita dikejar lawan, padahal ada yang perlu ditolong

1. Hambatan kultural. Dalam situasi tersebut, jangan membayangkan dengan pikiran non-medis. Membedakan laki2 & perempuan..?

2. Tanggung guggat. Standard Op Precedure vs Standar Profesi ..?

3. Di RS: unacceptable

4. Tenaga medis: combatant & non-combatant

KEMUNGKINAN KONFLIK

5. Seorangtua menyeberang, tiba2 jatuh dan tak sadar ditengah jalan. Ada penyeberang lain yg mengaku sebagai mhs ked / tenaga medis tanpa memperlihatkan jati diri. Yang dilakukan dianggap salah, haruskah kita menegur?

6. Korban tabrak lari. Apakah menolong, dengan segala konsekuensinya?

7. Anak menderita leukemia myeblast akut, perlu transfusi darah. Padahal ia menganut sekte yg tidak boleh dilakukan transfusi

1. Bekerjasama!! Bila tidak yakin dg tindakan org lain, komunikasi dg baik.

KEMUNGKINAN KONFLIK

8. Ada 2 pasien di IGD, datang berbarengan. Penolong kekurangan tenaga, pada hal keduanya dalam keadaan darurat.

9. Tabrak lari malam hari. Ketika akan menolong, ternyata kita mempunyai keperluan mendadak yang lain (keadaan gawat).

10. Dr. PTT ke daerah, hanya ada 1 RS. Terjadi konflik sosial. Dr. mendapat ancaman agar tidak menolong kelompok lainnya.

KEMUNGKINAN KONFLIK