School of Medicine, Catholic University of Atma Jaya, Jakarta
It is difficult to afford health care services in Indonesia if you are poor. How come in such a rich country, the national budget for health care insurance for poor people is only 5.1 trillion Rupiah to cover 76.4 million poor people? Even if the number of poor people in Indonesia is predicted to be as low as 60,5 million according to the National Statistic Biro (2010), accessibility to health care for poor people is still limited. Poor people who are hospitalized and who cannot pay their bill are often taken “hostage” until their families pay the “ransom” to take them home.
Let us look at some random data during the year 2010. On April, 23, a patient was taken “hostage” in Bina Kasih Hospital in Medan, North Sumatera. It happened again on May, 25 in Persahabatan Hospital in Rawamangun (East Jakarta), followed by another “hostage” situation in Darus Syifa Hospital in Surabaya (East Java) on June, 24 July 2010. Another “hostage” situation occurred on August 25 in a public hospital in Tangerang, West Java and just this month it happened again on November 2 in Sura Syifa Hospital in Kediri (East Java). The case I propose here occurred in East Java (Indonesia) on October 14, 2010.
Looking at the criteria that had been drawn by the Indonesian government to define poor people, Sarmini and his family are poor. Being poor limited the access to public facilities and health care. People do hope that they would not get sick, but who can escape from any sickness or tragedy in this life as it was occurred to Sarmini recently? Last July 2010 Sarmini was scalded with hot water so badly that he was sent to a hospital in Bali. He suffered serious wounds to his head, stomach, and chest. He had stayed in the hospital for only seven days before he was charged to pay 14 million Rupiah (1000 Euro). He paid this then went back to his family in Blitar, East Java. His condition worsened so that his family took him to a local government hospital where Sarmini stayed for almost two months.
The “drama” started on October 13, 2010, when Sarmini was about to leave the hospital. He was asked to pay 20 million (1,429 Euro) in order to leave the hospital but he could not pay. He was held “hostage” at the hospital. The doctors and nurses knew that even if he was held hostage for years, he would not be unable to pay the bill, but they could not avoid following the rule of the hospital.
At one time, Sarmini’s tribal chief came to the hospital and testified that he was poor, and asked the hospital to free him from any payment since poor people has health insurance as provided by the Indonesian government. But the tribal chief as well as the family failed to show the health insurance mentioned, so Sarmini was not allowed to leave. For the hospital, no matter what the reason is, someone has to prove of being poor by showing the insurance card as registered by the government. This was the problem of Sarmini when he could not prove himself as a poor citizen.
MEDICAL STATE OF THE ART
What occurred to Sarmini was a real tragedy. Hot water scalding categorized as second-degree burns has caused serious wounds to Sarmini’s head, stomach and chest.
From a medical point of view, the second-degree burns manifested as erythema with superficial blistering of the skin. It can involve more or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. Deep dermal burns usually take more than three weeks to heal and should be seen by a surgeon familiar with burn care, as in some cases severe hypertrophic scarring can result. Burns that require more than three weeks to heal are often excised and skin grafted for best result.
The process of healing for second-degree burns is slower than for the first-degree burns. The wound is the cause of the morbidity and mortality of burn injuries and until the wound is healed the patient remains at risk of complications.
Sarmini and many other poor people do not want to be hospitalized, even for a single day. The unpredictable situation like this put Sarmini at his vulnerable edge where staying longer at the hospital damaging him financially, psychologically and mentally.
ETHICAL QUESTIONS ARISE
The situation faced by Sarmini portrays a reality in Indonesia where poor people have limited access to health care. Unfortunately, this situation is less discussed or rarely hit the headlines of mass media compare to the criminal news, political news, or entertainment news. Why does society pay less attention to such a problem? If society or a country does not have enough money to be spent for health care, is it mean that people do not have right to ask for health care? Should we say that poor people just accept this condition by the fact that government does not have enough budgets to afford health care for all citizens? How could you say that poor people should accept their unlucky situation when they know that they should be protected as citizens?
It is interesting to note that at the beginning of her ministerial office after appointed as Ministry of Health, Miss Endang Rahayu Sedyaningsih, has warned the hospitals not to hold “hostage” the patients because of their inability to pay the bill. Yet still many hospitals do not obey the instruction. Perhaps the absence of sanction is one reason why hospitals tend not to obey the instruction. However, the high cost of overheads and operations seems to be the main factor. Realizing that it is not easy to reimburse money from the government after providing health care to poor people who are using insurance card, the directors of the hospitals find themselves in a difficult situation whether or not to help poor people without card insurance. This condition prevented them not to take the risk of providing health care to those who do not have insurance card.
Assuming that the director of the hospital, physicians, nurses and all health care providers working at the hospital are religious persons, hold “hostage” a patient would create uneasiness and regret. Physicians or nurses who are Muslim know that a Muslim is the brother of another Muslim. He does not oppress him, nor does he leave him at the mercy of others.” Meanwhile those Christians doctors and nurses cannot simply free their conscience be bothered by the word of the Lord, says, “Love thy neighbor as you love yourself” or “Whatever you did for one of these least brothers of mine, you did for me.” After all, they also know that the second principle of “Five Principles” called Pancasila commands every Indonesian to be compassionate to her/his neighbors.
From medical art point of view, the physicians at the hospital understand one of the “Hippocratic Oath” saying that in performing medical arts, they will apply dietic measures for the benefit of the sick according to their ability and judgment; and that they will keep them from harm and injustice. Besides, as Indonesian physicians, they know also the first Ethical Code of Indonesian Physicians, saying: “I will dedicate my life for the sake of humanity.” Considering all these elements, a conclusion could be drawn as follow: doing good (benevolence) and do no harm (non-maleficence) as mentioned by the Hippocratic Oath or being a dedicated physician to humanity as prescribe by Ethical Code of Indonesian Physicians has been practiced so far as we considered the best interest of Sarmini. The problem arose not at the level of providing health care and curing the patient, but more on administrative level. However, being indifferent by not letting oneself helping patients dealing with administrative problem could undermine the whole practice of health care itself. It will “harm the patient” in broad sense as well as against some basic ethical principles related to the practice of medicine.
So, ethical questions would be: is it sufficient to base one’s act purely on administrative rules? In the name of do no harm to the patients, should physicians bother themselves only with the art of medicine as such without helping patients solve the administrative requirements? Doesn’t it mean that letting the patients struggle with his/her problem at the administrative is allowing other harm to occur? In performing their duties, should the physicians stop at their core duty of not harming the patients by maximizing the whole medical arts in order to cure them? Or, should their caring responsibility also go beyond the patients ward?
These questions should compel the physicians and nurses to rethink their role as care giver. In 1994 the American Board of Internal Medicine (ABIM) has tried to answer these and they came out with some medical professionalism characters that should be practiced by all physicians in delivering medical assistance and care. One of the many professional values proposed by ABIM was “altruism”. By altruism, ABIM acquires physicians to move from the responsibility to provide health care in common role of physician–patient relationship to social responsibility in terms of the ability to address also societal needs, promote humanistic values of honesty, integrity, and caring, compassion, altruism, and empathy.
In Sarmini’s context, what has been decided by hospital’s Director was not fully wrong. It was part of his responsibility in planning, budgeting, and controlling cash-flow of the hospital. However, should he or any physician on his position exercise responsibility in a manner that efficiency is placed as the highest priority? By holding “hostage” Mr. Sarmini, the Director’s of the hospital has made a legal decision, and it was not wrong at all. People cannot sue or against the decision if the law is to be respected. However, there is something insufficient in making such a decision. Doing good and avoid harm through providing health care to Mr. Sarmini became meaningless when the decision made to hold him hostage in fact harm him psychologically. The question then did the physicians lack any fundamental and ethical principles by which their professional acts be justified as moral act?
FOUR ETHICAL CONSIDERATIONS
Discussing this case at the “Ethical Committee” level has brought up at least four ethical reflections and deliberations. They can be grouped into two main categories. The first two are more about ethical discourses which lead to practical consideration, while the last two are more on concrete ethical actions in terms of what to do in order to solve the problem.
First ethical reflection regarding the case could be formulated as follow: it is necessary to provide health care by mean of curing patient, but still insufficient not to take into consideration the whole dignity of the patient. To do justice to the physicians, we should admit the fact that Mr. Sarmini was about to leave the hospital has proven that the physicians and nurses have performed their duty in providing health care needed. However, should the doctors get rid of or liberate themselves from non-clinical business such as looking for ways to solve financial problems or proposing specific scheme of payment for the patients? This question is relevant when the profession of caring and curing the patient is contextualized in an institutional dimension of care. By this we mean that medical profession exercised by physicians cannot be separated from institutional dimension where nurse, as well as administrative staff, director and the whole board of the hospital, patient’s family, and society at large with its system of health care come into play. Only within this institutional dimension of care that we come to a better understanding of what is to be compassionate doctors or altruistic physicians.
“Compassionate” or “altruistic” physician is used to describe the ability to put oneself in the place of other and readiness to involve oneself helping others to attain a particular or an ultimate goal in life, named happiness. Using the concept of “rational altruism”, we could say that the reason for having an altruistic attitude toward a moral subject is driven by a motivation to promote a future end. From the perspective of patient as “the vulnerable other” who compel responsibility from care providers that we understand the whole policies of providing health care—including also economical condition of the patients, are they able to pay the bill, how are they going to pay, and so forth—as the hard core of the arts of medicine. According to Edmund Pelegrino, the hard core of the whole arts of medicine is “patient centered medicine”. For him, patients are vulnerable and their vulnerability places them in a stage of “damaged humanity”. It means that providing health care means reconstructing humanity. It requires from a physician an ability to move from an act of profession (in terms of curing only physical illness) to what he called noblesse oblige, which is curing the “damaged humanity” of the patient. In Pellegrino’s point of view, damaged humanity can be caused by physical illness, certain psychological pathologies, and social injustices. The vulnerability of patients cannot but compel me, entrapped my freedom and limit it to the extent that his/her wellbeing is part of my project.
Still using Pelegrino’s notion of vulnerability of the patient as “damaged humanity”, the noblesse oblige he proposed could be practiced only when the physicians or care providers in general are willing to involve in the whole process of providing or giving health care. To be more precise, we can use the social science theory of “hands-on” and “hands-off”. “Hands-off” physicians describe the physicians who are just perform their professionalism duty without playing social role in terms of commitment and action to construct a healthier society as well as healthier health system where access to health care will be accessible to every citizen. On the other hand, “hands-on” medical doctors express the character of compassionate and altruistic physicians who play certain social and/or political role in advocating a health system where the interests of marginalized and vulnerable people are placed as ends of medical care. They can play such a role because of their knowledge, skill, and bargaining power in society.
As a matter of fact, medical doctors as well as hospitals have strong bargaining power in society. Medical doctors have professional union in national level, province or regional level, or even based on certain religion. On the other hand, with all sources and human resources they have, the bargaining and political power of the union of hospitals cannot simply be undermined. In the Indonesian context, together with other social organization, they (the union of medical doctors and hospital) could play a strategic role in reforming a better health law by which the whole citizen (including poor people) will be covered by health insurance. If national spending for education is up to 20% of the whole national budget in a year, why do the medical doctors’ union and hospitals’ union not press the government to budgeted so or even more for the health sector? In a democratic country where expression of opinion is given place, maximizing other democratic tools like strikes, protests, public debates, or lobbying could be consider also as part of physicians role together with the whole community in fighting the right to affordable health care for all. This can be considered as a proposal to our moral consideration in a macro level.
Second ethical reflection puts the case discussed here in the context of justice. What is justice principle here that are not fulfilled or taken into practice? The thoughts of Paul Ricoeur describe sufficiently the problem of justice faced by Sarmini. For Paul Ricoeur, justice cannot be realized in an unjust society when he said, “The pursuit of the good life together with and for others in a context of just and fair institutions.” Here Paul Ricoeur warned us of the importance of constructing a just society and fair institution through which justice is not only recognized and given place but also fulfilled. In the context of health care, type of hands-off doctor will only perpetuate the unjust institution and state, whereas the hands-on physicians will shed light and pave the way to constructing more humanistic and dignified health care system where rights to health care can be realized.
Most of the health care problem in Indonesia expressed what Vicky Cattel called as “social exclusion”. According to Cattel, most of the poor people in an unjust society have very limited access to health care, and by that they are excluded from societal health care services.  Here then a call to involve oneself as individual physician or as professional union in a movement to reform health law or by organizing a small community to fight for the right to health care can be one way of combating this social exclusion. Again we need hands-on physicians. However, considering the fact that this effort is more to deal with society at large where political interests often block certain movement for change, physicians or health care providers should not forget the real problem they are facing daily: poor people are coming to the clinics and to the hospitals every day. Also the undeniable fact that many of them do not have health insurance and that they cannot be refused simply because of their inability to pay the bill.
The third ethical consideration proposed here is very concrete one, and it is aimed to be a short term way out to the problem face by Sarmini and the hospital. To be honest, this is not a new proposal since it has been practiced by physicians and medical students at the Faculty of Medicine, Brawijaya University of Malang (East Java). The program named as “doctor 1000” was created by Rita Rosita, MD, by which every member of the family in a small community donates 1,000 Rupiah (10 cent) per month and submit it to people in-charge. The money collected will be used to pay the bill of those who are accessing the health care. This has nuance with the research done by Vicky Cattel in East/North East London where “social exclusion” because of poverty seemed to be easily combated by social network in which the community is not only empowered, but also consider other as his/her sister’s keepers. This kind of “community insurance” will bring forth two impacts all together. The first is related to the importance of social solidarity where in the absence of national health insurance, people can work hand in hand to help each other. The second impact would be a warning to the state, that the unity shared by social solidarity has a real power to end up political contract where political power gained its legitimacy. In a democratic society it says that the end of a regime is coming to an end.
Finally, the fourth ethical consideration is something to do with the payment of the bill itself. The “Ethical Committee” has proposed a change of the scheme of payment by which poor people are offered possibilities to gradually pay the bill. Here “Ethical Committee” realized that this proposal will change a little bit payment system in the hospital, but as a concrete realization of being hands-on physicians in a just institution, hospital should be courageous enough to initiate a new approach. It is undeniable that certain difficulty will appear soon, especially things that related to hospital’s system of administration. However, should we withdraw our commitment because of our discouragement to face certain changes? After all, we should learn also from what has been done by Bandung Hospital in Medan (North Sumatra) where patients were offered to pay their health bill gradually. At the end, it is our responsibility to make sure that they can pay the bill gradually.
Being responsible to one’s profession as physicians is not only simply providing health care, do good or does no harm to patients. Being a medical doctor means also committed one-self by taking responsibility to form a good and just society in which the right to health care is available and accessible to whole community impartially. The physicians, be it individual or as a corps, has a great contribution to make it happen, whether in the national level or in small community where he/she cannot but face “the vulnerable other” come to clinics or hospitals, seeking for health.
WHAT DID I LEARN FROM “ETHICAL COMMITTEE” MEETING?
I consider the “Ethical Committee” meeting held on November 22, 2010 as part of the exercise on how to conduct an “Ethical Committee” discussion. I found out that the meeting was useful and helpful for my later work as an ethicist or bioethicist in a faculty of medicine. Two things can be said here. First, I have to be more precise and focus on delivering the ethical question(s). It is important to help others “taste” ethical problem(s) related to the case presented. Second, I should open myself to other approaches and different point of views regarding ethical problems. After all, I think ethical deliberations resulted in an “Ethical Committee” meeting is not a one sided opinion, but an opinion shared by the whole member. As a learning experience, it was a great exercise.
The author thanks Ms. Joke Lemiengre, Associated Researcher at Centre for Biomedical Ethics and Law, Kapuncijnenvoer 35, Leuven for her useful comments and inputs during the “Ethical Committee” meeting. The author thanks also other member of the “Ethical Committee” who participated actively by giving their comments and suggestions.
Burggraeve, Roger, The wisdom of Love in the Service of Love: Emmanuel Levinas on Justice, Peace, and Human Rights, Marquette University Press, Milwaukee, 2002.
Buchanan, Allen E., The Right to a Decent Minimum of Health Care, Philosophy and Public Affairs, Vol. 13, No. 1 (Winter, 1984).
Cattell, Vicky, Poor people, poor places, and poor health: the mediating role of social networks and social capital, Social Science & Medicine 52 (2001).
Churchill, Larry C., “Damaged Humanity”: The Call for A Patient-Centered Medical Ethic in the Managed Care Era. Theoretical Medicine 18: 1997. Kluwer Academic Publishers.
Denier, Yvonne & Tom Meulenbergs, “Health care needs distributive justice. Philosophical remarks on the organization of health care systems.” In Paul Schotsmans, Reidar Lie, Bart Hansen, Tom Meulenbergs (Eds.), European Perspectives on Health Care Ethics, Leuven, Peeters, 2002.
Gastmans, Chris, “The Care Perspective in Healthcare Ethics”, in A. Davis, V. Tschudin & L. de Raeve (eds.), Essentials of Teaching and Learning in nursing ethics. Perspectives and methods. Elsevier, Edinburgh, 2006.
Health Law of the Republic of Indonesia, Number 36, 2009.
Levine, Carol, Connie Zuckerman, Hands On/Hands Off: Why Health Care Professionals Depend on Families but Keep Them at Arm’s Length, Journal of Law, Medicine &Ethics, 28, 2000.
M. Swick, MD, Herbert, Toward a Normative Definition of Medical Professionalism, Academic Medicine, Vol. 75, No. 6 / June 2000.
Nagel, Thomas, the Possibility of Altruism, Princeton University Press, NJ, 1978.
Paul Simmons, William, the Third. Levinas’ theoretical move from an-archical ethics to the realm of justice and politics, Philosophy & Social Criticism. Vol 25 no 6, Sage Publications: 1999 (London, Thousand Oaks, CA and New Delhi) . pp. 83–104.
Ricoeur, Paul, the Just, the University of Chicago, 2000.
http://www.depkes.go.id (Accessed: November 18, 2010, 07:10 PM). This is an Official Website of The Ministry of Health of Republic of Indonesia.
http://www.tempointeraktif.com/ Accessed: November 21, 2010, 06:47 PM.
http://www.harian-global.com/ Accessed: November 21, 2010, 9:30 PM.
http://www.kompas.com/ (October 14, 2010 edition)/ Accessed: November 21, 2010, 06:00 PM.
The criterion to define poor people in Indonesia is based on the fulfillment of basic needs. According to National Statistic Biro , a family is poor if (1) eat meal less than twice a day; (2) daily expenses is less than 7,000 per day (0,56 Euro); (3) do not have a house or have it with the size that less than 8 m2; (4) the floor of the house is not cemented; (5) each member of the family do not have different clothes for work, attend the school, or stay at home; and (6) never eat meat, eggs, or fish during the week.
Article 4 of the Health Law Number 36, 2009 of the Republic of Indonesia stated, “Every citizen has right to health.” It makes clear in Article 5 of the law, stated, “Every citizen has the right to a safety, qualified, and affordable health care.”
http://www.depkes.go.id/index.php/berita/press-release/472-pejabat-eselon-i-dan-ii-depkes-tandatangani-pakta-integritas.html. Accessed: November 18, 2010, 07:10 PM.
Any hospital does not want to suffer any budgetary deficit as happened in a public hospital of Tasikmalaya Region in West Java, where local government could not reimburse the claim of the hospital after giving health care to the poor people who used insurance card. Tempo Interaktif, Kamis, 14 Oktober 2010. On line edition available at: http://www.tempointeraktif.com/hg/bandung/2010/10/14/brk,20101014-284697,id.html.Accessed: November 21, 2010, 06:47 PM.
 In Indonesia one has to have a certain religion among six religions that are accepted legally by constitution and law. These religions are Muslim, Christian (Protestant), Catholic, Hinduism, Buddhism, and Konghucu.
Sahih Muslim Book 032, Number 6219.
Gospel according to Matthew, 22:39.
Gospel according to Matthew 25:40.
 Pancasila is the official philosophical foundation of the Indonesian state. It consists of two Sanskrit words, “panca” meaning five, and “sila” meaning principles. It comprises five principles held to be inseparable and interrelated: (1) Belief in the one and only God, (2) Just and civilized humanity, (3) The unity of Indonesia, (4) Democracy guided by the inner wisdom in the unanimity arising out of deliberations amongst representatives, and (5) Social justice for the all of the people of Indonesia.
Herbert M. Swick, MD, Toward a Normative Definition of Medical Professionalism, Academic Medicine, Vol. 75, No. 6 / June 2000, pg. 614-615.
Chris Gastmans, “The Care Perspective in Healthcare Ethics”, in A. Davis, V. Tschudin & L. de Raeve (eds.), Essentials of Teaching and Learning in nursing ethics. Perspectives and methods. Elsevier, Edinburgh, 2006, pg. 144-145.
Thomas Nagel, the Possibility of Altruism, Princeton University Press, NJ, 1978, pg. 48.
 The whole notion of “the vulnerable other” is cannot but drawn from the very concept of the third person as proposed by Emmanuel Levinas. Compare to the self-interested of the first person, the face of the third person cannot be reduced to one’s interest by any means, how much more by an instrumental project of reducing him/her as means to attain the first person’s interest. Whenever appear to the first person, the face of the third person is not a biological feature but a vulnerable other. The first person can reduce him/her for his own purpose and interest but he/she prevent him/her self not to do that, not because of his/her inability, but because the third person is not an object. Meeting a third person is an invitation to enter into a relationship where the vulnerable other, as well as the vulnerability of the first person, strengthened the both side to be responsible to one another. More responsibility should be bear by the one more powerful. In the context of physicians-patients relation, since the patients are more vulnerable, it should be the responsibility of the physicians to make sure that they are not reduced for any projects in the whole process of medication. Cf. William Paul Simmons, The Third. Levinas’ theoretical move from an-archical ethics to the realm of justice and politics, Philosophy & Social Criticism. Vol 25 no 6, Sage Publications: 1999 (London, Thousand Oaks, CA and New Delhi) . pp. 83–104.
 Cf. Larry C. Churchill “Damaged Humanity”: The Call for A Patient-Centered Medical Ethic in the Managed Care Era. Theoretical Medicine 18: 1997. Kluwer Academic Publishers: 114-118.
In social sciences, the theory of “hands-on” and “hands-off” are used to describe two main types of state. Socialism or communism is a state where the government involves not only in the whole process of doing politics but also controlling the way people live their life. The opposite is the notion of hands-off in liberal society where government functioned as regulator in guaranteeing that people’s liberty and private rights are respected and that they are not in disharmony with other’s individual rights. See Yvonne Denier & Tom Meulenbergs, “Health care needs distributive justice. Philosophical remarks on the organization of health care systems.” In Paul Schotsmans, Reidar Lie, Bart Hansen, Tom Meulenbergs (Eds.), European Perspectives on Health Care Ethics, Leuven, Peeters, 2002, pg. 274-276. Cf. Carol Levine, Connie Zuckerman, Hands On/Hands Off: Why Health Care Professionals Depend on Families but Keep Them at Arm’s Length, Journal of Law, Medicine &Ethics, 28 (2000): 5-18.
Article 20 of the Health Law Number 36, 2009 of the Republic of Indonesia stated, “Through a national system of insurance, government has the duty to provide health insurance for every citizen.”
 As quoted by Yvonne Denier: 2002, op.cit, pg. 266.
Vicky Cattell, Poor people, poor places, and poor health: the mediating role of social networks and social capital, Social Science & Medicine 52 (2001), pg. 1502.