Revision of the Medical Practice Law; between Essence and Urgency
A revision of the medical practice law was once proposed by the Indonesian Physicians Association a few years ago, mainly on consideration that some articles were prone to punishment-liable criminalization of doctors.
Law No. 29/2004 on Medical Practice has recently become a topic of discussion among the public and medical circles, who envision revising this law.
The calls for revision were also loudly echoed by members of the House of Representatives (DPR). In fact, a proposed revision or amendment of a law in this country is common, as long as the proposed change touches the essence or substance. The 1945 Constitution has also been amended several times.
The legislation of the medical practice carries a mandate to provide protection and legal certainty to the public as recipients of medical or health services, and also to the physicians as medical practitioners. Since being enacted about 18 years ago, the law on medical practice has provided protection for people in seeking health services, especially that provided by the physicians.
I can say it is not necessary to seek an immediate revision because there are no urgently demanding issues to be incorporated in the current regulations of medical practice.
With the law considered quite old and medical science and technology as well as the healthcare system having also developed rapidly, a revision or amendment to several articles in the law is very important with prudent and in-depth study. The question is whether the revision or amendment should be accomplished as immediately as urged by some as if there is an emergency or something very urgent to attend to. The answer is definitely no. I can say it is not necessary to seek an immediate revision because there are no urgently demanding issues to be incorporated in the current regulations of medical practice.
A revision of the medical practice law was once proposed by the Indonesian Physicians Association (IDI) a few years ago, mainly on consideration that some articles were prone to punishment-liable criminalization of doctors. The provisions were approved by the Constitutional Court (MK) for annulment.
Rationale behind proposed revision
There are several issues that have triggered the calls for a revision of the medical practice law. First is Article 1, Paragraph 12, which stipulates that the professional organizations are the Indonesian Physicians Association (IDI) for medical doctors and the Indonesian Dentist Association (PDGI) for the dentists. It can be interpreted that IDI is the only government-sanctioned medical professional organization as mandated by the law. There is no place for other medical professional organizations.
It has given rise to an assumption that the medical practice law places IDI as a "superbody" organization that can easily dismiss its members and therefore needs to be revised immediately. It is undeniable that the discourse on the revision of the medical practice law has emerged due to the recent dismissal of Terawan Agus Putranto from his IDI membership for serious ethical violations.
This dismissal has since drawn pros and cons from the public and among doctors. In fact, the assumption is wrong and incorrect. Dismissal of a member from a professional organization due to ethical violations commonly occurs, especially regarding serious ethical violations.
The article on "professional organization is IDI" in the Medical Practice Law is endorsed by the Constitutional Court (MK) through its decree No. 10/PUU-XV/2017. Of course, it is justifiable and reasonable why this article was included in the law and later confirmed by the Constitutional Court's decision.
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As befits a professional organization, IDI applies a code of ethics, which requires members to be responsible for their expertise. IDI formulates competency and education standards that apply nationally and universally. When there are more than one, two or three medical professional organizations, it is likely that several regulation standards overlap each other with different interpretations, which in the end will certainly harm and confuse the public.
A member facing ethical problems, for instance, may move to another professional physisians’ organization. However, this does not necessarily mean that a physician cannot form a physicians’ organization (not a professional organization) because freedom of association is protected by the Constitution. Several years ago, an organization called Dokter Indonesia Bersatu (DIB), or United Indonesian Doctors Organization, was formed whose members were from IDI. The World Medical Association (WMA) rules, as stated by its secretary-general several days ago, WMA recognized only one professional physician organization from each member country.
A professional medical society is referred to by bioethicist Pellegrino as a moral enterprise, which is formed for the benefit of the community, in addition to its members (Kompas, 23/5/2022).
The second is about the necessity of a doctor having a recommendation from IDI to obtain a medical service permit (SIP) from the local health office (Article 38, Paragraph 1.c). It is clear that IDI does not issue SIP itself because it is entirely under the authority of the government, in this case the local health office. The IDI recommendation is one of several requirements, which also include registration certificate (STR) issued by the Indonesian Medical Council (KKI).
Judging from its essence, the recommendations given by IDI to a medical doctor will help the government provide assurance to the public that the doctors who have received recommendations will provide the services professionally and competently, based on the code of ethics or medical discipline. IDI chapters in the regencies and municipalities are expected to assist in monitoring its members in delivering daily servised to the public. IDI will monitor and, in the case of ethical and disciplinary violations, report to higher institutions, such as the KKI and the Indonesian Medical Disciplinary Honorary Council (MKDKI).
For big cities, it causes no problem because there are enough specialist or subspecialist doctors so that one or two practice places are sufficient to serve people in need.
The third is the issue of practice permits, under which a doctor is only given a maximum of three service places (Article 37). This article may need to be reviewed or revised. For big cities, it causes no problem because there are enough specialist or subspecialist doctors so that one or two practice places are sufficient to serve people in need.
However, in peripheral and remote areas and islands, where specialist doctors are still scarce, a doctor needs to be given more flexibility in term of the workplace for the sake of equitable distribution of health services. It is common to find a regency/municipality has only one pediatrician, internal medicine
specialist, surgeon or obstetrician-gynecologist specialist. In addition to serving in the hospital, a doctor may perform health services in more than three remote locations. Thus, the rules on workplace need changes based on adjustment to the local situation and the availability of health personnel and facilities. The rules should not be generalized across the country. Remote areas or small towns require special provisions regarding the number of service places for doctors.
There are other issues that have not been addressed in the Medical Practice Law, such as the distribution of doctors and telemedicine services. The problem of unequal distribution of doctors, including specialist doctors, needs attention in order to serve the community with a fair distribution throughout the country.
In fact, it is sufficient to legislate this issue through a ministerial or government regulation, whose status is below the law. The same applies to telemedicine. As a long-distance medical service, telemedicine is increasingly important nowadays, not only as an anticipatory response to emergency conditions like the current pandemic outbreak, but also as an effort to give even distribution of health services to citizens regardless the geographical situation in Indonesia, which currently makes it difficult for people to access health care facilities.
Advancement in medical science and technology is taking place rapidly and regulations regarding remote medical services should be sufficiently legislated through the relevant ministeries, so that they will be easier to revise or improve than an enacted law.
Citizens' rights to health by standardizing the quality of long-distance medical services need immediate attention from various related parties through the provision of health-service and other facilities.
Revision urgency
Looking at the description above and considering its essence and substance, the revision of the Medical Practice Law is not so urgent at this time, but is still necessary, and can be accomplished by making adjustments to the development of medical science and technology advancement.
I am of the same opinion as lawmaker Saleh Daulay, who stated that in addressing this issue we must think clearly and be rational.
There absolutely is no justification for immediate revision or amendment of Law No. 29/2004. However, it must be admitted that there are provisions that need to be refined or issues that need to be promulgated with the aim of providing better medical services to the community. I am of the same opinion as lawmaker Saleh Daulay, who stated that in addressing this issue we must think clearly and be rational.
In the face of controversies revolving around the calls for revision of the Medical Practice Law, we need to adopt wise attitudes, rational thinking and prudent actions. Emotional attitudes should not be given free reign. Discussions among related parties -- government, DPR, medical professional organizations and the community -- are needed to produce better regulations and deliver better health services. This is all for the benefit of society and future generations. Hopefully.
Sukman Tulus Putra
Sukman Tulus Putra, Chairman of the Indonesian Pediatric Cardiology Association; Head of the Development Division of the Medical Ethics Honorary Council; Member of Advisory Council of the IDI Executive Board
(This article was translated by Musthofid)
