Competence of Male Circumcision by Healthcare Professionals Under

Health Law

Asmin

Universitas 17 Agustus 1945 Jakarta, Indonesia

Keywords: Competence, Circumcision, Health Law.

Abstract: Indonesia as a rule of law, where almost all provisions must be contained in legislation. From the health

aspect, it's also inseparable from the legal aspect, one of which is circumcision. Circumcision is a medical

and invasive procedure whose implementation and evaluation is monitored by experts and professionals. In

this study, I raised several legal health issues, namely: Do all health care professionals have the competence

to perform circumcision actions under the health law? The aim of this study was to determine the legal

aspects of the circumcision of boys by home service doctors and the liability of doctors in the event of

disability or even death. This research method is legal normative. Based on the results of the literature

study, The authority for circumcision in boys is only with doctors, this is evidenced by the 2012 Indonesian

Doctors' Competence Standards which are proficiency level 4A, meaning doctors are able to perform

circumcision actions independently. Authority for circumcision can be delegated through a warrant by

healthcare professionals, so it's necessary for a body to issue a certificate of competence for healthcare

circumcision workers so that doctors can delegate authority only to competent health professionals.

1 INTRODUCTION

Health is a human right for all Indonesian citizens. It

is not only the right to health, but also the right to

receive health services. This is an important

obligation for the government on how to manage

and regulate in realizing the right to health of

Indonesian citizens so that the highest degree of

health is achieved and implemented on the basis of

non-discriminatory, participatory, protective and

sustainable principles, as stated. in consideration of

the law n. 36 of 2009 on health (Jatmiko 2017).

According to the hierarchical theory of L. Blum,

the state of health depends on four factors: (1)

environmental factors, which play a 40% role, (2)

behavioral factors, which play a 30% role, (3) of the

health service, which have 20% and (4) genetic

factors (heredity), which have a role of 10%. These

four factors must be mobilized by the government

through clear regulations to achieve a high degree of

health.

Indonesia as a state of law as indicated in Article

1 paragraph 3 of the 1945 Constitution reads "The

State of Indonesia is a state of law",where all aspects

of life must be based on positive laws that apply

both written and unwritten, both outside the health

sector and in the health sector. One of the author's

highlights is the legal aspect in the health sector,

namely the act of circumcision or circumcision /

circumcision.

Based on the prevalence of circumcisionrefers to

the proportion of men in a given population they

havecircumcised. This does not refer to the

proportion of newborn males who are circumcised

today. Estimates of the worldwide proportion of

circumcised males vary from1∕6

As far as1/3.World

Health Organization (WHO) estimates that globally,

30% of males aged 15 and over are circumcised,

with nearly 70% of them circumcised.Mussulman.

The most common male circumcision inMuslim

world(almost universal), part ofSoutheast

AsiaAndAfrica, inUnited States of America,

inPhilippines,Israel, AndSouth Korea (Constitution

of 1945) .

In Indonesia, circumcision / circumcision is

mainly performed by non-health workers, this

happens due to the limited number of health workers

and this circumcision act has existed since before

health organizations existed in Indonesia. Based on

data from the Ministry of Health that over 10,000 or

6% of Puskesmas in Indonesia do not yet have a

doctor (Sulaiman, 2022), in addition to the problem

258

Asmin, .

Competence of Male Circumcision by Healthcare Professionals Under Health Law.

DOI: 10.5220/0011979600003582

In Proceedings of the 3rd International Seminar and Call for Paper (ISCP) UTA â

Z45 Jakarta (ISCP UTA’45 Jakarta 2022), pages 258-263

ISBN: 978-989-758-654-5; ISSN: 2828-853X

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

of the uneven distribution of the number of doctors,

this is evident from the data that Quantity doctorin

Indonesia they were 123,691 thousand as of

December 31, 2020. However, the distribution of

doctors in the country is not yet equally distributed

in each region. The distribution of national doctors is

still centered on the island of Java. The number is

71,286 doctors or represents about 57.63% of the

total number of doctors in Indonesia (Annur, 2022).

From another point of view, the development of

circumcision techniques and tools over time

continues to change and becomes more advanced

and modern. As a quote from Tuti Widyaningrum

says "Education is the most important thing in the

life process of living beings that distinguishes them

from other created beings. Without education,

humans will not be called intelligent creatures,

toolmakers, or even wise creatures (Widyaningrum,

2022: 44-54)." Likewise, continuous training for all

profiles of health professionals, not only the number

of human resources that are reproduced and

distributed evenly, but also of quality so that they

are said to be competent health professionals in the

field of circumcision.

Looking at the above data, the authors found

several cases of alleged incompetence of a

circumcision practitioner / performer, for example in

2016 there were allegations of negligence caused by

nurses in performing circumcision. The case

occurred in the Baturaja area, Ogan Komeriang Ulu

Timur Regency, where a person with the initials DL

was suspected of having committed negligence

during the circumcision of a child so that his vital

organs were cut, there is another case in September

2018 in which there was an alleged negligence that

led to the cutting of the genitals of a boy with the

initials MI is nine years old in Kubang Hamlet,

Pekalongan Regency, (Sibaranim, 2019: 2)or the

latest case in 2019 of a 10-year-old boy in West

Lampung conducted by S. Based on the above data,

the authors are interested in discussing Competence

in male circumcision by health professionals

according to the health law.

2 PROBLEM FORMULATION

1. Do all health professionals have the

competence to perform circumcision

according to the health law?

2. What is the authority of circumcised health

workers in home visitation services?

3 RESEARCH METHODS

The research method used is normative legal

research. The research method in this research uses

the juridical-normative. The research approach uses

a statutory approach. In the method of the legal

approach, it is necessary to understand the hierarchy

and principles in the laws and regulations. Pursuant

to article 1, point 2, of law no. 12 of 2011, the

statutory regulations are written regulations that

contain legally binding rules in general and are

established or determined by state institutions or

authorized officials through the procedures provided

for by laws and regulations (Marzuki, 2016: 136) .

Legal-normative research or normative legal

research is a legal research library (Soekanto, S &

Sri Mamudji, 2007: 23).

4 DISCUSSION

The stipulation of Indonesia as the rule of law in

Article 1 paragraph (3) of the 1945 Constitution of

the Republic of Indonesia is the ideal of the

Constitution and one of the dimensions of the rule of

law is to make Indonesia a just and prosperous

country company (social status), the third

amendment of 2001 to law no. -The 1945

Constitution of the Republic of Indonesia, another

paragraph is added to the provisions of Article 1,

namely the paragraph (3), which states that

"Indonesia is a state of law". A constitution

statement that states that the highest supremacy in

Indonesia is the rule of law, and the law is the

commander-in-chief who guides the life of the

nation and state in the context of realizing a just,

prosperous and prosperous society (welfare State) as

another dimension of the rule of law (Sirait, 2016:

2).

In order to provide legal certainty and protection

to improve, direct and provide the basis for health

development, dynamic tools of health law are

needed. These legal instruments should be able to

achieve increasingly complex developments, which

will occur in the future (Asyhadie, 2018: 2).

When it comes to legal instruments, it is usually

the source of the law that applies in Indonesia. The

main sources of law in the legal system in Indonesia

are the 1945 Constitution, government regulations,

jurisprudence, international treaties / conventions,

and customs. It also contains the health law, but

there are several authorities and competences that

are not yet clearly detailed and there are still

Competence of Male Circumcision by Healthcare Professionals Under Health Law

259

overlaps for which special explanations are needed.

The author takes the competence of male

circumcision as an example.

A Healthcare Operators

Definition of healthcare professionals according to

the provisions of Article 1 point 6 jo. Article 1 point

1 of Law no. 36 of 2014 on the subject of Healthcare

Workers defines that: "Healthcare Worker means

any person who is dedicated to the health sector and

possesses knowledge and / or skills through

education in the health sector which for some types

requires the authority to make efforts for health.

“This law also explains the grouping: medical

personnel, clinical psychological personnel, nursing

personnel, obstetrics personnel, pharmacy personnel,

public health workers, environmental health

workers, nutritionists, physiotherapy personnel,

medical technical personnel, biomedical

engineering, traditional medical health personnel (RI

Law No. 36 of 2014 on healthcare workers). After

the Judicial Review in the process to the decision of

the Constitutional Court that doctors are not

included as health professionals. With this ruling,

the Constitutional Court decided to partially accept

the appeal of the defendants, stating that article 11,

paragraphs 1 and 2, article 90 and article 94 of the

Law on health care personnel are in contradiction

with the Constitution. of 1945 and have no binding

legal force (Judicial review of Mahkamah Konstitusi

no. 82 / PUU / XIII / 2015).

According to Anna Kurniati and Ferry Efendi,

the definition of a health worker is “Any person who

receives education, whether formal or non-formal,

who is dedicated to various efforts to prevent,

maintain and improve the health of the community.

Article 65 of law no. 36 of 20014 on the subject

of health provides that "in the performance of health

services, health professionals may receive the

delegation of medical actions from medical

personnel. The delegation of the acts referred to in

paragraphs (1) and (2) is carried out with the

following provisions : the delegated action is

included in the skills and competences possessed by

the delegated recipient, the implementation of the

delegated action remains under the control of the

delegated agent, the delegated person remains

responsible for the actions taken delegated as long as

the implementation of the action is in accordance

with the mandate given and the delegated action is

not included in the basic decision-making process of

implementing the action.

So based on the above law, it is clear that

circumcision is an action that can be delegated both

in writing and orally giving priority to the recipient

of the delegation is a person who already has skills

in the field of circumcision and is still under the

supervision of the delegate.

B Competence Theory

In Bloom's taxonomy theory, the meaning of

competence is defined as the skill necessary to do or

do or perform a job based on knowledge, skills and

work attitudes. There are three elements in seeing a

person if he has competence, namely the cognitive,

affective and psychomotor domains.

Spencer and Spencer (1993), competence is the

character of attitudes and behaviors, or individual

will and abilities that is relatively stable in the face

of situations and workplaces formed by synergies

between character, self-concept, internal motivation

and knowledge capacity conceptual.There are five

basic characteristics of competence (basic

competence) according to Spencer and Spencer,

namely: (1) Knowledge, (2) Skill, (3) Character, (4)

Motives, and (5) Self-concept (Wicaksana, 2019:

63).

1. Knowledge is the information that a person has

in a particular field in the performance of his

duties and responsibilities, with sufficient

knowledge of his work, a competent person is

expected to be able to perform his duties under

any conditions. Sufficient knowledge will

influence the techniques and strategies used to

achieve good results in a job. In addition to the

knowledge of circumcision techniques that

continue to develop along with the progress of

the device.

2. Skills are a person's ability and experience in

completing tasks well, as well as determining

the best method of circumcision for each

different patient condition.

3. Attitude is a person's behavior that is shown in

response to everything that happens. The

attitude is closely related to the emotional

nature that exists within a person, such as the

ability to control oneself in special conditions

such as bleeding during circumcision, an

attitude that remains calm when the patient is

not cooperating. A person's character will also

affect a circumcision practitioner's motives in

carrying out their duties.

4. Motivations are basic thoughts that emerge

from within a person and become the goals and

desires to be achieved in the organization

ISCP UTA’45 Jakarta 2022 - International Seminar and Call for Paper Universitas 17 Agustus 1945 Jakarta

260

personally, which will have an impact on the

actions they will take. The reason for the act of

circumcision is very different from person to

person, but it will be noble if it is based on

humanitarian reasons according to the oath of

the profession of health care workers.

5. The concept of self is the ability that a person

has to convince himself, motivate himself to

work and carry out his duties and

responsibilities well. This concept of self is

owned by a person linked to the health

profession which is an added value and has

great value in the eyes of the community.

From the above theory, it can be concluded that a

person has the competence of circumcision if he can

be assessed capable in these three aspects, namely

cognitive (knowledge), affective and psychomotor

which have been tested at both formal education and

nurturing levels. informal. In the formal education

stage, it means that these skills are taught and

included in the curriculum of an educational

institution, and it means that they have special

training in circumcision. For medical personnel, in

this case, doctors are very clearly indicated in the

2002 SKDI (Standards of Medical Competence)

which are included in level 4 (four) A, which means

that all doctors must be able to perform the

circumcision independently.

C Understanding the Action of

Circumcision

M.according to Wikipedia the definition of

circumcision, circumcision or circumcision is

the act of cutting or removing part or all of the skin

that covers the front of the penis. The frenulum of

the penis can also be cut at the same time in a

procedure called a frenectomy. The word

circumcision comes from the Latin circum and

caedere.

Circumcision is a surgical procedure to remove

or cut the skin (foreskin) that covers the penis,

which is made up of muscle tissue and blood

vessels. When the foreskin is removed, the opening

of the urethra (external urethral mouth or urinary

opening) and the glans penis (head of the penis) are

uncovered (Task Force on Circumcision of the

American Academy of Pediatrics, 2012: 585). This

circumcision is an invasive procedure, i.e. an action

that injures or injures the patient, so it should be

performed by qualified professionals who see that

there will be many risks for this invasive procedure.

Meanwhile, according to the Regulation of the

Minister of Health number 290 / Menkes / Per / III /

2009 Article 1 paragraph (4) the invasive action is a

medical action that can directly affect the integrity

of the patient's body tissue, paragraph (5) states that

medical actions that contain a high risk are medical

actions that, based on a certain level of probability,

can lead to death and disability.

D Theory of the Authority in Health

Law

Authority is the power that has legitimacy

(legitimate power), while power does not require

legitimacy. Within authority there are powers.

Authority is the realm of public legal action, the

realm of governmental authority, it doesn't just

include the authority to make government decisions

(Yahya, 2020: 49).

According to Bagir Manan, authority in the

language of law is not the same as power. Power

only describes the right to do or not to do. In law,

authority means rights and duties at the same time

(Ridwan H. R, 2006: 102). Authority (competence,

bevoegheid) is the power to carry out a public legal

action, for example it is the authority to sign or order

an authorization to an official on behalf of the

minister which is referred to as the delegation of

authority (Atmosudirjo, 1994:78).

The legal aspect is the main aspect in every

country that adheres to the rule of law as a

commander in the state order, the principle of

legality is the basis for the administration of the state

and government, especially in the form of authority

granted by the law, the substance of which is this

authority. Government authority is regarded as the

ability to implement applicable law, so that a legal

relationship can be created between the government

and citizens (Ridwan H. R, 2006: 102).

In theory, authority derived from laws and

regulations can be obtained in three ways, namely

(1) attribution; distribution of power to various

institutions or agencies, (2) delegation; delegation of

powers from the highest position to a lower

institution or agency, (3) Mandate; transfer of

authority to an institution or agency to another

agency on its behalf, so that the mandate holder

cannot escape the responsibility and responsibility

for the work of the mandate holder.

Clinical authority must be distinguished from the

authority of a physician personally as a health care

practitioner contained in the Health Act, as well as

in the Medical Practice Act. The authority contained

in the Health Law as well as the Medical Practice

Law is inherent and directly derived from the law

Competence of Male Circumcision by Healthcare Professionals Under Health Law

261

after the doctor has completed his studies and is

considered competent for issuing STR (Surat Tanda

Registrasi) and SIP (Surat Tanda Practicing) , so that

this authority is genuine and cannot be delegated to

another person. The authority based on this law is

attributive so that the responsibility and liability fall

on the legal entity as established in the basic

regulations (Kartamihardja,2017: 144). so that the

authority for medical action in this circumcision case

is the authority of the physician.

There are several conditions in which a doctor

must delegate powers to nurses pursuant to Law no.

38 of 2014 on Nursing Article 32 which provides

that the delegation of powers to carry out a medical

action is delegated by medical staff to nurses

accompanied by the delegation of responsibility. The

delegation is only given to trained professional

nurses or professional nurses who have the

necessary skills.

Authority may also be entrusted to nurses in

accordance with the regulation of the Minister of

Health of the Republic of Indonesia number 26 of

2019 relating to the regulations implementing the

law of the Republic of Indonesia number 38 of 2014

on nursing in articles 27 and 28, this article explains

that the delegation of powers must be carried out in

a delegative manner and the mandate is

accompanied by a written letter relating to the

delegation of powers to professional nurses or

professional nurses who have been trained to carry

out medical actions under supervision (Regulation of

the Minister of Health of the Republic of Indonesia

Number 26 of 2019).

In the Regulation of the Minister of Health

number 2052 / Menkes / Per / X / 2011 relating to

the licensing of the exercise and implementation of

medical practice, Article 23, paragraph 1, also

explains that a doctor or dentist can delegate a

medical action or dental action to a nurse, midwife

or dentist. other health personnel in writing in

performing medical or dental procedures

(Regulation of the Minister of Health Number 2052 /

Menkes / Per / X / 2011 concerning the qualification

to practice and the implementation of medical

practice). Obviously, in the delegation of powers

from medical personnel to health professionals, not

all medical acts can be delegated because different

conditions must exist, namely: (Muntaha, 2017: 91)

1. Medical diagnosis and the determination of

medical therapy cannot be delegated.

2. Delegation of medical action is allowed if

the physician is very confident that the nurse

receiving the authority is able to perform.

3. Done in writing, in detail, with clear

instructions.

4. There must be monitoring, guidance and

supervision.

The Nursing Act in article 32 paragraph (4) reads

"Delegable medical actions, among others are the

injection, installation of infusions and the provision

of basic vaccinations in accordance with government

programs" and paragraph (5 ) reads "Medical actions

taken can be mandated, including delivery of

parenteral therapy and wound closure. The phrase"

by the way "contains such a broad meaning that

many medical actions were not included in the

explanation of the law.

From the various theories above, the authors

argue that based on regulatory law, not all healthcare

professionals are able to meet the criteria as a

competent person in circumcision, and circumcision

is an invasive surgical procedure, so this medical

procedure is not easy to delegate to health care

professionals, and certain conditions so that the

delegation of authority should only be carried out by

health personnel competent in matters of

circumcision. so that according to the author a

special institution is required by law to provide

competent certification in the field of circumcision

so that people can receive excellent health services

and are served by professionals.

5 CONCLUSION

1. The authority for circumcision in boys is an

attributive authority assigned to doctors, in

accordance with the 2012 Indonesian Medical

Competence Standards that circumcision

competence is at level 4 (four) A, i.e. doctors

are able to perform circumcision actions

independently.

2. The authority for circumcision may be

delegated by medical staff to nurses through

the delegation of authority, provided that the

recipient of the mandate is a person competent

in matters of circumcision and under the

control of the competent authority for

authorization.

6 SUGGESTION

1. There is a need for a special institution to

issue circumcision proficiency certificates for

healthcare professionals so that physicians can

ISCP UTA’45 Jakarta 2022 - International Seminar and Call for Paper Universitas 17 Agustus 1945 Jakarta

262

only delegate authority to competent

healthcare professionals.

2. The need for local government participation in

educating the public on the importance of

circumcision performed by competent

personnel.

REFERENCES

Reserve

Ashhadie, Zaeni. (2018). Aspek-aspek Hukum Kesehatan

di Indonesi, Depok: Rajawali Pers.

Atmosudirjo, S. Prajudi. (1994). Hukum Administrasi

Negara, Jakarta: Ghalia Indonesia

Marzuki, Peter Mahmud. (2016). Peneltian Hukum,

Jakarta: Kencana Perdana Media Group.

Muntaha, (2017). Hukum Pidana Malpraktik

Pertanggungjawaban dan Penghapusan Pidana,

Jakarta: Sinar Graphica.

R, Ridwan H. (2006). Hukum Administrasi Negara,

Jakarta: Raja Grafindo Persada.

Soekanto, Soerjono and Sri Mamudji, (2007). Penelitian

Hukum Normatif Suatu Tinjauan Singkat, Jakarta: PT

Rajagrafindo Persada.

Yahya, Makmur jaya, . (2020).Pelimpahan Wewenang &

Perlindungan Hukum Tindakan Kedokteran Kepada

Tenaga Kesehatan Dalam Konteks Hukum

Administrasi Negara, Bandung: Rafika Aditama,

Articles, Theses, Newspapers

Task Force on Circumcision of the American Academy of

Pediatrics. Statement on the policy of circumcision.

Pediatrics. September 2012; 130 (3): 585-6.

Jatmiko, Priya A. Perlindungan Hukum Terhadap Pasien

Dari Pelayanan Kesehatan Yang Tidak

Bermutu,Thesis, Surabaya: University of Airlangga,

2017.

Kartamihardja, Achmad Hafiedz Azis.P. Lindawaty S.

Sewu and Tri Wahyu Murni S, , Kewenangan Klinis

Dalam Tindakan Pembedahan Dan Asas

Perlindungan Hukum Bagi Pasien, Soepra Journal of

Health Law, vol. 3 n. 2 Th. 2017,

Sibaranim, Tamara Roully. Pertanggungjawaban Pidana

Tenaga Kesehatan Terhadap Malpraktik Dan

Negligence Dalam Tindakan Khitan (Sirkumsisi),

Journal,JOM Faculty of Law, University of Riau

Volume VI Edition 1 January-June 2019.

Sirait, Timbo Mangaranap, Urgensi Perluasan

Pertanggungjawaban Pidana Korporasi Sebagai

Manifestasi Pengejawantahan Konstitusi, Jurnal

Konstitusi, Volume 13, Number 3, September 2016

Wicaksana, Pengembangan Kompetensi Sumber Daya

Manusia Pada Universitas Warmadewa Dalam

Rangka Penguatan Daya Saing Perguruan Tinggi di

Masa Depan, Jurnal Lingkungan & Pembangunan,

October 2019.

Widyaningrum, Tuti. Januar Agung Saputera, Ansadila

Niar Sitanggang, Optimalisasi Ruang Belajar Ramah

Anak di Sekolah Alam Taman Siswa Pesisir Cilincing

Jakarta Utara, BERDIKARI Journal Vol. 5, No.1

Period January - June 2022: 44

Legislation

Constitution of 1945.

RI Law No. 36 of 2014 on healthcare workers.State

Gazette of the Republic of Indonesia No. 114 of 2009.

Judicial review of Mahkamah Konstitusi n. 82 / PUU /

XIII / 2015.

Regulation of the Minister of Health of the Republic of

Indonesia Number 26 of 2019 relating to the

implementing regulations of the law of the Republic of

Indonesia Number 38 of 2014 on nursing.

Internet

https://id.wikipedia.org/wiki/Prevalensi_sunat, Wikipedia,

Circumcision Prevalence, accessed 01 August at 06.01

https://www.suara.com/health/2022/06/10/205717/pemerat

aan-tenaga-kesehatan-kunci-pelayanan-kesehatan-

yang-optimal-di-daerah, Suara, pemerataan tenaga

kesehatan kunci pelayanan kesehatan yang optimal di

daerah, accessed 03 August 2022 at 08.25 pm

https://databoks.katadata.co.id/datapublish/2022/03/07/tak

-merata-mayoritas-dokter-di-indonesia-masih-central-

di-jawa, box data, irregular majority of doctors in

Indonesia are still based in Java, accessed 03 Aug

2022 08:33 am

https://www.tribunnews.com/regional/2019/10/01/bocah-

di-lampung-penisnya-terpotong-saat-sunat-begini-

nasibnya. Tribunnews, bocah di lampung penisnya

terpotong saat sunat begini nasibnya, diakses 02

agustus 2022 jam 18.55 wib, accessed 02 Aug 2022

6:55 pm

https://p3ai.polsri.ac.id/admin/assets/files/7325Taxonomi

%20Bloom.pdf.Access on 02 August 2022 at

08:32.AM

Competence of Male Circumcision by Healthcare Professionals Under Health Law

263