Answers to common medical ethics questions Flashcards
Does Euthanasia Have A Place In Modern Medicine?
First things first, what is euthanasia? This is the term given to describe actions taken to deliberately end someone’s life, often to relieve suffering. There are many different types of euthanasia, such as active euthanasia, passive euthanasia, voluntary euthanasia and involuntary euthanasia. Establish that this is a complicated issue with lots of shades of grey and no straightforward answer.
While weighing up both sides, think of the four pillars of medical ethics: justice, autonomy, benevolence and non-maleficence. All of these play a pivotal role in this issue!
Start with legality if you know it, since it is the clearest cut aspect. Currently, active euthanasia and assisted suicide is against the law in the UK. However, euthanasia is legal in the Netherlands, Colombia, Luxembourg, Belgium, Canada and Spain. In addition, assisted suicide is legal in Switzerland, Germany, South Korea, Japan and some states in the US. Make sure to keep up to date with any changes.
Euthanasia allows the patient to exercise their right to decide their own fate and end suffering (benevolence). However, arguments against euthanasia include the principles of the Hippocratic Oath which state a doctor shall “do no harm” and the related ethical concept of non-maleficence.
Assessing mental capacity and competency of patients (Mental Capacity Act 2005) is crucial in the discussion of euthanasia, as legalisation of this could potentially put vulnerable adults at risk. Some cases of patients who have travelled abroad for these end-of-life services have also been a hot topic in the media, so it would be good to reference any of these cases that you are aware of. The discussion of euthanasia is a sensitive one and thus it is always best to look at the ethical guidelines provided by the GMC.
Common mistakes:
Starting with a strong viewpoint one way or the other. It is important to establish that this is a complicated issue with arguments for both sides and to present these in a balanced way.
Not using the four pillars of ethics. These should be referenced throughout balancing of the two sides.
Do You Agree With Abortion?
Start by acknowledging that this is a complex issue with two sides and many shades of grey. Then walk through both sides in a balanced way, showing an appreciation of the four pillars of ethics.
Is it legal? Under current UK legislation (The Abortion Act) an abortion can only be carried out if certain criteria are met: the pregnancy is in its first 24 weeks, it is carried out in a hospital or licenced clinic, and two Doctors must agree that an abortion would cause less damage to a woman’s physical or mental health than continuing the pregnancy. In rare situations, an abortion may also be allowed to be carried out after 24 weeks.
If we consider patient autonomy, there is a case to say that patients should have the right to have an abortion if they wish. Considering the ethical concept of beneficence first, it is important to have the best interests of the mother at the centre of their healthcare (both psychological and physical wellbeing). Secondly, an abortion may be the most loving thing to do in the case of a foetus with severe deformities, as this presents issues with quality of life.
Addressing non-maleficence, it is important to prevent any harm, so considering the harm to both the mother and the foetus is important in the discussion of abortion. It is also important to consider the sanctity of life and some, based on this principle, may disagree with abortion. But it’s quite subjective. As with all consultations, confidentiality must be upheld in the case of abortions. The discussion of abortion is a sensitive one, so it is always best to look at the ethical guidelines provided by the GMC
Common mistakes:
Starting with a strong viewpoint one way or the other. It is important to establish that this is a complicated issue with arguments for both sides and to present these two sides in a balanced way.
Not using the four pillars of ethics. These should be referenced throughout balancing of the two sides.
A Patient Refuses Treatment For A Life-Threatening Condition.
in a scenario like this, there are many ethical issues involved. It is important to look at each one individually in order to fully understand and weigh up the scenario.
First of all, we can consider the duty of the Doctor. In a case like this, it is crucial that the Doctor fully informs the patient of the benefits of the treatments and the risks associated with not having the treatment. If we consider the concept of patient autonomy, then Doctors must respect the decision made by a patient. However, patient autonomy is not absolute, particularly if a patient is not competent.
Beneficence and non-maleficence often link together, and this is no exception. The most beneficial thing to do may be to provide the patient with the treatment they need. However, if this is against the patient’s wishes, this might do more harm than good. Whatever the patient’s decision may be, Doctors must continue to provide the best care in the patient’s best interests. Always be clear that you would adhere to the GMC’s guidelines.
Common Mistakes:
Not knowing about patient autonomy. You need to be clear about all four pillars of ethics. This is a key issue that trips many people up.
A 14-year-old Patient Goes To The GP And Asks For The Oral Contraceptive Pill.
Currently, under UK Legislation, those under the age of 16 are not able to give consent to sexual activity. It is always important to consult the GMC and their ethical guidelines on young people and sexual activity for the most up to date information.
If we begin with the duty of the Doctor, they must fully inform the patient of the benefits of the treatment (protected sex) and the risks associated with not having the treatment (unprotected sex). The Doctor also has a duty to society to ensure the safety of their patients and to ensure child protection and safety.
Therefore, competence is a major aspect to consider. Establishing and assessing competence (Gillick competence) is very important in a case like this to ensure sexual abuse is not taking place.
Autonomy – Doctors must respect the decision made by a patient. However, patient autonomy is not absolute, again linking to assessing competence, which will be an important part of this answer.
Beneficence and non-maleficence – Doctors must continue to provide the best care in the patient’s best interests, and their personal views must not interfere with their professional duties. It is also important to consider confidentiality and the effect on the Doctor-patient relationship, which is built upon trust.
Common Mistakes:
Being judgmental. Saying something like “14-year-olds shouldn’t be engaging in sexual activity in the first place” is a red flag
A Patient Diagnosed With HIV Reveals To Their GP They Have Not Disclosed This Information To Their Partner.
The Doctor must fully inform the patient of the risks associated with not disclosing this information and encourage the patient to disclose this information to their partner. The Doctor also has a duty to protect and ensure the safety of society (justice) and, based on these grounds, may choose to make a disclosure to the patient’s partner about the patient’s HIV status. However, this would be a last option and the Doctor would need to inform the patient of their actions.
Autonomy – This links to patient autonomy as Doctors must respect the decision made by a patient. But patient autonomy is not absolute, particularly in a case like this where society/another patient is at risk. In this case, confidentiality may be broken, which may also affect the Doctor-patient relationship.
Beneficence and non-maleficence – Doctors must continue to provide the best care in the patient’s best interests. When making a disclosure, it is important to weigh up the benefits (protecting another patient’s health) against harm (could affect the Doctor-patient relationship and future disclosures). You can say to the interview panel that it is always important and helpful to consult the GMC’s ethical guidelines in cases like this.
Common Mistakes:
Not knowing but claiming you do. If you are aware of the above, that’s great. If you think you are, then say that you are not sure but you think it is the case. If you don’t know the legalities, then be honest about it.
Coming up with a common sense reply, like “logically you should tell the partner”. You have to be aware of the legal ramifications as well.
You Are A Medical Student At School.
One Day In The Teaching Hospital, You See One Of Your Fellow Students Putting Medical Equipment From The Stock Room Into Their Bag. When You Ask Them About It, They Say They Only Want To Practise Their Clinical Skills And Not To Tell Anyone.
What Would You Do?
This question is designed to examine your awareness of the duties of a medical school and a Doctor according to the GMC publications Good Medical Practice and Tomorrow’s Doctors.
The first thing you must do when answering this question is to explain what the dangers of the situation are: practising clinical skills without supervision could lead to the student seriously harming themselves; taking equipment from a hospital is a serious breach of ethics and could risk lives (if that equipment leads to a shortage of supplies); the student’s actions (while well-meaning) are not in keeping with the professional standards of a doctor; if you do not report this act, you are also not acting in accordance with these standards and risk being sanctioned or removed from the Medical School.
You should also explain the risks of the situation: if you confront the student, they may react negatively; the student may have received permission from someone to do this (unlikely, but possible); such an incident could damage the ties between the teaching hospital and the university.
Acknowledge what your authority is and therefore how you should approach the situation. You are not a doctor, nor are you a faculty member. So you need to approach the student in a calm and supportive manner and not threaten them with negative outcomes.
Example – I would encourage the student to see the danger of their actions and to come clean about what they have done, and support them emotionally with any difficulties that might have led them to such a drastic act. If the student refused to act, I would then approach a faculty member and discretely report the situation.
Common Mistakes:
Not having read Good Medical Practice or understanding the standards you will need to live up to as a Doctor or medical student.
Immediately confronting the student without outlining your concerns and the reasons for your actions.
Reporting the student immediately without considering why the student is behaving erratically – are they suffering from stress or anxiety?
What Does ‘Patient Confidentiality’ Mean?
When Would It Be Appropriate To Breach This?
Have an understanding of what patient confidentiality means and what kind of information it covers. Briefly mention the purpose of having patient confidentiality and how it builds trust in the Doctor-patient relationship.
mention different situations where patient confidentiality can be breached. This may be where the patient poses a significant risk to the health of themselves or others.
Countries may have differing guidance in place about this. Know what your country recommends by consulting the appropriate literature. An example of an organisation which sets such guidance is the GMC in the UK.
You may wish to mention implied consent, where a patient is aware that a Doctor will share information about them to other individuals in the healthcare team to provide the patient with the best possible care.
Mention how it is important to have a conversation with a patient about confidentiality as a Doctor or even as a medical student.
Explain how one is duty-bound as a Doctor to abide by the regulations that are in place to protect patient confidentiality and how professional duty should always come above personal beliefs.
Common Mistakes:
Not knowing the actual meaning of patient confidentiality.
Not knowing the situations that patient confidentiality is applied in. As a medical student, you will also be bound by the rules of patient confidentiality.
Mentioning incorrect situations where patient confidentiality can be breached or saying that it can never be breached. It is better not to mention specific scenarios if you are not confident that they are correct.
when can patient confidentialtiy be breach?
Breaking confidentiality is done when it is in the best interest of the patient or public, required by law or if the patient gives their consent to the disclosure. Patient consent to disclosure of personal information is not necessary when there is a requirement by law or if it is in the public interest.
Examples of when disclosures are required by law (according to GMC guidance) include:
Notifications of specific infectious diseases
Disclosures to various regulatory bodies
Disclosures to court
A 13-Year-Old Patient Reveals To You That They Are Sexually Active And That Their Parents Do Not Know.
What Would You Do As A Doctor In This The Situation?
You must take the legal aspects of this scenario into account. This patient is below the age of consent, which is 16 in the UK, but you must also consider Doctor-patient confidentiality.
Explain that you would encourage the patient to make their parents aware that they are sexually active.
Consider the four pillars of ethics – here you are concerned with beneficence. You must take into account the effects that being sexually active might have on the physical and mental wellbeing of your underage patient. You might also have concerns about whether the young patient is being taken advantage of.
Doctors may provide advice on sexual health and contraception to underage patients as long as the young person is capable of understanding this advice and their physical/mental wellbeing will most likely suffer without it. In general, patient confidentiality must be respected, which means the parents must not be informed.
However, if a Doctor deems that the safety or physical/mental wellbeing of an underage patient is at risk, they have a duty to follow child protection protocol. This means breaching patient confidentiality if it is in the patient’s best interests.
NICE guidelines are a useful resource when dealing with ethical questions like this.
Common Mistakes:
Forgetting about the legalities of Doctor-patient confidentiality. Even when dealing with a very young patient, you cannot simply inform their parents of their actions if you are concerned. You must follow the proper protocol.
Failing to mention the potential risks of such a young patient being sexually active and the fact that, in some cases, a third party may need to be contacted in order to protect the patient.
A Depressed Patient Who Has Refused Treatment Has Mentioned Having Suicidal Thoughts And You Are Concerned About His WellBeing.
Discuss The Ethical Issues Involved.
When addressing an issue like this, it is important to consider the four pillars of ethics, especially non-maleficence, beneficence and patient autonomy in this case.
Mention that it is important to ensure the patient is aware of and understands the treatment options available to them so they can make an informed decision.
Autonomy – In this case, the patient has chosen to refuse treatment and, in general, their decision should be respected.
Beneficence and non-maleficence – In this situation, you are concerned about the patient being a danger to themselves. This means that the risk to their wellbeing must be weighed against the harm that could come from breaching patient confidentiality in order to protect the individual.
Consider mentioning the possible repercussions of informing a third party of your concerns. For example, the patient might be less open about their mental health issues in the future, having lost trust in their doctor.
Common Mistakes:
Failing to take into account the legalities involved, such as the principle of Doctor-patient confidentiality.
Not considering the four pillars of ethics. These can help you to structure your answer and ensure that you touch on some of the points that interviewers are looking for.
Do You Think The NHS Should Fund Treatment For Smokers?
A question like this is different to “discuss the issues that arise when considering whether the NHS should fund treatment for smokers.” This is a direct question about your opinion, and therefore the interviewer eventually wants a yes or no answer from you.
However, this does not mean that you should jump straight into your opinion. The best way to answer this question is to give a broad, well-balanced overview of the ethical issues that arise, and then give your opinion with justifications.
On one side of the argument, it can be said that the NHS should provide care for everyone indiscriminately, as supported by the ethical principle of justice. This is also in line with the ethical principle of autonomy, which means that patients have the right to make decisions for themselves.
However, the NHS has limited resources. In an ideal world, all treatment would be funded for all patients, but unfortunately this is simply not feasible. Thus, making decisions about resource allocation is not optional. The ethical theory of utilitarianism deals with the best way to maximise the use of resources for the greater good of society. The question is therefore: why shouldn’t smokers receive funding for treatment?
Some may believe that their illness is self-inflicted, and therefore such patients are less ‘worthy’ of funding than those who had no control over their disease. However, this does not take into consideration the complex psychosocial factors that lead to smoking. It is well known that smoking is more common amongst the lowest socioeconomic groups. Would such a funding decision simply serve to further worsen the health inequalities that already exist in society?
These arguments are very topical and so it is important to be familiar with them. It is also worth reading the NHS constitution principles.
When you feel you have adequately discussed both sides of the argument, outline your opinion on the matter, using justifications from ethical principles/theories if you can.
Common Mistakes:
Discussing only one side of an argument.
Jumping straight into giving your opinion without giving a well-balanced overview of the ethical issues.
Discussing both sides of the argument equally without actually committing to your own opinion – remember, the interviewer wants to see how you think. There is not necessarily a right or wrong answer, as long as you can justify it.
What Would You Do If You Saw A Colleague Making A Mistake With A Patient’s Medication?
This is a situational question that wants you to consider what you would do in a practical situation. It is therefore imperative that you are aware of the GMC guidelines in place for Doctors.
GMC guidelines state that you have a duty to raise concerns if you believe that patient safety or care is compromised. This is the most important part, and it is applicable in this scenario as you have seen a colleague make a mistake with patient medication.
The first step would be to report the mistake. The best way to do this is to actually talk to the colleague who has made the mistake and encourage them to report it themselves. This should be done in a non-confrontational way, making it clear that it is a matter of patient safety and continual professional development, rather than a personal attack.
However, if you do not feel comfortable doing this, or if the colleague refuses to report their own mistake, then you must escalate the situation to a senior colleague.
The NHS wants to encourage candour and transparency in the work environment, and this relies on non-threatening policies around errors, based on openness and continual development, rather than blame and punishment.
GMC guidelines have a specific section on ‘Raising and acting on concerns about patient safety.’ Since this is a common theme for interview questions, it is a good idea to be familiar with this.
Don’t forget, even as a Doctor you are not expected to know everything. If you are not sure what the guidelines are, simply saying you would look them up and act on them may be sufficient.
Common Mistakes:
Not making it clear that patient safety is the most important issue.
Failing to report the mistake, or failing to state that you would check the guidelines.
Stating/insinuating that you would help the colleague to cover the mistake up. (This may seem like an unlikely thing for you to say, but if this question was explored in the form of a role-play, the actor might put pressure on you to do this). It’s important to remember that ensuring patient safety overrides any personal or professional loyalties.
Is It Ever Ethically Acceptable For NHS Doctors To Go On Strike?
This is a topical issue because of the Junior Doctor strikes that took place. However, this does not mean that your discussion has to be shaped by the events that took place. Whilst it is important to mention them in order to show your awareness of current affairs, you do not have to be limited by this.
Firstly, what is a strike and why is it morally problematic? A strike is defined as a refusal to work as a form of protest. The most obvious issue with this, in the case of Doctors, is the potential for patients to be harmed. This goes against the ethical principle of non-maleficence and therefore, some would argue, cannot be justified.
This barrier could be overcome, because a strike may be designed so that emergency care would still be covered and only elective treatments would be delayed. However, this is still disruptive for patients. In order to decide whether it is morally acceptable, we must know what the reason for the strike is. Do the benefits outweigh the risks? This approach is called ‘consequentialism’ and considers whether the outcome of something justifies the means by which it is achieved.
If Doctors decided to strike because they wanted better food in the cafeteria, this could not be justified. However, if the reason was that they believed it would make a difference to their working conditions, this has more potential to be justifiable.
The deontological ethical theory states that Doctors have a duty of care to their patients. This could be interpreted to mean that Doctors should never strike, as no matter what it is they want, they should put their patients first. Conversely, it could be argued that the duty of care to patients is dependent on an ethical duty of self-care. Detrimental effects on Doctors’ personal welfare will have a direct detrimental effect on patient safety, and so in this context, striking may be justified.
Therefore, to answer the question: striking can be ethically acceptable, but it depends on the reasons, circumstances and potential outcomes of the strike.
Common Mistakes:
Getting too political. Don’t get worked up, and try to be balanced in your arguments, whilst still giving your opinion.
Only discussing the Junior Doctor strikes that happened, without any broader consideration of the issues.
You Are A GP, And Your Patient Confides In You That They Are Regularly Using Illicit Drugs
In this situation, it is important to be aware of your duty of confidentiality to your patients. You do not have a legal obligation to report illegal activity unless you believe that the patient, or someone else, is in immediate danger.
In GMC guidelines, it states that Section 115 permits disclosure to organisations such as the police, local authorities and probation services, but does not create a legal obligation to do so. Information should only be disclosed if the patient consents, if there is an overriding public interest, or if it’s in response to a court order.
Therefore, your course of action should be advisory rather than legal. You have a duty to ensure that the patient is aware of the health risks associated with illicit drug use and to explore whether they have considered stopping. You should also make them aware that drug cessation services are available and refer them as needed. It is also important to find out whether the patient is experiencing any adverse health effects and advise or treat the patient accordingly. For example, you may advise the patient about needle exchange programmes.
If the patient in the scenario has a child, and you feel that they are at risk of being harmed, then this changes your course of action. In this case, it is your duty to inform social services immediately.
Common Mistakes:
Forgetting about confidentiality when it comes to illicit drugs.
Thinking that the duty of confidentiality applies in all circumstances.
Should Vaccination Of Children Become Mandatory?
Should Vaccination Of Children Become Mandatory?
You must consider both sides of the argument, presenting a variety of arguments for and against. You should then summarise and come to a balanced conclusion, before stating whether you agree or disagree.
Show appreciation that vaccination has been quite controversial and that there are arguments on both sides. For example, mention Andrew Wakefield. Some arguments for making vaccination mandatory could be that it allows for eradication of diseases (e.g. polio, smallpox, etc). Generally, vaccines are highly safe and effective. You could also mention the concept of herd immunity.
As vaccination rates decline, the number of infectious diseases increases (e.g. when Andrew Wakefield released his study in 1998, incorrectly linking the MMR vaccine and autism, the rates of vaccinations decreased and incidence of measles increased).
Some arguments against making vaccinations mandatory could be that whilst the evidence against vaccinations is scarce, some people argue against making vaccinations mandatory because they believe that the government should not be able to control such health-related decisions. If people are afraid of needles or react badly to them, they shouldn’t be forced to get vaccinated. There may also be alternatives to mandatory vaccinations such as educational interventions that teach children and adults how important vaccines are.
Common Mistakes:
A lack of good examples when arguing for and against.
Failing to reach a balanced conclusion.
Lack of balance and swayed to one side, showing no recognition that there are two sides to the argument.
