Behavioral Science - Ethics

Question 1

Respect patient autonomy

Answer 1

• Obligation to…
  
  • Respect patients as individuals (Ž–> truth-telling, confidentiality)
  • Create conditions necessary for autonomous choice (–>Ž informed consent),
  • Honor their preference in accepting or not accepting medical care.

Question 2

Beneficence

Answer 2

• Physicians have a special ethical (fiduciary) duty to act in the patient’s best interest.
• May conflict with autonomy (an informed patient has the right to decide) or what is best for society (traditionally patient interest supersedes).

Question 3

Nonmaleficence

Answer 3

• “Do no harm.”
• Must be balanced against beneficence
• If the benefits outweigh the risks, a patient may make an informed decision to proceed (most surgeries and medications fall into this category).

Question 4

Justice

Answer 4

• To treat persons fairly and equitably.
• This does not always imply equally (e.g., triage).

Question 5

Informed consent

• Definition
• Exceptions to informed consent

Answer 5

• Definition
  
  • A process (not just a document/signature) that legally requires:
    
    • Disclosure: discussion of pertinent information
    • Understanding: ability to comprehend (assess)
    • Mental capacity: unless incompetent (a legal determination)
    • Voluntariness: freedom from coercion and manipulation
  • Patients must have an intelligent understanding of their diagnosis and the risks/benefits of proposed treatment and alternative options, including no treatment.
  • Patient must be informed that he or she can revoke written consent at any time, even orally.
• Exceptions to informed consent
  
  • Patient lacks decision-making capacity or is legally incompetent
  • Implied consent in an emergency
  • Therapeutic privilege—withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity
  • Waiver—patient explicitly waives the right of informed consent

Question 6

Consent for minors

• Definition
• Situations in which parental consent is usually not required: parents can’t stop kids from getting treatment for…

Answer 6

• Definition
  
  • A minor is generally any person < 18 years old.
  • Parental consent laws in relation to health care vary state by state.
  • In general, parental consent should be obtained unless minor is legally emancipated (e.g., is married, is self-supporting, or is in the military).
  • Some states have “mature minor” laws, in which parental consent is not required
    
    • Nonetheless, physicians should always encourage healthy minor-guardian communication.
• Situations in which parental consent is usually not required: parents can’t stop kids from getting treatment for…
  
  • Sex (contraception, STDs, pregnancy)
  • ƒƒDrugs (addiction)
  • Rock and roll (emergency/trauma)

Question 7

Decision-making capacity

Answer 7

• Physician must determine whether the patient is psychologically and legally capable of making a particular health care decision.
• Components:
  
  • Patient is ≥ 18 years old or otherwise legally emancipated
  • Patient makes and communicates a choice
  • Patient is informed (knows and understands)
  • ƒƒDecision remains stable over time
  • Decision is consistent with patient’s values and goals, not clouded by a mood disorder
  • ƒƒDecision is not a result of delusions or hallucinations

Question 8

Advance directives

Answer 8

• Instructions given by a patient in anticipation of the need for a medical decision.
• Details vary per state law.

Question 9

Oral advance directive

Answer 9

• Incapacitated patient’s prior oral statements commonly used as guide.
• Problems arise from variance in interpretation.
• If patient was informed, directive was specific, patient made a choice, and decision was repeated over time to multiple people, the oral directive is more valid.

Question 10

Living will (written advance directive)

Answer 10

• Describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity.
• Usually, patient directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state.

Question 11

Medical power of attorney

Answer 11

• Patient designates an agent to make medical decisions in the event that he/she loses decision-making capacity.
• Patient may also specify decisions in clinical situations.
• Can be revoked anytime patient wishes (regardless of competence).
• More flexible than a living will.

Question 12

Surrogate decision-maker

Answer 12

• If an incompetent patient has not prepared an advance directive, individuals (surrogates) who know the patient must determine what the patient would have done if he/she were competent.
• Priority of surrogates: spouse, adult children, parents, adult siblings, other relatives.

Question 13

Confidentiality

• Definition
• General principles for exceptions to confidentiality
• Examples of exceptions to patient confidentiality (many are state-specific)

Answer 13

• Definition
  
  • Confidentiality respects patient privacy and autonomy.
  • If patient is not present or is incapacitated, disclosing information to family and friends should be guided by professional judgment of patient’s best interest.
  • The patient may voluntarily waive the right to confidentiality (e.g., insurance company request).
• General principles for exceptions to confidentiality
  
  • Potential physical harm to others is serious and imminent
  • Likelihood of harm to self is great
  • No alternative means exists to warn or to protect those at risk
  • Physicians can take steps to prevent harm
• Examples of exceptions to patient confidentiality (many are state-specific)
  
  • Reportable diseases (e.g., STDs, TB, hepatitis, food poisoning)—physicians may have a duty to warn public officials, who will then notify people at risk
  • The Tarasoff decision—California Supreme Court decision requiring physician to directly inform and protect potential victim from harm
  • Child and/or elder abuse
  • Impaired automobile drivers (e.g., epileptics)
  • Suicidal/homicidal patients

Question 14

Appropriate response for the ethical situation:

• Patient is not adherent.

Answer 14

• Attempt to identify the reason for nonadherence and determine his/her willingness to change.
• Do not coerce the patient into adhering or refer him/her to another physician.

Question 15

Appropriate response for the ethical situation:

• Patient desires an unnecessary procedure.

Answer 15

• Attempt to understand why the patient wants the procedure and address underlying concerns.
• Do not refuse to see the patient or refer him/her to another physician.
• Avoid performing unnecessary procedures.

Question 16

Appropriate response for the ethical situation:

• Patient has difficulty taking medications.

Answer 16

• Provide written instructions
• Attempt to simplify treatment regimens.
• Use teach-back method (ask patient to repeat medication regimen back to physician) to ensure patient comprehension.

Question 17

Appropriate response for the ethical situation:

• Family members ask for information about patient’s prognosis.

Answer 17

• Avoid discussing issues with relatives without the permission of the patient.

Question 18

Appropriate response for the ethical situation:

• A patient’s family member asks you not to disclose the results of a test if the prognosis is poor because the patient will be “unable to handle it.”

Answer 18

• Attempt to identify why the family member believes such information would be detrimental to the patient’s condition.
• Explain that as long as the patient has decision-making capacity and does not indicate otherwise, communication of information concerning his/her care will not be withheld.

Question 19

Appropriate response for the ethical situation:

• A child wishes to know more about his/her illness.

Answer 19

• Ask what the parents have told the child about his/her illness.
• Parents of a child decide what information can be relayed about the illness.

Question 20

Appropriate response for the ethical situation:

• A 17-year-old girl is pregnant and requests an abortion.

Answer 20

• Many states require parental notification or consent for minors for an abortion.
• Unless she is at medical risk, do not advise a patient to have an abortion regardless of her age or the condition of the fetus.

Question 21

Appropriate response for the ethical situation:

• A 15-year-old girl is pregnant and wants to keep the child.
• Her parents want you to tell her to give the child up for adoption.

Answer 21

• The patient retains the right to make decisions regarding her child, even if her parents disagree.
• Provide information to the teenager about the practical issues of caring for a baby.
• Discuss the options, if requested.
• Encourage discussion between the teenager and her parents to reach the best decision.

Question 22

Appropriate response for the ethical situation:

• A terminally ill patient requests physician assistance in ending own life.

Answer 22

• In the overwhelming majority of states, refuse involvement in any form of physician-assisted suicide.
• Physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient’s life.

Question 23

Appropriate response for the ethical situation:

• Patient is suicidal.

Answer 23

• Assess the seriousness of the threat
• If it is serious, suggest that the patient remain in the hospital voluntarily
• Patient can be hospitalized involuntarily if he/she refuses

Question 24

Appropriate response for the ethical situation:

• Patient states that he/she finds you attractive.

Answer 24

• Ask direct, closed-ended questions and use a chaperone if necessary.
• Romantic relationships with patients are never appropriate.
• Never say, “There can be no relationship while you are a patient,” because this implies that a relationship may be possible if the individual is no longer a patient.

Question 25

Appropriate response for the ethical situation:

• A woman who had a mastectomy says she now feels “ugly.”

Answer 25

• Find out why the patient feels this way.
• Do not offer falsely reassuring statements (e.g., “You still look good.”).

Question 26

Appropriate response for the ethical situation:

• Patient is angry about the amount of time he/she spent in the waiting room.

Answer 26

• Acknowledge the patient’s anger, but do not take a patient’s anger personally.
• Apologize for any inconvenience.
• Stay away from efforts to explain the delay.

Question 27

Appropriate response for the ethical situation:

• Patient is upset with the way he/she was treated by another doctor.

Answer 27

• Suggest that the patient speak directly to that physician regarding his/her concerns.
• If the problem is with a member of the office staff, tell the patient you will speak to that person.

Question 28

Appropriate response for the ethical situation:

• A drug company offers a “referral fee” for every patient a physician enrolls in a study.

Answer 28

• Eligible patients who may benefit from the study may be enrolled, but it is never acceptable for a physician to receive compensation from a drug company.
• Patients must be told about the existence of a referral fee.

Question 29

Appropriate response for the ethical situation:

• A physician orders an invasive test for the wrong patient.

Answer 29

• No matter how serious or trivial a medical error, a physician is ethically obligated to inform a patient that a mistake has been made.

Question 30

Appropriate response for the ethical situation:

• A patient requires a treatment not covered by his/her insurance.

Answer 30

• Never limit or deny care because of the expense in time or money.
• Discuss all treatment options with patients, even if some are not covered by their insurance companies.