BS - Ethics (Ethical principals, consent, & confidentiality)

Question 1

Name 4 core ethical principles.

Answer 1

(1) Respect patient autonomy (2) Beneficence (3) Nonmaleficence (4) Justice

Question 2

What does the core ethical principle of respecting patient autonomy encompass?

Answer 2

Obligation to respect patients as individuals (=> truth-telling, confidentiality), to create conditions necessary for autonomous choice (=> informed consent), and to honor their preference in accepting or not accepting medical care

Question 3

What does the core ethical principle of beneficence encompass? With what may this conflict?

Answer 3

Physicians have 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 4

What does the core ethical principle of nonmaleficence encompass? With what must this be balanced, and how so?

Answer 4

“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 5

What does the core ethical principle of justice encompass? What is an important distinction to keep in mind with regard to this?

Answer 5

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

Question 6

Define informed consent, including and defining its individual requirements.

Answer 6

A process (not just a document/signature) that legally requires: (1) Disclosure: discussion of pertinent information (2) Understanding: ability to comprehend (assess) (3) Mental capacity: unless incompetent (a legal determination) (4) Voluntariness: freedom from coercion and manipulation

Question 7

What two kinds of knowledge must patients have for informed consent?

Answer 7

(1) Patients must have an intelligent understanding of their diagnosis and the risks/ benefits of proposed treatment and alternative options, including no treatment. (2) Patient must be informed that he or she can revoke written consent at any time, even orally.

Question 8

What are 4 exceptions to informed consent?

Answer 8

Exceptions to informed consent: (1) Patient lacks decision-making capacity or is legally incompetent (2) Implied consent in an emergency (3) Therapeutic privilege - withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity (4) Waiver - patient explicitly waives the right of informed consent

Question 9

Who is generally considered a minor?

Answer 9

A minor is generally any person < 18 years old.

Question 10

What determines parental consent laws in relation to health care?

Answer 10

Parent consent laws in relation to health care vary state to state

Question 11

In general, in what situations should versus should not parental consent be obtained? What role should physicians play in this?

Answer 11

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.

Question 12

What are 3 general situations in which parental consent is usually not required?

Answer 12

Situations in which parental consent is usually not required: parents can’t stop kids from getting treatment for: (1) Sex (contraception, STDs, pregnancy) (2) Drugs (addiction) (3) Rock and roll (emergency/trauma)

Question 13

What role does the physician play with regard to decision-making capacity?

Answer 13

Physician must determine whether the patient is psychologically and legally capable of making a particular health care decision

Question 14

What are the major components for determining decision-making capacity?

Answer 14

Components: (1) Patient is >= 18 years old or otherwise legally emancipated (2) Patient makes and communicates a choice (3) Patient is informed (knows and understands) (4) Decision remains stable over time (5) Decision is consistent with patient’s values and goals, not clouded by a mood disorder (6) Decision is not a result of delusions or hallucinations

Question 15

Define advance directives. According to what do the details vary?

Answer 15

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

Question 16

What are 3 major options for advance directives?

Answer 16

(1) Oral advance directive (2) Living will (written advance directive) (3) Medical power of attorney

Question 17

What does an oral advance directive encompass? What problems may arise? What factors make the oral directive more valid?

Answer 17

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

Question 18

What is another name for living will? What does it encompass?

Answer 18

Living will (written advance directive); 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 19

What is a medical power of attorney? What control does the patient reserve? How does medical power of attorney compare/contrast to a living will?

Answer 19

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 20

What is a surrogate decision-maker? What is the priority of surrogates?

Answer 20

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 21

What does the concept of confidentiality encompass? What guides physician? What rights do patients have in this regard?

Answer 21

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).

Question 22

What are four general principles for exceptions to confidentiality?

Answer 22

General principles for exceptions to confidentiality: (1) Potential physical harm to others is serious and imminent (2) Likelihood of harm to self is great (3) No alternative means exists to warn or to protect those at risk (4) Physicians can take steps to prevent harm

Question 23

Give 5 examples of exceptions to patient confidentiality.

Answer 23

Examples of exceptions to patient confidentiality (many are state-specific) include: (1) 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 (2) The Tarasoff decision - California Supreme Court decision requiring physician to directly inform and protect potential victim from harm (3) Child and/or elder abuse (4) Impaired automobile drivers (e.g., epileptics) (5) Suicidial/homicidal patients