Ethics

Question 1

What are the four core ethical principles?

Answer 1

Respect patient autonomy

Beneficence

Nonmaleficence

Justice

Question 2

What is meant by respecting patient autonomy?

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 is meant by the principle of beneficence?

Answer 3

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 4

What is meant by the principle of nonmaleficence?

Answer 4

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

Question 5

What is meant by the principle of Justice?

Answer 5

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

Question 6

What is legally required in informed consent (4)?

When can patients revoke written consent?

Answer 6

A process (not just a document/signature) that requires:

1. Disclosure: Discussion of pertinant information
2. Understanding: Ability to comprehend (assess)
3. Mental capacity: Unless incompetent (legal determination)
4. Voluntariness: Freedom from coercion and manipulation

Overall goal: Patient must have an intelligent understanding of their diagnosis and risks/benefits of proposed treatment and alternative options, including no treatment.

Patient must be informed that they can revoke written consent at any time, even orally.

Question 7

What are some exceptions to informed consent? (4)

Answer 7

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 8

Is parental consent generally required for minors (<18)?

Answer 8

Yes - except for in certain situtations.

Physicians should always encourage healthy minor-guardian communication.

Question 9

What does it mean to be legally emancipated? What is included?

What are “mature minor” laws?

Answer 9

Legally emancipated: Minor capable of making informed consent without parental approval. Includes minors who are married, self-supporting, or who are in the military.

Mature minor: Parental consent is not required under certain circumstances.

Question 10

What are situations in which parental consent is usually not required: Parents can’t stop their children from getting treatment for… (3)

Answer 10

1. Sex (contraception, STDs, pregnancy)
2. Drugs (addiction)
3. Rock and roll (emergency/trauma)

Question 11

What are requirements for decision-making capacity?

Answer 11

Physician must determine if 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)

Decision remains stable over time

Decision is consistent with patient’s values and goals; not clouded by mood disorder

Decision is not result of delusions or hallucinations

Question 12

What are advance directives?

Answer 12

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

Question 13

What are oral advance directives?

Answer 13

Incapacitated patient’s prior oral statements commonly used as a 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 14

What is a living will?

Answer 14

Describes treatments the patient wishes to receive or not receive if he/she loses decision-making capacity.

Usually directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state.

Question 15

What is medical power of attorney?

Answer 15

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

More flexible than a living will.

Question 16

What is a surrogate decision-maker?

Answer 16

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 17

What is meant by confidentiality?

How should patient information be disclosed to family and friends when the patient is incapacitated or not present?

Answer 17

Confidentiality: Respects patient’s privacy and autonomy.

If patient is incapacitated, disclosing information to friends and family should be guided by professional judgment of patient’s best interest.

Patient can waive right to confidentiality (e.g., insurance company request)

Question 18

What are some general principles for exceptions to confidentiality (4)

Answer 18

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 protect those at risk
4. Physicians can take steps to prevent harm

Examples:

1. Reportable diseases (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 (epileptics)
5. Suicidal/homicidal patients.