Professionalism and Medical Ethics Flashcards
Which one of the following is NOT a required component for assessing an individual’s capac- ity to make a specific treatment decision?
a. Understand the information
b. Retain the information for long enough to
be able to make the decision
c. Use or weigh up the information to make
the decision
d. Communicate their decision
e. Make a rational decision
e. Make a rational decision
A lack of capacity can be permanent or tempo- rary and should be assessed in relation to a spe- cific decision to be made. A person with the capacity to consent to therapy should be able to understand the relevant information (treat- ments purpose, nature, likely effects and risks, chances of success and alternatives to the pro- posed treatment), retain the information, weigh up the information to make a decision and be able to communicate it in some way. In the UK, the Mental Capacity Act 2005 a might be used to give treatment for physical health problems to someone aged over 16 years who lacks capacity in their best interests (e.g., because of a mental illness, dementia, learning difficul- ties, unwell).
An 8-year-old boy requires a posterior fossa craniotomy for a space occupying lesion. His parents consent to the treatment plan. Which one of the following would you try to establish with respect to the child himself?
a. Informed consent
b. Informed assent
c. Parens patriae
d. Gillick competence
e. Coercion
b. Informed assent
Historically, children have been thought to lack capacity and are hence unable to provide consent on their own. Typically, decisions were made by their surrogate, usually a parent or guardian, and often without the input of the child. More recently, developmentally capable minors can be allowed to consent on their own, and those without the developmental capacity still partici- pate in the process of decision-making through assent. The American Academy of Pediatrics issued a policy statement in 1995 on assent that should be followed where possible. The process of assent involves (1) helping the child achieve a developmentally appropriate awareness of the nature of his/her condition, (2) telling the child what they can expect from tests and treatments, (3) assessing the child’s understanding of the situ- ation and the factors influencing how they are
For each of the following descriptions, select the most appropriate answers from the list above. Each answer may be used once, more than once or not at all.
1. To treat equals equally and unequals unequally according to morally relevant inequality.
2. The right not to be killed and to possess property.
3. Take from each according to ability and give to each according to need.
4. A rational person who makes a decision behind a veil of ignorance will look after the least well off.
5. Act to maximize welfare for the greatest num- ber at the least cost.
responding, and (4) soliciting an expression of the child’s willingness to accept the proposed care. In other jurisdictions (e.g., England, Australia, Canada), this presumption may be rebutted through proof that the minor is “mature” (e.g., “Gillick competent” in the UK) although it is still good practice to also seek parental consent/agree- ment. Although there is no lower age limit defined for which a child can be deemed Gillick competent, it is unlikely to apply for children under 13 years old. In cases of incompetent minors, informed con- sent is usually required from a person with parental responsibility. If the person with parental respon- sibility refuses to consent for a specific treatment and is deemed negligent, medical treatments can be given in the best interests of the child in emer- gencies or the treating team can make an applica- tion to the High Court which can exercise its power as parens patriae (legal protector of citizens unable to protect themselves) by making the child a ward of the Court, such that it takes on the responsibility for consenting for the child.
A 61-year-old male is admitted with a right frontal space occupying lesion, consistent with a glioblastoma multiforme. His imaging shows a significant amount of edema and midline shift and he is started on high-dose dexameth- asone. He is confused with a mild left hemipar- esis. His family arrive a few hours later, and you explain that he will need an operation and that the mass is probably cancerous. As you take them back to his bedside, they ask you not to tell their father about the likely diagnosis. Which one of the following princi- ples would be most compromised by operating on him at this point in time?
a. Autonomy
b. Non-maleficence c. Justice
d. Beneficence
e. Futility
a. Autonomy
This case highlights challenges to the consent process often seen in neurosurgical patients. Firstly, his capacity to make autonomous deci- sions is compromised because of the effects of his tumor. Therefore, the immediacy of the clin- ical situation will dictate whether we can afford to
wait and see if he regains capacity after a period of dexamethasone treatment or if a surrogate deci- sion maker (e.g., partner, family member) is con- sulted about what they think the patient would request to have done if they had the capacity. Sec- ond, the family has asked that information be withheld from the patient. In a patient with com- petence or capacity, the withholding of informa- tion does not allow the patient to make an informed decision hence any subsequent consent cannot be valid. For patients, full disclosure of relevant information (including risks and bene- fits) is a right but not a duty—they may not wish to have this information disclosed to them. In this situation they are effectively waiving their right to consent (as valid consent must be informed)— hence it must be well documented and reasons explored. In the case above, while it may be rea- sonable to withhold certain information while he remains confused, if he regains capacity before any planned operation then an attempt to get informed consent must be made.
A 31-year-old female who has been treated for recurrent cerebral metastases from breast cancer presents with multiple new cerebral lesions, including several radiation necrosis lesions from previous radiosurgery. She is mildly drowsy but understands her situation and is competent to make decisions regarding her care. During the consultation palliative care is discussed, but her husband demands that she be treated with any available life prolonging treatment. She says she doesn’t want to go through it any more, to which he responds by threatening to leave her if she is just going to give up. Which one of the follow- ing principles is potentially at risk in this situation?
a. Capacity
b. Voluntariness
c. Disclosure of relevant information
d. Authorization
e. Justice
b. Voluntariness
An action such as consenting to a treatment is con- sidered voluntary if it is undertaken freely, without undue influence or coercion from others. How- ever, medical decisions are almost always influ- enced by the opinion of doctors, family, friends, and past experience or knowledge. Identifying the difference between persuasion which is allow- able and under certain circumstance perhaps even obligatory (e.g., if a particular option is clearly in the best interests of a particular patient), and the coercion demonstrated in the husband’s threat to leave her if she doesn’t want to keep going is key to maximizing patient autonomy.
Which one of the following is/are NOT part of the four principles of biomedical ethics?
a. Autonomy
b. Utilitarianism
c. Beneficence
d. Non-maleficence
e. Justice
b. Utilitarianism
work for analyzing ethical problems. The four principles must be applied in the appropriate con- text and should have equal importance (allowing conflicts to arise). They are:
* Autonomy—freedom of the patient to choose and be an advocate for their own health.
* Beneficence—what is considered to be of the patient’s best interest.
* Non-maleficence—the harm that may come to a patient because of a specific deci- sion/treatment (“first do no harm”).
* Justice—thelegalaspectsthatimpactupon the ethical scenarios.
A mother does not want her son, a 12-year-old bright, good athlete without neurological def- icits, to know that his cerebellar astrocytoma has only been partially removed. She thinks that knowing this fact would place her son in emotional jeopardy, because a second proce- dure could diminish his sporting abilities. Over time, the follow-up MRI showed a slow but clear progress of the tumor requiring fur- ther surgery. Which one of the following eth- ical principles are most relevant?
a. Autonomy and beneficence
b. Beneficence and justice
c. Autonomy and justice
d. Justice and non-maleficence
e. Autonomy and non-maleficence
a. Autonomy and beneficence
When parents request information to be kept from their children, it may be legally permissible, but at the same time compromises the right of the child to autonomy. Therefore, a careful assess- ment of the following aspects is obligatory:
(1) The ability of the minor to fully understand the situation and to anticipate and evaluate future consequences.
(2) Whether the parental surrogate decision- making is in the best interests of the child or is it obstructing beneficence.
After assessment of these aspects, it is the duty of the physician to form a personal opinion (with help from ombudsmen or other authoritative persons or bodies, as needed), based on the con- cept of beneficence, and to try to act accordingly to work with the parents to take the right approach.
A34-year-old woman has a long history of epilepsy since the age of 24. She only has seizures when she sleeps, and her last seizure was 3 weeks ago. She is known to be compliant with every medication she’s been given. She retains the driving license which she applied for last year. Which one of the following is most accurate?
a. She must stop driving because her seizures are not well controlled
b. She may be able to continue driving as her seizures only occur during sleep
c. She must stop driving immediately as she has not been seizure free for 1 year
d. The doctor must inform the DVLA and stop her driving
e. She must give up driving indefinitely
b. She may be able to continue driving as her seizures only occur during sleep
When patients have their first seizure, they should inform the licensing agency and must stop driving. In this case, patient has been diagnosed
with epilepsy for at least 10 years and during that time she is only known to have seizures during her sleep. She is also very compliant with her doctor’s treatments. Given she has reapplied for the license recently, the licensing agency may be satisfied she does not pose any danger to the public.
A7-year-old boy presents with a reduced GCS and CT head scan shows significant intraven- tricular hemorrhage and hydrocephalus. You discuss the imaging and the plan for an emergency external ventricular drain with the father but he is not willing to proceed if there is any chance his son will be left a “vegetable.” What is the next step in management?
a. Call social services
b.Obtain a court order to proceed with surgery
c.Do not performs urgery as lacking parental consent
d. Proceed to surgery in the best interests of
the child
e. Keep the child sedated and ventilated on
NICU until consent is gained
d. Proceed to surgery in the best interests of the child
In an emergency where you consider that it is the child’s best interests to proceed, you may treat the child, provided it is limited to that treatment which is reasonably required in that emergency. Therefore, in this case, the surgery should be per- formed. In the UK this is governed by the Family Reform Act 1969
