Ethics & Professionalism
Medical Ethics — Boards-Style Scenarios
Ethics & Professionalism

Medical Ethics — Boards-Style Scenarios

Capacity, consent, confidentiality, surrogates, end-of-life, professionalism.

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◆Four principles & priority

  • •Autonomy (gold standard; overrides everything else for competent adult)
  • •Beneficence (best interest)
  • •Nonmaleficence (do no harm)
  • •Justice (fair distribution)
  • •On boards: AUTONOMY always wins for competent adult

◆Decision-making capacity

  • •4 components: Understanding + Appreciation + Reasoning + Communication of choice
  • •ANY physician can assess (don't need psychiatry)
  • •Decision-SPECIFIC and can fluctuate
  • •Dementia, mental illness, intoxication do NOT automatically mean incapacity
  • •Schizophrenia patient who can explain dx, tx, risks, reasoning → has capacity even if odd
  • •Intoxication acutely → wait for sobriety (unless life-threatening, then emergency consent)

◆Informed consent — required elements

  • •Diagnosis
  • •Risks + benefits
  • •Alternatives
  • •RISK of refusing (could they die?)
  • •Person performing procedure should obtain consent
  • •Telephone consent OK with witness
  • •Pregnant women can refuse anything (fetus not legally a person)

◆Exceptions to informed consent

  • •Emergency: life-threatening + cannot consent + no surrogate → treat
  • •Therapeutic privilege: rarely correct — only if disclosure causes severe psychological harm
  • •Waiver: patient voluntarily declines info
  • •Implied: routine low-risk procedures (blood draw)

◆Minors

  • •Generally cannot consent; emergencies = always treat
  • •FULL emancipation: marriage, military, financially independent, minor parent
  • •PARTIAL (specific conditions): contraception, prenatal care, STI testing, substance abuse, mental health (varies by state)
  • •Parents can NOT refuse life-saving treatment for child based on religion (Jehovah's Witnesses) → court order if time permits; transfuse if not
  • •Judicial bypass for parental-consent abortion laws

◆Confidentiality — exceptions (mandatory disclosure)

  • •Suspected child abuse OR elder abuse (suspicion alone, no proof needed)
  • •Gunshot wounds
  • •Reportable infections: HIV/AIDS, syphilis, TB, gonorrhea, measles, mumps
  • •Tarasoff: identifiable target + imminent harm → warn AND protect (police + victim)
  • •Impaired drivers (some states)
  • •SPOUSAL abuse: cannot report without consent of competent adult victim

◆Confidentiality — protected

  • •Minors STI/contraception/prenatal: do NOT disclose to parents
  • •Spouse cannot demand records or HIV results
  • •Police without warrant: do NOT disclose
  • •HIPAA: no chart access without treatment/payment/operations purpose

◆Surrogate decision-making hierarchy

  • •1. Living will (patient's documented wishes)
  • •2. Healthcare proxy (DPOA): overrides default family
  • •3. Spouse → Adult children → Parents → Siblings → Friends
  • •Substituted judgment: 'what would the patient want?'
  • •Best interest standard: only for patients who NEVER had capacity
  • •Disagreement: encourage consensus → ethics committee (last resort)

◆End-of-life

  • •Withholding = withdrawing (ethically equivalent)
  • •Double effect: ethical to give high-dose opioids if intent is pain relief (even if hastens death)
  • •DNR/DNAR: applies only to CPR; doesn't preclude ICU, surgery, dialysis
  • •DNR + surgery: discuss preoperatively
  • •Brain death = legal death; any physician can declare; EEG NOT required
  • •Organ donation: separate physician (not transplant team) declares brain death
  • •Physician-assisted death: legal in Oregon, WA, etc. (capacity, repeated requests, self-administered)
  • •Euthanasia (physician administers): ILLEGAL everywhere in US

◆Professionalism

  • •Sexual contact with current patients: ALWAYS prohibited
  • •Psychiatrists: never with current OR former patients
  • •Gifts: small from patients OK; industry <$100 educational only
  • •Impaired colleague: mandatory report (resident → program director; attending → dept chair or state board)
  • •Good Samaritan: no obligation to start; once start, must transfer to EMS
  • •Errors: disclose to patient; apology + transparency
  • •'I'm sorry' laws in many states protect expressions of sympathy
  • •Wrong-site surgery, retained foreign body = NEVER events → full disclosure + RCA

◆Research ethics

  • •IRB approval REQUIRED before enrolling subjects
  • •Patient can withdraw at any time without penalty
  • •Clinical equipoise: genuine uncertainty required for randomization
  • •Placebo arm unethical if effective standard exists (Declaration of Helsinki)
  • •Financial COI: mandatory disclosure
  • •Prisoners: identical rights; no coercion with promises of release
  • •Organ donation request: separate from treating team

◆Pregnant patients

  • •Right to refuse C-section even with fetal distress (fetus not a legal person)
  • •Spousal consent NEVER required
  • •Brain dead + pregnant: somatic support to allow fetal maturation if family requests

◆Quality improvement

  • •Value = Quality / Cost
  • •Lean methodology: optimize workflow, eliminate waste
  • •PDSA cycle: Plan-Do-Study-Act
  • •Measures: structural, process, outcome, balancing
  • •SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound
  • •Root-cause analysis (RCA): RETROSPECTIVE after sentinel event
  • •FMEA: PROSPECTIVE, identifies how processes could fail
  • •Strong actions: forcing functions; weak: training, double-checks
  • •Active errors: sharp end (operator); latent: blunt end (system flaws)

High-yield pearls

  • ◆AUTONOMY > Beneficence on boards — competent adult can refuse anything
  • ◆Capacity ≠ Competence (clinical vs legal)
  • ◆Tarasoff: duty to warn AND protect
  • ◆Brain death = legal death; no EEG required
  • ◆Spousal abuse: cannot report without consent (vs child/elder = mandatory)
  • ◆PROXY > family hierarchy
  • ◆Pregnant women can refuse C-section regardless of fetal outcome
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