USMLE Ethics Topics

Basic Vocab

Autonomy
The obligation to respect patients as individuals and to honor their preferences in medical care

Beneficence
Physicians have a special ethical (fiduciary) duty to act in the patient's best interest. This may conflict with autonomy. If the patient can make an informed decision, ultimately the patient has the right to decide.

Nonmaleficence
"Do no harm." However, if the benefits of an intervention outweigh the risks, a patient may make na informed decision to proceed (most surgeries and medications fall into this category)

Justice
Treating a person fairly

Disclosure

Patients have a right to know about their medical status, prognosis, and treatment options (full disclosure). Physicians are obligated to inform patients of mistakes made in their medical treatment. A patient's family cannot require that a doctor withhold information from the patient. A doctor may withhold information only if the patient requests not to be told or in the rare case when a physician determines that disclosure would severely harm the patient or undermine informed decision-making capacity (therapeutic privilege).

Confidentiality 

Information disclosed by a patient to his/her physician and information about a patient's medical condition is confidential and cannot be divulged without express patient consent. However, a patient may waive the right to confidentiality (e.g. with insurance companies). In addition, it is ethically and legally necessary to override confidentiality in the following situations:

• Patient intent to commit a violent crime. [The Tarasoff decision set a precedent that if a patient presents a serious, credible danger of violence to a third party, physicians have a duty to protect the intended victim through reasonable means (e.g. warn the victim or notify police). 
• Suicidal patients
• Child abuse, elder abuse
• Infectious diseases (duty to warn public officials and identifiable people at risk)
• Gunshot and knife wounds
• Impaired automobile drivers

Informed Consent

Defined by willing acceptance (without coercion) of a medical intervention by a patient after adequate discussion with a physician about the nature of intervention, indications, risks, benefits, and potential alternatives (including no treatment). Patients may change their minds at any time. Exceptions include:

• Consent is implied when emergency treatment is required
• Consent can be obtained from a surrogate decision maker when patients lack decision-making capacity or patient is legally incompetent
• Patients who sign waivers to the right of informed consent
• Therapeutic privilege - withholding information when disclosure would severely harm the patient or undermine informed decision-making capacity

Consent for minors: A minor is any person < 18 years of age. Parental consent must be obtained unless minor is emancipated (e.g. is married, is self-supporting, has children, or is in the military). However, parental consent is NOT required in emergency situations, when prescribing contraceptives, or in treatment of STD's, medical care during pregnancy, or the management of drug addiction. Even if a parent requests information, confidentiality can be broken only with the patient's permission or if the minor is a danger to him/herself or others.

Competence and Decision-Making Capacity

Competence is a legal term referring to a patient's authority to make personal and medical choices.

Decision-making capacity is a medical term referring to a patient's capacity to accept or refuse treatment. It is determined by a medical provider and is defined as the ability to understand relevant information, appreciate the medical situation and its consequences, communicate a choice, and deliberate rationally about one's values in relation to the decision.

• Patient makes and communicates a choice
• Patient is informed (knows and understands information)
• Decision remains stable over time
• Decision is consistent with patient's values and goals
• Decision is not a result of delusions or hallucinations

 The patient's family cannot require the physician to withhold information from the patient.

Refusal of Treatment

All competent patients have the right to refuse or discontinue treatment as long as this will not harm other parties (e.g. Jehovah's Witnesses can refuse blood products). An incompetent or decisionally incapacitated patient (e.g. an intoxicated patient with altered mental status) cannot refuse treatment.

A parent has the right to make treatment decisions for his/her child as long as those decisions do not pose a serious threat to the child's well-being (e.g. refusing immunizations). If a decision is not in the best interest of the child, a physician may seek a court order to provide treatment against parental wishes. In emergent situations, if withholding treatment jeopardizes the child's safety, treatment can be initiated on the basis of legal precedent.

Advance Directives

Advance Directives
Instructions given by a patient in anticipation of the need for medical decision.

Oral Advance Directive 
Incapacitate 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.

Living Will (Written Advance Directive)
Describes treatments the patient wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions. Usually, patient directs physician to withhold or withdraw life-sustaining treatment if he/she develops a terminal disease or enters a persistent vegetative state. Examples include: DNR and DNI orders. DNR/DNI does not mean "do not treat". Patients should still receive maximum medical intervention short of these specific problems.

Durable Power of Attorney
Patient designates a surrogate to make medical decisions in the event that he/she loses decision-making capacity. Patient may also specify decisions in clinical situations. Surrogate retains power unless revoked by patient. More flexible than living will. Surrogates should make decisions consistent with the person's stated wishes. If no living will DPOA exists, decisions should be made by close family members (spouse, adult children, parents, and adult siblings), friends, or personal physicians, in that order.

Withdrawal of Care

Patients and their decision makers have the right to forgo life-sustaining treatment. There is no ethical distinction between withholding and withdrawing life-sustaining interventions. This includes ventilation, fluids, nutrition, and medications (e.g. antibiotics). It is ethical to provide palliative treatment to relieve pain and suffering even if it may hasten a patient's death.

Euthanasia and Physician-Assisted Suicide

Euthanasia 
The administration of a lethal agent with the intent to relieve suffering. It is opposed by the AMA Code of Medical Ethics and is illegal. Patients who request euthanasia should be evaluated for inadequate pain control and comorbid depression.

Physician-Assisted Suicide
Prescribing a lethal agent to a patient who sill self-administer it to end his/her own life. This is currently legal in Oregon (since 1997), Washington (since 2008), Vermont (since 2013), and New Jersey (recently approved in 2014). 

Futility

Physicians are not ethically obligated to provide treatment and may refuse a family's request for further intervention on the grounds of futility when:

• There is no pathophysiological rationale for treatment
• Maximal intervention is currently failing
• A given intervention has already failed
• Treatment will not achieve the goals of care

Conflict of Interest

Occurs when physicians find themselves having two interests in a given situation. For example, a physician may own stock in a pharmaceutical company (financial interest) that produces a drug he is prescribing to his patient (patient care interest). Patients, research participants, supporting institutions, and readers (i.e. of journal articles and books) have the right to know about any existing conflicts of interest.

Malpractice

The essential elements of a civil suit under negligence include the four D's:

• The physician has a Duty to the patient
• Dereliction of duty occurs
• There is Damage to the patient
• Dereliction is the Direct cause of damage

Unlike a criminal suit, in which the burden of proof is "beyond a reasonable doubt," the burden of proof in a malpractice suit is "more likely than not".

Ethical Situations

Patient is noncompliant.
Appropriate Response: Attempt to identify the patient's reasons for noncompliance and determine his/her willingness to change; do not attempt to coerce the patient into complying or refer the patient to another physician.

Patient desires an unnecessary procedure.
Appropriate Response: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.

Patient has difficulty taking medications
Appropriate Response: Provide written instructions; attempt to simplify treatment regimens.

Family members ask for information about patient's prognosis.
Appropriate Response: Avoid discussing issues with relatives without the permission of the patient.

A child wishes to know more about his/her illness.
Appropriate Response: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.

A 17-year old girl is pregnant and requests an abortion.
Appropriate Response: Many states require parental notification or consent for minors to obtain 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.

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.
Appropriate Response: 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.

A terminally ill patient requests physician assistance in ending his life.
Appropriate Response: In the overwhelming majority of states, refuse involvment in any form of physician-assisted suicide. Physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient's life.

Patient is suicidal.
Appropriate Response: 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.

Patient states that he/she finds you attractive.
Appropriate Response: 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 it implies that a relationship may be possible if the individual is no longer a patient.

A middle-aged married woman who had a mastectomy says she feels "ugly" when she undresses at night.
Appropriate Response: Find out why the patient feels this way. Do not offer falsely reassuring statements (e.g. "You still look good.")

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

Patient is upset with the way he was treated by another doctor.
Appropriate Response:   Suggest that the patient speak directly to that physician regarding his concerns. If the problem is with a member of the office staff, tell the patient that you will speak to the individual.

A drug company offers a "referral fee" for every patient a physician enrolls in a study.
Appropriate Response: 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.

A physician orders an invasive test for the wrong patient.
Appropriate Response: No matter how serious or trivial a medical error, a physician is ethically obligated to inform a patient that a mistake has been made.

A patient requires a treatment not covered by his/her insurance.
Appropriate Response: 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.

Rapid Review

Questions:
1) True or False: Once patients sign a statement giving consent, they must continue treatment.
2) List exceptions to the requirement of informed consent.
3) a 15-year old pregnant girl requires hospitalization for preeclampsia. Should her parents be informed?
4) What is wrong with a doctor referring a patient for an MRI at a facility that he owns?
5) Involuntary psychiatric hospitalization can be undertaken for what three reasons?
6) True or False: Withdrawing life-sustaining care is a more serious measure than withholding care.
7) When can a physician refuse to continue treating a patient on the grounds of futility?
8) An 8-year old child is in a serious accident. She requires emergent transfusion, but her parents are not present. What do you do?

Answers:
1) False. Patients may change their minds at any time.
2) Emergency situations, patients without decision-making capacity, and patients who sign waivers to the right of informed consent.
3) No. Parental consent is not necessary for medical treatment of pregnant minors.
4) Conflict of interest
5) Patient is a danger to self, a danger to others, or gravely disabled (unable to provide for basic needs)
6) False. Withdrawing and withholding life-sustaining treatment are the same from an ethical standpoint
7) When there is no rationale for treatment, maximal intervention is failing, a given intervention has already failed, and treatment will not achieve the goals of care
8) Treat immediately. Consent is implied in emergency situations.