Ethical and Legal Issues

1. Competent patients have right to refuse medical treatment:

Who owns the body? = Autonomy (including all reproductive decisions: sterilization, abortion, contraception)
Pregnant woman can refuse therapy (fetus is not a person, but once born parents cant prevent his life saving)
Unreasonable answers for refusing ttt is not equivalent to incompetence
Also have the right to refuse to receive (know) diagnostic information (but you must try to explore the pts
concerns and explain why he needs to know: to make ttt decisions)
Autonomy is about accepting or refusing ttt but not selecting inappropriate ttt
2. Always assume that patient is competent. Competence is a legal (not medical) issue
Clear evidence of incompetence:
- Attempting suicide (trying to kill himself in any way)
- Patients state prevents simple communication
If youre in the middle = hes competent
Can you give and take info from a drunken?
Maybe Yes, maybe No => Once maybe = Competent
But if blood alcohol level >100 = impaired decision making = incompetent (incapacitated)
Patients diagnosis (e.g. Alzheimer, Schizophrenia, mental retardation) tells you nothing about patients competence
= its a legal issue
3. Avoid going to court (NEVER PASS OFF)
Dont seek legal counsel, talk to ethics committee, or seek advice from another physician.
4. When surrogates make decisions, it should follow this order:
a) Subjective Standard (Advance directives) = what patient said as expression of wishes in the past.
Familys own wishes are not relevant
b) Substituted Judgment (Next Kin) = the person who most likely knows the pts wishes, usually in this order:
Spouse, older child, parents.
c) Best-interest Standard (with no way of knowing patients wishes)
= Its your choice, for the patients own interest only
5. When patient is incompetent, physician should rely on advance directives:
The most recent wishes are the most reliable
Can be orally said to you historically (Enough evidence)
Living will (written expression of wishes), Limitations:
ONLY applies for end of life care
May not be clear
Health power of attorney (speaks with the patients voice), its NOT applied if:
- Patient told you NOT to
- If the persons opinion directly contradicts the living will, in an end of life care
6. Feeding tube is a medical treatment and can be withdrawn at patients request (even if led to their death)
7. Do nothing to actively assist the patient to die SOONER:
Passive (allowing to him die) is OK
Active (helping him to die, killing) is NOT OK
You should treat PAIN aggressively but dont kill the patient!
8. The physician decides when the patient is dead:
Flat EEG for 24hours = Death
Lack of HOPE (dont stop treatment) VS Lack of LIFE (must stop treatment)
Discuss with the family before pulling the plug off (explain to them)
9. Never abandon a patient:
You can refuse to take him, but once took him you cant leave him (for life)!
Even if annoying or difficult patient
You cant even threaten abandonment.
10. You are not allowed to have intimate relation with anybody who has been your patient, or parents of a child pt:
Dont say I cant because I am still your physician because that encourages the pt to terminate the physician-pt
relationship, but rather say its always unethical to date a pt
Dont treat friends or family of a pt (except in emergencies)
Dont accept gifts (bigger than a token, a meal, a scarf; a nominal modest gift is acceptable) esp. with psychiatrists
Never accept Cash Gifts (including gift certificates or vouchers)
Maintain consistency, so if the office has no-gift policy, then no gifts from everyone, regardless the value of the gift
11.STOP HARM:
Stop harm from happening from anyone to anyone
Take whatever action is required to prevent harm (break confidentiality, must inform both the law enforcement as
well as the potential victim)
We cannot release a drunk pt (with Blood alcohol level >200) until hes sober
If a pt TOTALLY refuses to get ttt for TB he gets incarcerated in the hospital (until not more infectious)
If pt TOTALLY refuses to give her child a lifesaving ttt you might get a court injunction to mandate the ttt
12. ALWAYS obtain informed consent (even for a CBC):
Patient must understand the benefits, risks and all other options (they choose) + adverse effects of not getting ttt
Consent is specific (for each procedure; you need one for operation in the Rt knee and another for the Lt knee)
The person performing the procedure should obtain the consent (he knows more and we should tell pt everything)
Telephone consent is valid with the decision maker (must be witnessed)
HIV testing requires a separate consent from regular blood testing
Four Exceptions:
- Emergency, Waiver by patient, incompetent, therapeutic privilege (you have the right to deprive pts Autonomy
in the interest of his health/health of others, e.g. Violent pt must take haloperidol and get restrains; BUT doesnt
allow you to hold info from the patient for their own sake)
- In Emergency: unless theres extremely clear (documented) advance directive, theres implied consent
Extremely clear = cant be a friend saying he wanted to or he didnt want to
Emergency can be low oxygen saturation and need for intubation
Can be oral (for any level of therapy, e.g. heart transplant, if patient cant write)
Written consents can be revoked orally anytime
13. Children (<18) are legally incompetent EXCEPT:
Older than 13 and taking care of self (Emancipated Minor); like marriage, high school graduate, homeless, working,
(but not pregnancy or giving birth)
14. Parents cant withhold life- or limb-saving treatment from their children:
It must be a life/death issue
15. Good Samaritan Law limit liability in accident situations:
You are not required to stop for help
If you offered help, youre shielded from liability
You must not leave before another competent personnel (another doctor/EMTs) arrives
If you accepted any compensation (gift, fee,) = No more following the Good Samaritan Law, now every legal
liability applies to you and your work
16. Confidentiality is absolute:
Always act paranoid when taking a consult
Patient must sign a release form before allowing his information (medical records) transferred to anyone
If you received a court subpoena, SHOW up in court but DONT divulge any info about your patient (unless he asked
you to, there was a court order to divulge, or a search warrant to his medical records) and dont even answer
whether hes your patient or not (even if he wasnt your patient)
If theres threat (to specific person in a specific way) MUST break confidentiality
In reportable diseases: name of the pt is not divulged
Best way = Husband tells wife, in your office, with you there with them (in STDs)
HPV (genital warts) is not a reportable disease, so husband must not know unless wife signs release consent!
Two situations where its okay to share info with the family:
- If the pt doesnt object sharing (eg: if pt is with a family visit and you asked if its okay to discuss his condition now,
and he didnt object)
- If the pt is not present (undergoing surgery/emergency care) and your professional judgment is that sharing info is in
the pts best interest ( ) and in this condition the shared info is limited to the general details of
his acute condition and prognosis, but specific conditions (like substance abuse should always be kept confidential)
17. Patients should be given the chance to state DNR orders:
Refers to cardiopulmonary resuscitation only including:
- No intubation/mechanical ventilation
- No defibrillation or IV drugs to treat a terminal rhythm (amiodarone, lidocaine)
- No chest compressions
Continue treatments (can still undergo surgeries, go to the ICU, get intubated)
An advance directive, power of attorney, or next kin can state no resuscitation to an incompetent pt
18. Committed mentally ill patients retain all their civil rights:
Marry, vote, do business
Can refuse to get treatment, but not if they were harmful
Can command a jury trial to determine sanity
19. Detain patients to protect them or others:
You can detain, but only a judge can commit!
20. Stop physician who pose risk to patients from patient contact:
Report only behaviors that affect pt care (not outside the practice)
- Infectious Disease (TB)
- Substance abuse
- Depression / too sleepy
- Incompetent
You must protect the patient not your collogue
In emergent situations of colleague malpractice report immediately to the locally (directly) above supervisor
 In non-emergent situations, you should contact the hospital committee (physician health program)
In cases of disagreements in medical situations, discuss, if still, bring the issue to the above supervisor

Other important points

The involvement of ethics committee or risk management on USMLE is almost always a WRONG ANSWER
Offering to personally compensate a pt for an error is completely inappropriate
Dont prescribe to other physician colleagues (unless they are already your pt) except in emergency
Ttt of family and friends should be limited to emergency situations when no other physician is available!
Theres no problem in
HIPPA doesnt require identity proof of a pt family member
Always ask the pt about his advance directives once hes hospitalized as a part of the admission process
In an nonresponsive Jehovahs Witness pt in emergency, you will transfuse blood (even if a family member told you
not to) unless hes carrying a card (like a living will) expressing his wish not to receive blood transfusion
Failure to adhere: 1st acknowledge that its difficult to take meds every day (esp. for a silent dis) then explore
Parents can refuse futile care to their children
In non-emergent situations the physician must challenge parents refusing ttt to their child, first try to discuss, then you
may involve the ethics committee, then if no resolution yet, you may reach for a court order (for the child interest)
If a parent is not allowing his child to freely express himself, you may politely ask the parent to leave the room
You must inform the patient of what could happen if he doesnt choose the therapy that you offer (not only the
adverse effects and benefits)
Patient has an absolute right to free access to his medical information and get a copy of the records, without telling
any reasons (but cannot take sole possession of the physical medical records)
In correcting medical records: draw a line through it and then initial the correction. If you forgot to put a note in the
pts chart yesterday, you cannot put it today with yesterdays date on it (dont back date notes) put todays date.
Euthanasia = prescribing and administering the method of death (worse than physician assisted suicide)
Brain death (loss of brainstem reflexes; more important than EEG): NO EEG required to confirm the clinical signs
- Pupillary light reflex
- Corneal reflex
- Oculocephalic (dolls eyes reflexes)
- Caloric responses
- Spontaneous respiration
Must exclude other causes: OD of barbiturates, hypothermia, hypotension, neuromuscular blocking agents
(pancuronium, vecuronium, succinylcholine)
Abortion is unrestricted in first trimester, but in third trimester its done only if theres threatening to mothers life
Sterilization is unrestricted to both genders (no matter what the other partner wants)
Selling of unfertilized ova and sperms are unrestricted (but only donation is allowed for fertilized ova)
Organ Donor Network gets to ask for consent for donation (not the physician)
Its acceptable to obtain costs to cover the donation but not to sell organs
 No obligation on an HIV positive physician (even if he was a surgeon) to inform his pts of his HIV status, only
universal precautions are supposed to be maintained, as well as no obligation for a pt to state his HIV status to the
physician before a surgery. We treat all pts as if they are ALL HIV positive (universal precautions)
Refusing to treat an HIV positive pt is not ethical but its not illegal
Herpes is generally not reportable and no contact tracing
If partner notification is going to occur, you must inform the pt that you will inform his partner
Malpractice = is a preventable error resulting in harm to the pt (both must have occurred, if one, its not malpractice)
Gifts from pharmaceutical industry are always assumed to carry influence toward a product, but can be accepted if:
medical/educational, up to $100 worth books/medical equipment, meals associated with lectures/conferences; also
speakers can be sponsored but will have to disclose all financial participation with the company
Domestic partner abuse (intimate partner violence): not reported unless she agrees; otherwise you must do
everything possible to prevent more abuse
1) Ensure privacy 2) No pressure to disclose, report, press charges or leave partner 3) Ask if she feels safe 4) Ask
about emergency safety plans 5) provide referrals to shelters, domestic violence agency, mental health assistance
Women are at highest risk in the third trimester!
Elderly Abuse:
If you are suspicious you must 1st interview the pt alone OR report immediately if son refused to leave you alone
Then screen by asking about: 1) Do you feel safe? 2) Who makes your meals? 3) Who handles your checkbook?
You must report elderly abuse even if he/she refused
Social worker: can meet with the family members and assess any social factors affecting the pt returning home,
identify barriers to adherence, develop alternate strategy. Shes very helpful esp. in discharging elderly pts with poor
medication adherence even with a child supervision, to ensure right way of supervision
Seizure and visual disorders are mandatory reportable to the DMV, but 1st step is to encourage pt to report himself and
limit his driving
Never participate (at any level, even attending) in executions or torture (in military or prisons), but you can give
anxiolytic medication prior to the day of execution to relieve the suffering of the person condemned
Torture must be reported (not just treated).
Gunshot/Stabbing wounds are mandatory reportable (even if victim objects).
Institutional Review Board (IRB):
Review clinical protocols prior to their implementation to ensure their ethical integrity
You must disclose ) (all your financial sources of your research
The Department of Heath doesnt ask or report immigration status
The employer has no right to know any of the pt medical info without a signed release from the pt
No mandatory reporting for cancers (they are not transmissible after all)
A team physician may inform the coach in order to protect a player from further injury (so you can disclose the
injury information to coach without student athletes consent, to protect his health/safety).
Student athletes usually sign an authorization form permitting physician to share health info with coaches.
College health records on student athletes are not subject to HIPPA privacy rule.
The physician is obligated to refer the pt to another provider who can perform the requested medical service if the
this medical service is against the physicians personal beliefs (eg: abortion)
The Emergency Medical Treatment and Active Labor Act (EMTALA) imposes 3 requirements on all hospitals:
1- Screening to anyone who comes to the ED seeking medical care
 2- Treat and stabilize the emergency condition
3- Must not transfer an unstable individual with emergency condition
Hospice Care: when pts (or advance directives or surrogate) choose not to have any life-prolonging ttt OR when
expected survival 6 months (substantiated/proven by the physician)
Focus on quality of life, not cure or life prolongation
Symptom control (pain, nausea, dyspnea, agitation, anxiety, depression)
Interdisciplinary team (medical, nursing, psychological, spiritual, bereavement care)
Services provided at pts own home, a nursing home, or in a dedicated hospice facility
Eg: in cancer pts, pts with end-stage cardiomyopathy, end-stage COPD and in pulmonary fibrosis
In initial encounters with new pts, address them with their surnames, then ask them their preferred names
Older pts should initially be addressed as Ms., Mrs., or Mr. to show respect then ask them their preferred names
Standardized pt handoffs: the process of transferring responsibility of care, using sign-out notes about the pt
Its very imp. esp. when multiple providers are responsible for the same pt (at different times of the day) to prevent
discontinuity of care. Eg: between admitting physician and the ICU team
Provide hospital discharge checklist: to those pts discharged with too many medications and too many follow up
appointments, esp. if older pt, to increase the adherence. It includes: all instruction of medications, follow-up
appointments, pending laboratory measurements or tests, emergency contact number, medication changes during the
hospitalization period. Differentiated from hospital discharge summary which is for the physicians.