Ethical Principles

There are 4 core ethical principles

Autonomy
-respecting patients as individuals

-honoring patient's preferences in medical care

-the patient's preferences take priority when making medical decisions

-therefore, the decider of decisions is patient word > living will > next of kin

-respecting confidentiality

Beneficence
-acting in patient's best interest

-balance autonomy and beneficence, but autonomy trumps beneficence

-Nonmaleficence

-"do no harm"

Justice
-distributive Justice

-governs allocation of limited resources

-formal Justice

-equals must be treated equally

Other Principles

-Breaking bad news

1. set up the interview

2. assess the patient's perception
3. obtain the patient's invitation (i.e. permission)
4. give the patient the necessary knowledge
5. address the patient's emotions with empathetic responses
 Patients (in general) have a right to know their diagnoses
  Open-ended questions are the best way to elicit a patient history; closed-ended questions are useful for
follow-up or clarification

Many patient encounters necessitate a combination of the above ethical principles--a few general principles
include:

 encourage open communication between patients and other treating physicians

 attempt to preserve the patient's relationship with other health-care providers.
 nonetheless, ensuring that the patient is receiving the best available care is always the primary priority
 if a mistake is discovered the physician should disclose that to patient/family with an apology

Privacy and the doctor-patient relationship

 all patients, regardless of age, should have the option of speaking to their physician alone
 this includes adolescents, spouses, and elderly adults.
 parents should be asked to leave the room so teenage patients can discuss:
i sexual activity
ii STDs
iii drugs and alcohol

Conflicts of interest:

 Physicians should report conflicts of interest

 Physicians can accept honoraria and be compensated for travel expenses, but cannot have assistance
with slide presentations from pharmaceutical companies

Capacity

 physicians can determine capacity which is the ability for the patient to understand their treatment as
well as the risks, benefits and alternatives
 competence is a legal designation and cannot be determined by a physician

Legal Principles
Introduction

Capacity, Competence, and Consent

Capacity vs competence

 capacity is a medical term

  competence is a legal term

Competent patients have the right to refuse medical information and medical treatment(s)

a feeding tube is a medical treatment

a competent person can refuse lifesaving hydration or nutrition

 Assume that the patient is competent unless

 history of suicide attempt
 psychotic
 patient cannot communicate

Obtain informed consent

patient must understand

i risks
ii benefits
iii alternatives

including no treatment

patient must agree with plan of care without coercion

Exceptions

 emergencies
 waiver by patient
 patient lacks decision-making capacity
 therapeutic privilege
 physician deprives an unconscious or confused patient of his autonomy in order to protect the patient's
health (paternalism)

Note that written consent can be revoked orally at any time

Components of informed consent include:

 patient makes and communicates a choice

 patient is informed
 information has not been withheld from the patient
 decision remains stable over time
 decision is consistent with patient's values and goals
 decision is not result of delusions or hallucinations
 consent from a patient's spouse is not required treatment of a patient with capacity
End-of-Life Issues

If the patient cannot make decisions, surrogate decision makers must use the following criteria:

 subjective standard (advance directive of patient)

 living will = patient provides specific instructions to withhold or withdraw life-sustaining treatment
 substituted judgment (what would the patient want)
 durable power of attorney = patient designates healthcare proxy to make decisions
 supersedes living will if both exist
 "best interests" of the patient

when no living will or durable power of attorney exists, the clinician is responsible for determining an appropriate
surrogate decision maker from available family members

the priority of next-of-kin for surrogate decision making is as follows:

 legal guardian appointed by a court

 spouse
 adult children (> 18 yrs)
 parents
 adult siblings
 grandparents/grandchildren
 friend of the patient

Euthanasia

passively allowing patient to die is acceptable

but do everything you can to relieve patient's suffering

active killing of the patient is not acceptable

when treatment should stop

physician thinks treatment is futile but family insists on treatment

continue treatment

after declaraion of brain death but family insists on treatment

stop treatment

Confidentiality

Confidentiality between physician and patient is generally absolute

Exceptions
  suspicion of child/elder abuse
 gunshot or stabbing injuries must be reported to the police
 communicable disease must be reported
 the patient is a harm to others or self
 tarasoff decision
 no alternative means exists to warn others
 patient waves right to privacy
 e.g. for insurance purposes

Minors

Minors cannot give informed consent unless emancipated through:

 marriage
 a parent
 military service
 living alone

A minor's refusal of treatment can be overruled by a parent

Parents cannot withhold life- or limb-saving treatment from their children, but can refuse other treatments

Examples

17-year-old girl whose parents cannot be contacted

physician may treat a threat to health under in locum parentis

17-year-old girl living on her own

patient can choose whether or not to give consent

17-year-old girl who is requests birth control

provide access even in absence of parental consent

17-year old girl who requests treatment for an STI

notification of parents is not required

16-year-old girl refuses but mother consents

treat

16-year-old girl consents but mother refuses

do not treat
Never abandon a patient

Transferring a patient to another physician's care is rarely (if ever) a correct answer on the USMLE

If a treatment (such as abortion, birth control, etc) is against a physician's personal beliefs - that physician does
not have to provide that treatment; however, they are responsible for referring their patient to a provider who
is willing and able to provide such care

Disclose all errors, regardless of harm

Consulting risk management alone is rarely (if ever) a correct answer on USMLE

Child and Elder Abuse

If suspected abuse is occurring, physicians are mandated reporters and MUST report

UWORLD POINTS:
1. Physicians are ethically obligated to disclose medical errors to patients regardless of whether
serious harm has occurred. A straightforward explanation of the medical facts and simple
apology can actually build trust and strengthen the physician-patient relationship.
2. Whether the patient was unharmed or even benefited from the erroneous intervention is
irrelevant
3. Physicians are not required to provide medical services that are against their personal
beliefs. However, once a patient-physician relationship is established, the physician is obligated
to refer the patient to another provider who can perform the requested medical service.
4. The physician should be nonjudgmental, refrain from imposing moral values, and
convey respect for the patient's autonomy.
5. Physicians should confirm that violence is wrong and undeserved, but they should not counsel
the patient in a directive way. Confronting denial or pressuring the patient to disclose, report
the abuse, or leave the partner should be avoided
6. In the United States, disability is a form of insurance that is administered by private insurance
carriers or by the Social Security Administration. It provides financial assistance to workers who
are unable to continue working due to a medical or psychiatric condition. Certification of
disability by a physician is usually required by these entities before the benefit is granted.
7. When interacting with demanding patients, the best approach is to politely but firmly explain
that determining medical disability requires further assessment of his symptoms,
physical examination, and testing if indicated.
8. It is premature to suggest that this patient is attempting to commit fraud without performing
an appropriate history and physical examination.
9. The AMA Code of Medical Ethics, Opinion 8.14 - Sexual Misconduct in the Practice of Medicine,
states that romantic and sexual relationships with current patients are always considered
unethical due to potential exploitation or interference with the physician's objective clinical
judgment. It would be unethical for this physician to date the patient and continue in his role as
her physician.
10. Some ethicists argue that relationships between non-psychiatric physicians and former
patients may be ethically acceptable provided the physician-patient relationship is terminated
prior to initiating a personal relationship.
11. Romantic relationships between psychiatrists and former patients are always considered
unethical.
12. Every individual has autonomy over his/her own body, including all reproductive health
decisions (sterilization, abortion, contraception). Consent is obtained from the patient
alone. Although the physician can encourage the patient to share and discuss her decision to
undergo the procedure with her partner, consent from a spouse (or unmarried partner) is not
required. The physician should ensure that the patient understands the risks and benefits of the
procedure and its alternatives (including the permanent nature of tubal ligation compared to
other forms of birth control).
13. The best course of action is to acknowledge the mother's concerns and politely ask her to wait
outside while the physician speaks with the patient privately. All adolescent visits should
 include an opportunity to interview the patient alone to discuss topics such as drugs, alcohol,
tobacco, and sexual activity.
14. Continuing the visit in the presence of the patient's mother will likely lead to unproductive
conflict or the patient pacifying his mother by agreeing and allowing her to continue to speak
for him
15. These cultures often value beneficence and nonmaleficence over the Western emphasis
on autonomy.
16. These cultures often value beneficence and nonmaleficence over the Western emphasis
on autonomy. As such, direct disclosure of a serious illness to a family elder may be considered
unnecessarily cruel or disrespectful. Instead, emphasis is placed on family members making
health care decisions for the patient. Other cultural reasons for non-disclosure include the
belief that open discussion may cause the patient unnecessary anxiety, depression, or
hopelessness or that speaking aloud about a condition makes death or terminal illness more
certain.
17. If the patient has capacity and expresses a clear preference, it is important to respect these
wishes by withholding the information. However, care must be taken to fully document all
pertinent conversations with the patient and family.
18. Physicians are ethically obligated to protect patient confidentiality in all situations,
including non-medical settings and in interactions with physician colleagues who are not
serving as health care providers for the patient. The most appropriate response in this situation
is for the physician to not divulge any information regarding the patient's condition or
treatment, including whether she is his patient. The physician should neither lie to protect
patient confidentiality nor confirm or deny whether she is, in fact, a patient.
19. Apologizing for or correcting the intern in front of the patient is unprofessional and creates an
awkward situation for the patient and team. The attending physician should model the correct
behavior in front of the patient and discuss minor matters of conduct with the intern privately
20. Building a therapeutic physician-patient relationship requires finding an optimal balance
between friendliness and professional formality. First impressions are important, and initial
encounters with new patients should ideally include asking them their preferred names
21. The main goal of HIPAA is protection of patient privacy and confidentiality. A physician can
respond to a family member's request for information only if the patient has specifically
provided verbal or written authorization for release of information to the family member.
22. If there is suspicion for abuse, asking permission to interview the child alone is the next
step. Parental refusal to allow the child to be interviewed alone is considered concerning for
abuse.
23. If an incapacitated patient does not have an advanced directive designating a proxy, a
patient's family member can act as the surrogate decision maker. If the patient has no family,
then a person who cares about and knows the patient's wishes can act as a substitute
24. When inquiring about the patient's sexual partners, the physician should maintain a neutral,
open, and nonjudgmental stance, but questions should be direct and specific. Physicians
should avoid making assumptions about patients' sexual orientation and behaviors and inquire
about all sexual partners. Asking this patient whether he has sexual contact with men, women,
or both allows him to discuss his sexual activity without labels or judgment.
25. “Thank you very much, I’ll give you best care with or without gifts “This response is judgmental as
it implies that the gift was given to obtain preferential treatment. This patient does not appear
to be attempting to "buy" special treatment from the physician but is instead only expressing
gratitude.
26. Addressing medication errors promptly is important in solving recurrent problems and
preventing further harm to patients.
27. Typically, the best approach is to employ a root cause analysis, which aims to identify what,
how, and why an undesirable outcome occurred.
28. The first step in a root cause analysis involves collecting data to obtain complete information
about the event or events. This involves interviewing multiple staff members involved to
understand why and how the adverse outcomes occurred
29. Untreated bacterial meningitis is a medically dangerous and potentially lethal condition.
Physicians have an ethical duty to advocate for the best interests of the child and, in such cases,
should challenge parental authority to make medical decisions for the child. The physician
should first attempt to address the parent's concerns about hospitalization and possible
misconceptions about the risks of meningitis. When efforts to resolve the situation are
unsuccessful, a court order or involvement of a state child protection agency may become
necessary.
30. Discharging the patient against medical advice would be an acceptable choice if the patient
were a competent adult. The physician must act to protect the child's life despite parental
wishes.
31. Physicians are ethically obligated to protect patient confidentiality and keep all personal health
information private unless the patient gives specific consent to release the information.
32. Maintaining patient confidentiality is essential to developing a trusting physician-patient
relationship as patients would otherwise be less likely to share sensitive information, which
could negatively impact their care.
33. “I will not disclose your information but let’s discuss/consider” Both of these statements are
judgmental and coercive. The physician should be neutral with regard to the patient's decision
and not force her into actions with which she may be uncomfortable.
34. Treatment of friends should be limited to emergency situations when no other physician is
available. The most appropriate response is for the physician to explain that she is
uncomfortable with the request and recommend that her friend seek appropriate care from her
personal physician.
35. In the interests of doing no harm, the physician should agree, at least in a generic sense, to
keep the patient in their thoughts/prayers
36. Physicians are ethically and legally obligated to report impaired colleagues in a timely manner
37. This can usually be done anonymously. In a non-emergency situation, a person
should contact the designated hospital committee, commonly called a physician health
program. If this is not possible or such a body does not exist, then the state licensing
board should be contacted.
38. The most appropriate response is to gently explore her belief that the situation is her
fault. This will help assess her level of understanding of Down syndrome and also allow the
physician to address the specific reasons behind her self-blame (thus alleviating some of her
immediate distress).
39. During subsequent visits, the physician should educate the patient about the condition and her
options, using a culturally and religiously sensitive approach and offering to answer any
questions she may have.
40. In situations in which one physician disagrees with another's practices (but that physician's
practices are within the standard of care), it is inappropriate and unprofessional to undermine
that physician's judgment during discussions with the patient.
41. When the patient is incapacitated or is not present, basic information can be shared if in the
physician's professional judgment doing so is in the patient's best interest. In this case, there is
no way of knowing for sure whether informing this woman (whether she is his wife or not) is in
the patient's best interest. However, the woman is distressed, and leaving her to worry for an
extended period could cause the patient emotional harm if she is indeed family.
42. The courts should intervene in medical care decisions when there is no next of kin available
who is competent to make medical decisions for an incapacitated or incompetent patient. In
such cases, the court will appoint a guardian to act on the patient's behalf.
43. Patients with decision-making capacity have the right to refuse treatment based on the
ethical principle of autonomy. Those who refuse treatment should be assessed for decision-
making capacity.
44. Low levels of literacy often impair patient functioning in the health care setting, affecting
patient-physician and patient-staff communication and resulting in lower quality of medical
care. Patients with low literacy experience difficulties in forming a therapeutic alliance, poor
understanding of written or spoken medical advice, and adverse health outcomes.
45. Physicians must be alert to signs of low literacy and address these communication gaps
with alternate modes of explanation and education. Visual resources such as videos or
drawings can help convey information on the patient's condition and treatment in a format that
does not require high levels of literacy to understand.
46. As part of the admission process, patients should be asked whether they have advance
directives and informed about options for creating them if they do not.
47. Advance directives consist of 2 main components: a living will and a health care proxy. A living
will specifies the patient's end-of-life wishes and often includes specific directives regarding
intubation, cardiopulmonary resuscitation, enteral feeding, and other life-prolonging
interventions. A health care proxy document allows the patient to designate a specific
individual to make health care decisions should the patient become incapacitated. The proxy
decision maker must always make these decisions in accordance with the patient's wishes, as
outlined in the living will.
48. Physicians must respond to revelations of sexual abuse with clear expressions
of empathy and support. Acknowledging the sexual abuse and gently asking the patient if she
would like to discuss it further is the most appropriate initial response.
49. Although referral to a therapist may be indicated later, the physician should initially
communicate a willingness to hear about the trauma directly.
50. The Health Care Consent Act allows a physician to treat an incapacitated patient without
consent in an emergency setting. It would be unacceptable to withhold blood products from
the mother when death is otherwise imminent