Professionalism and Medical Ethics Flashcards
Which one of the following is NOT a required component for assessing an individual’s capacity 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.
A 45-year-old female presents with WFNS grade I subarachnoid hemorrhage on evening. Vascular imaging reveals a 1.2 cm left supracli- noid internal carotid artery aneurysm. The operating neurosurgeon specializes in func- tional neurosurgery and elects to perform a clipping the following morning as there is no aneurysm surgeon available for a further 36 h. During the dissection around the aneu- rysm, an intraoperative rupture occurs and the surgeon struggles to obtain proximal con- trol leading to intraoperative hypotension from blood loss and prolonged cerebral ische- mia from temporary clipping. Postoperatively the patient wakes up on the neurointensive care unit with complete hemiplegia and global aphasia. Which one of the following factors is LEAST relevant to this surgical complication?
a. Task factors
b. Individual factors
c. Team factors
d. Patient factors
e. Organizational factors
f. Situational factors
f. Situational factors
A34-year-oldwomanhasalonghistoryofepi- lepsy 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-oldboypresentswithareducedGCS and CT head scan shows significant intraven- tricular hemorrhage and hydrocephalus. You discuss the imaging and the plan for an emer- gency 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.Obtainacourtordertoproceedwithsurgery
c.Do not performs urgery as lackin g 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
Which one of the following is NOTrequired for a valid advanced decision?
a. Mental capacity present when made
b. It applies to the situation where it is being
considered
c. You must be aged 25 or over
d. Must be signed by you and a witness if you wish to refuse life-sustaining treatments
e. Must have been made without harassment by anyone else
c. You must be aged 25 or over
An advance decision to refuse treatment (Living Will; advance directive) is legally binding as long as it complies with the Mental Capacity Act 2005, applies to the situation and is valid; it aims to take the place of best interest decisions made for you by other people. Advance decisions are valid if:
* youareaged18oroverandhadthecapacityto make, understand and communicate your decision when you made it
* youspecifyclearlywhichtreatmentsyouwish to refuse
* you explain the circumstances in which you wish to refuse them
* it is signed by you and by a witness if you want to refuse life-sustaining treatment
* you have made the advance decision of your own accord, without any harassment by anyone else
* you haven’t said or done anything that would contradict the advance decision since you made it (for example, saying that you have changed your mind)
Frasier guidelines are best described as clar- ifying circumstances surrounding which one of the following?
a. Competenceofachildtoconsenttomedi- cal treatment without parental involvement
b. Competenceofachildtoconsenttomen- tal health disorder treatment without
parental involvement
c. Competence of a child to consent to contraceptive advice and treatment without parental involvement
d. Competence of a child to withhold con-
sent to medical treatment without paren-
tal involvement
e. Competence of a child to withhold con-
sent to mental health disorder treatment without parental involvement
c. Competence of a child to consent to contraceptive advice and treatment without parental involvement
The House of Lords case Gillick versus West Norfolk and Wisbech Area Health Authority
[1985], was presided over by Lord Scarman and Lord Frasier and regarded legal action taken against the advice given to doctors in a health cir- cular that they could prescribe contraception to minors at their discretion. Victoria Gillick felt prescribing contraception in under 16s was illegal because the doctor would commit an offence of encouraging sex with a minor, and that it would be treatment without parental consent. The case had two main outcomes relevant to health professionals:
1. The concept of “Gillick competence”: which declared the parental right to deter- mine whether or not their minor child below the age of 16 will have medical treatment ter- minates if and when the child achieves suffi- cient understanding and intelligence to understand fully what is proposed (Lord Scarman).
2. Frasier Guidelines which outline the criteria which must be met for doctors to lawfully provide contraceptive advice and treatment to under 16s without parental consent.
You are a junior doctor in the Emergency Department (ED). A 5-year-old boy who has been in ED four times previously this year with several episodes of trauma that did not seem related. Today, the child is brought with a complaint of “slipping into a hot bathtub” with a small burn wound on his lower leg. Which one of the following would you do next?
a. Admit the child to remove him from pos- sibly dangerous environment
b. Phone the patient’s family doctor
c. Report your concerns to the local social
services
d. Accept the parent’s explanation
e. Ask the parent whether there has been
any abuse
c. Report your concerns to the local social
services
The British Medical Association guidance for doctors who have concerns about a child state “where a doctor has a reasonable belief that a child is at serious risk of immediate harm, he or she should act immediately to protect the inter- ests of the child, and this will involve contacting one of the three statutory bodies with responsibil- ities in this area: the police, the local authority social services or the NSPCC, and making a full report of their concerns.”
A 14-year-old boy presents with precocious puberty and headaches. Cranial imaging reveals a pineal region mass with hydroceph- alus. An endoscopic third ventriculostomy is planned and discussed with the family, but the boy refuses to have the operation. He is aware that without surgery, death is likely.
What is the next appropriate step in management?
a. Gain parental consent and proceed to surgery
b. Apply to High Court for wardship
c. Respect the boy’s decision and do not
operate
d. Proceed to treat in best interests under
Mental Capacity Act 2005
e. Call child protection services
a. Gain parental consent and proceed to surgery
A 7-year-old boy is a Jehovah’s Witness and was involved in a RTA (road traffic accident). He is in hemorrhagic shock and requires emer- gency blood transfusion but his mother refuses to give parental consent. Which one of the fol- lowing is the most appropriate next step?
a. Call child protection services
b.Give blood anyway as this is an emergency situation
c. Do not give blood transfusion due to lack of parental consent
d. Contact the courts by telephone
e. Get advice from the Hospital Liaison
Committee for Jehovah’s Witnesses
b.Give blood anyway as this is an emergency situation
Section 8 of the Family Reform Act 1969 states that in an emergency where you consider that it is in 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, the child should be given the transfusion. Traditionally, where young children are concerned, the power to give or withhold consent to medical treatment on their behalf lies with those with parental responsibility. Legally, except in an emergency, parental consent is necessary to perform any medical procedure on
a child. Two commonly used arguments when parents refuse treatment are parental rights to raise children as they see fit and religious freedom. Courts throughout the Western world recognize parental rights, but these rights are not absolute. Parental rights to raise children are qualified by a duty to ensure their health, safety, and wellbeing. Parents cannot make deci- sions that may permanently harm or otherwise impair their healthy development. If treatment refusal results in a child suffering, parents may be criminally liable. However, before any harm comes to the child the courts are usually asked to exercise their power under the doctrine of parens patriae which allows state interference to
protect a child’s welfare. This principle applies whether or not the child is in imminent danger, as parents are always required to make decisions in the child’s best interests.
A 16-year-old girl is a Jehovah’s Witness. She refuses a lifesaving blood transfusion. She is aware of and understands the consequences. What is the next step in management?
a. Gain parental consent to give blood
b. Give blood anyway as it is an emergency situation
c. Give blood anyway as she is not competent
d. Do not give blood transfusion but involve courts
e. Call child protection
d. Do not give blood transfusion but involve courts
The rights of adolescents to refuse medical treat- ment vary throughout the world and this judicial inconsistency creates confusion among health- care workers. In England and Wales, mature minors (Gillick competent or over 16) may con- sent to, but not refuse, treatment, with the courts using the “best interests” test to override the opinions of adolescents. In 1969, the Family Law Reform Act set the age of consent for medical treatment at 16 but did not specifically deal with parental-child conflict. The implication, how- ever, is that a child’s consent to a procedure over- rides parental opinion. The logical inference from Gillick is that competent children are com- petent to both accept and refuse treatment; yet subsequent decisions suggest that a child’s refusal may be overridden by a proxy’s consent to that treatment and that the child’s refusal, while important, may not be conclusive. Where treat- ment refusal was religion based, there was con- cern about the child’s freedom of choice in the context of a religious upbringing in addition to concerns about whether the child fully grasped the implications of treatment refusal. Thus, while a child’s refusal should be considered, it is likely that the court will override the refusal in the child’s best interests. In Scotland, although the Age of Legal Capacity (Scotland) Act does not specifically refer to treatment refusal, the infer- ence is that a child deemed competent could refuse, as well as consent to, treatment. In North America, the situation for mature minors is state/ province dependent.
Hilary is a 30-year-old schizophrenic patient. She has an abscess in her chest. But she is refusing treatment for it. She is also refusing to take her medication for schizophrenia for the last 2 weeks. She is thought to have full capacity, and understands the effects and con- sequences of not being treated for her chest abscess or taking any antipsychotic medica- tion. Which one of the following is true?
a. She can be detained for treatment of both her abscess and her schizophrenia
b. She can be detained for treatment of her abscess only
c. She can be detained for treatment of her mental health disorder only
d. She cannot be detained as she is competent
e. She cannot have capacity as she has a mental health disorder
c. She can be detained for treatment of her mental health disorder only
The Mental Capacity Act 2005 can only be used to give treatment to somebody aged over 16 without their consent if that person is assessed as lacking capacity to make a specific decision at that partic- ular time, and if treatment would be in their “best interests.” Mostly, the doctor who will be respon- sible for giving the medical treatment will be responsible for making the “best interests” deci- sion and in order to reach this decision, he or she must work through a process and statutory checklist which is contained in the Mental Capac- ity Act 2005. If hospital staff want to detain some- one for treatment under the Mental Capacity Act, they need to use the “Deprivation of liberty safe- guards” procedure. This should not be used to detain someone for treatment for a mental health problem—this is the role of the Mental Health Act 1983 (2007). This law allows people living in England and Wales who have a “mental disorder” to be admitted, detained and treated for their men- tal disorder in hospital without their consent (even if they have capacity/are competent)—either for their own health or safety, or for the protection of other people. This can be done under various sections of the Mental Health Act 1983 (2007):
Which one of the following remains valid when the principal dies?
a. Durable power of attorney
b. Ordinary power of attorney
c. Specific powers of attorney
d. General powers of attorney
e. Last will and testament
e. Last will and testament
A power of attorney is a document in which one competent person (the principal) appoints another person (the attorney-in-fact) to act for him or her. It becomes invalid when the principal dies and cannot be used to bequeath property upon the death of the principal (this is the func- tion of the last will and testament).
Respecting decisions made by those capable of making decisions.
Ethical concepts:
a. Autonomy
b. A positive right
c. A negative right
d. Beneficence
e. A categorical imperative
f. Justice
g. Non-maleficence
h. Virtue ethics
i. Futility
j. Utilitarianism
a. Autonomy
A doctor increases the dosage of painkillers/ sedation, at appropriate levels to control symptoms in the knowledge that this may have a life shortening side effect. The doctor is adamant that she only intends the pain- killing effect of the medication and not side effect.
Medically assisted dying:
a. Suicide
b. Physician-assisted suicide
c. Murder
d. Attempted murder
e. Voluntary euthanasia
f. Non-voluntary euthanasia
g. Involuntary euthanasia
h. Doctrine of double effect
h. Doctrine of double effect
