Ethics & Legal for USMLE Step 1

Ethical Principles

  • Autonomy= respect patient’s decisions about their own health
  • Non-maleficence = do no harm. Can still take calculated risk if potential benefits outweigh the potential risks
  • Beneficence = promote patients best interests
  • Justice = distribute medical benefits fairly and do not discriminate against any particular group

 

 Capacity/Competence

Capacity is a person’s mental ability to make informed decisions about their own health. A capacitated individual has to be able to understand the medical information given to them, retain that information, use the information given to them to make an informed decision and communicate that decision to their providers. The decision they make must be in line with their previous beliefs and not be the result of psychiatric symptoms (hallucinations of delusions). Certain psychiatric disorders, neurologic diseases, lack of consciousness, developmental disorders, age, severe pain, drugs or alcohol can all temporarily or permanently prevent someone from being capacitated. A couple clinical indicators or concern by a family member is not enough to deem a patient incompetent. A thorough examination of the patient must be performed before a patient is deemed incompetent. Patients are assumed to be competent until there is substantial proof showing otherwise. An individual who lacks capacity cannot give informed consent. Capacity is similar to the legal term Competence.

 

When a lack of capacity is involved, the requirement for informed consent is not removed. In these situations the responsibility of informed consent is transferred to a family member, friend or social worker. The physician should not be making these decisions for patient. Deciding which person will speak for the incapacitated patient follows a set of criteria. The first option is the patient speaking for themselves through an advanced directive or will. In this case the patient decides ahead of time what types of treatment they will want in certain scenarios. However, there are an infinite number of different scenarios that cannot all be outlined by the patient so a person is also needed to speak for the patient. The first person chosen to fill this role should be an individual identified by the patient (before they became incapacitated) through medical power of attorney. This person (called a proxy or surrogate) is identified by the patient ahead of time. If no such person has been identified by the patient a family member such as a spouse receives the responsibility. Whoever ends up being selected to speak for the patient should not be choosing what they want for the patient. They should be trying to relay what they think the patient would want if they could speak for themselves.

 

 Minors and Capacity

Minors (patients under the age of 18) are considered to not have the capacity to make medical decisions. This means that the patient’s parents give consent for medical treatment instead of the patient and that certain rules of confidentiality don’t apply to the parents.

 

Emancipation is the process in which a minor obtains the right to make their own medical decisions. For medical purposes a minor is emancipated if they file to become officially emancipated, live on their own, are married, have children of their own or are pregnant. In these cases a minor is treated as if they were an adult.

 

There are exceptions to the rule where minors have the right to confidentiality and do not need consent from a parent. The way I remember these exceptions is the phrase “sex, drugs and rock n’ roll.”Sex stands for contraception, treatment of STDs, treatment of pregnancy or just the fact that they are having sex which might be found during the history. Drugs stand for knowledge of alcohol or drug related activities as well as medical situations that may arise as a result of these substances. Rock N’ Roll stands for emergency situation in which a parent may not be able to be contacted in time to provide care.

 

Abortion is a situation where informed consent and confidentiality for minors is handled a bit differently. Some states require parent’s permission for an abortion (informed consent must be obtained from the parent) and other states only require parental notification (confidentiality is broken and parents are notified but they do not need to consent).

Informed Consent

Informed Consent is the process of describing the different treatment options to the patient and then asking for their permission to move forward with their chosen plan. For informed consent to be valid, the patient must be given all of the relevant information on the treatment plan before making their decision. This includes potential benefits, likely prognosis, potential negative outcomes, cost, alternative treatments available and the option to receive no treatment. Physicians not only have to make sure they tell their patient’s all of this information but also that their patients understand it. Any decisions must be made voluntarily by the patient. The patient cannot be coerced or pressured by the physicians.

 

The patient (or their appointed decision maker) has the right to reject any suggested treatment plan. A competent patient can choose to stop ongoing treatment or refuse starting treatment at any time for any reason. Refusing lifesaving medical care is not suicide and it is not automatically considered grounds for deeming a patient incapacitated. Based on the patient’s beliefs and wishes there are numerous situations where denying lifesaving care is a rational decision made by a competent person. Refusing one treatment option doesn’t mean they are refusing all treatment options and it doesn’t mean you abandon your patient. You still do everything you can for the patient except for the treatment options they choose not to accept. Discussing comfort care with the patient if they refuse lifesaving treatment is often the next step.

 

In emergency situations where a patient is incapacitated consent is assumed. In these situations you provide needed care until the patient becomes competent or the family can be contacted. There are a few other exceptions to informed consent (therapeutic privilege, waiver of consent …) but they are very rarely applied correctly and are low yield for Step 1.

 

 Confidentiality

Confidentiality is a set of rules and procedures that limits sharing patient information with anyone outside the medical team. It increases trust between the patient and physician while also increasing the volume and quality of information received. Confidentiality also prevents harm caused to a patient by having personal information released to people they don’t want to have it.

 

Confidentiality extends even to family members. You should not discuss details of a patient’s case with their family unless the patient tells you in private that you can do so. Asking the patient in front of their family if you can talk to their family is coercive. If the family member is present when you ask to disclose the patient information you may not get a true answer.

 

There are cases where confidentiality must be broken. Certain disease diagnoses are required to be reported to the proper government organizations for disease surveillance.

 

List of some Reportable Diseases:

³  Many infectious diseases

³  Cancer, TB, STDs

³  Adverse medical events (medical errors)

³  Severe cases of violence and all gunshot wounds

 

Certain Abuse cases also have to be reported to the proper authorities so the case can be investigated further. Physicians are required to report child or vulnerable adult (usually elder) abuse and neglect even if they just suspect something might be going on. You don’t have to definitely determine abuse has taken place. Just report the case so that it can be investigated further. It is not a physician’s job to investigate potential abuse. Just report a potential case and allow properly trained authorities to determine what is going on. Signs of abuse can include multiple unexplained injuries overtime such as bruises, healed fractures, burns, or retinal injury. Sexual abuse can include genital trauma or STDs. Signs of neglect include the patient having poor hygiene, failure to thrive, or malnutrition.

 

Intimate Partner Violence is not required to be reported automatically as long as the violence is not life threatening and the injury was not caused by a firearm. Unlike children and vulnerable adults, IPV victims are deemed competent to make their own decision about whether or not the authorities should be involved.

 

 End of Life care

If a terminal patient wishes to die, a physician can use potentially dangerous pain medications if it is for a legitimate medical reason. The patient’s death cannot be the goal of the treatment, but can be a possible outcome that results during the pursuit of controlling the patient’s pain. So a physician could use the medically appropriate amount of a pain medication even if the patient’s respirations are likely to be suppressed. In effect the physician is complying with the patients wish to die without breaking any laws.

 

Physician assisted suicide (usually an excessively large dose of pain medication) is only legal in a few states. Even in those states this situation arises very infrequently. And in these cases the physician cannot be the one to administer the drug directly. The physician can merely make the means available for the patient to use themselves.

 

In any state a patient can refuse to eat or drink anything given to them (just like they can refuse treatments) and die of dehydration. And any patient who is being sustained on a “machine” can still refuse care and request the treatment be stopped.  A patient or their representative can refuse this type of life saving treatment just like they can refuse any other type of treatment.

 

Now that you have finished the section on Ethics & Legal you should check out the next section in Behavioral Sciences that covers Doctoring.

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